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Modeling hospital-acquired pressure ulcer prevalence on medical-surgical units: nurse workload, expertise, and clinical processes of care.

ABSTRACT: This study modeled the predictive power of unit/patient characteristics, nurse workload, nurse expertise, and hospital-acquired pressure ulcer (HAPU) preventive clinical processes of care on unit-level prevalence of HAPUs.Seven hundred and eighty-nine medical-surgical units (215 hospitals) in 2009.Using unit-level data, HAPUs were modeled with Poisson regression with zero-inflation (due to low prevalence of HAPUs) with significant covariates as predictors.Hospitals submitted data on NQF endorsed ongoing performance measures to CALNOC registry.Fewer HAPUs were predicted by a combination of unit/patient characteristics (shorter length of stay, fewer patients at-risk, fewer male patients), RN workload (more hours of care, greater patient [bed] turnover), RN expertise (more years of experience, fewer contract staff hours), and processes of care (more risk assessment completed).Unit/patient characteristics were potent HAPU predictors yet generally are not modifiable. RN workload, nurse expertise, and processes of care (risk assessment/interventions) are significant predictors that can be addressed to reduce HAPU. Support strategies may be needed for units where experienced full-time nurses are not available for HAPU prevention. Further research is warranted to test these finding in the context of higher HAPU prevalence.

SUBMITTER: Aydin C

PROVIDER: S-EPMC4369213 | biostudies-other | 2015 Apr

REPOSITORIES: biostudies-other

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Modeling hospital-acquired pressure ulcer prevalence on medical-surgical units: nurse workload, expertise, and clinical processes of care.

Aydin Carolyn C Donaldson Nancy N Stotts Nancy A NA Fridman Moshe M Brown Diane Storer DS

Health services research 20141007 2

<h4>Objective</h4>This study modeled the predictive power of unit/patient characteristics, nurse workload, nurse expertise, and hospital-acquired pressure ulcer (HAPU) preventive clinical processes of care on unit-level prevalence of HAPUs.<h4>Data sources</h4>Seven hundred and eighty-nine medical-surgical units (215 hospitals) in 2009.<h4>Study design</h4>Using unit-level data, HAPUs were modeled with Poisson regression with zero-inflation (due to low prevalence of HAPUs) with significant covar ...[more]

PMID: 25290866

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Project description:To assess the financial effect of the 2008 Hospital-Acquired Conditions Initiative (HACI) pressure ulcer payment changes on Medicare, other payers, and hospitals.Retrospective before-and-after study of all-payer statewide administrative data for more than 2.4 million annual adult discharges in 2007 and 2009 using the Healthcare Cost and Utilization Project State Inpatient Datasets for California. How often and by how much the 2008 payment changes for pressure ulcers affected hospital payment was assessed.Nonfederal acute care California hospitals (N = 311).Adults discharged from acute-care hospitals.Pressure ulcer rates and hospital payment changes.Hospital-acquired pressure ulcer rates were low in 2007 (0.28%) and 2009 (0.27%); present-on-admission pressure ulcer rates increased from 2.3% in 2007 to 3.0% in 2009. According to clinical stage of pressure ulcer (available in 2009), hospital-acquired Stage III and IV ulcers occurred in 603 discharges (0.02%); 60,244 discharges (2.42%) contained other pressure ulcer diagnoses. Payment removal for Stage III and IV hospital-acquired ulcers reduced payment in 75 (0.003%) discharges, for a statewide payment decrease of $310,444 (0.001%) for all payers and $199,238 (0.001%) for Medicare. For all other pressure ulcers, the Hospital-Acquired Conditions Initiative reduced hospital payment in 20,246 (0.81%) cases (including 18,953 cases with present-on-admission ulcers), reducing statewide payment by $62,538,586 (0.21%) for all payers and $47,237,984 (0.32%) for Medicare.The total financial effect of the 2008 payment changes for pressure ulcers was negligible. Most payment decreases occurred by removal of comorbidity payments for present-on-admission pressure ulcers other than Stages III and IV. The removal of payment for hospital-acquired Stage III and IV ulcers by implementation of the HACI policy was 1/200th that of the removal of payment for other types of pressure ulcers that occurred in implementation of the Hospital-Acquired Conditions Initiative.

Project description:Composite indices are single measures that combine the strengths of two or more individual measures and provide broader, easy-to-use measures for evaluation of provider performance and comparisons across units and hospitals to support quality improvement.The study objective was to develop a unit-level inpatient composite nursing care quality performance index-the Pressure Ulcer and Fall Rate Quality Composite Index.Two-phase measure development study.5144 patient care units in 857 United States hospitals participating in the National Database of Nursing Quality Indictors® during the year 2013.The Pressure Ulcer and Fall Rate Quality Composite Index was developed in two phases. In Phase 1 the formula was generated using a utility function and generalized penalty analysis. Experts with experience in healthcare quality measurement provided the point of indicator equivalence. In Phase 2 initial validity evidence was gathered based on hypothesized relationships between the Pressure Ulcer and Fall Rate Quality Composite Index and other variables using two-level (unit, hospital) hierarchical linear mixed modeling.The Pressure Ulcer and Fall Rate Quality Composite Index=100-PUR-FR, where PUR is pressure ulcer rate and FR is total fall rate. Higher scores indicate better quality. Bland-Altman plots demonstrated agreement between pairs of experts and provided evidence for inter-rater reliability of the formula. The validation process demonstrated that higher registered nurse skill mix, higher percent of registered nurses with a baccalaureate in nursing or higher degree, higher percent of registered nurses with national specialty certification, and lower percent of hours supplied by agency staff were significantly associated with higher Pressure Ulcer and Fall Rate Quality Composite Index scores. Higher percentages of unit patients at risk for a hospital-acquired pressure ulcer and higher unit rates of physical restraint use were not associated with higher Pressure Ulcer and Fall Rate Quality Composite Index scores.The Pressure Ulcer and Fall Rate Quality Composite Index is a step toward providing a more holistic perspective of unit level nursing quality than individual measures and may help nurses nursing administrators obtain a broader view of which patient care units are the higher and lower performers. Further study is needed to examine the usability of the Pressure Ulcer and Fall Rate Quality Composite Index.

Project description:BackgroundThe importance of nurse staffing levels in acute hospital wards is widely recognised but evidence for tools to determine staffing requirements although extensive, has been reported to be weak. Building on a review of reviews undertaken in 2014, we set out to give an overview of the major approaches to assessing nurse staffing requirements and identify recent evidence in order to address unanswered questions including the accuracy and effectiveness of tools.MethodsWe undertook a systematic scoping review. Searches of Medline, the Cochrane Library and CINAHL were used to identify recent primary research, which was reviewed in the context of conclusions from existing reviews.ResultsThe published literature is extensive and describes a variety of uses for tools including establishment setting, daily deployment and retrospective review. There are a variety of approaches including professional judgement, simple volume-based methods (such as patient-to-nurse ratios), patient prototype/classification and timed-task approaches. Tools generally attempt to match staffing to a mean average demand or time requirement despite evidence of skewed demand distributions. The largest group of recent studies reported the evaluation of (mainly new) tools and systems, but provides little evidence of impacts on patient care and none on costs. Benefits of staffing levels set using the tools appear to be linked to increased staffing with no evidence of tools providing a more efficient or effective use of a given staff resource. Although there is evidence that staffing assessments made using tools may correlate with other assessments, different systems lead to dramatically different estimates of staffing requirements. While it is evident that there are many sources of variation in demand, the extent to which systems can deliver staffing levels to meet such demand is unclear. The assumption that staffing to meet average need is the optimal response to varying demand is untested and may be incorrect.ConclusionsDespite the importance of the question and the large volume of publication evidence about nurse staffing methods remains highly limited. There is no evidence to support the choice of any particular tool. Future research should focus on learning more about the use of existing tools rather than simply developing new ones. Priority research questions include how best to use tools to identify the required staffing level to meet varying patient need and the costs and consequences of using tools.Tweetable abstractDecades of research on tools to determine nurse staffing requirements is largely uninformative. Little is known about the costs or consequences of widely used tools.

Dataset Information

Modeling hospital-acquired pressure ulcer prevalence on medical-surgical units: nurse workload, expertise, and clinical processes of care.

Publications

Modeling hospital-acquired pressure ulcer prevalence on medical-surgical units: nurse workload, expertise, and clinical processes of care.

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