Analysis Examines Implementation of Evidence-Based Practices in Nursing Homes


The Pennsylvania Patient Safety Authority recently conducted an assessment of nursing homes with high and low healthcare-associated infection (HAI) rates that shows nursing homes with low infection rates implemented best practices better overall, but lacked in some areas compared to nursing homes with higher infection rates, according to an article published in the September Pennsylvania Patient Safety Advisory released today.

From October 2010 through November 2011, the Authority conducted on-site assessment visits to 10 Pennsylvania nursing homes with high HAI rates and 10 with low HAI rates.

"We wanted to study the impact of various levels of best practice implementation on HAI rates and determine patterns of care that could be targeted for improvement," says Sharon Bradley, RN, CIC, senior infection prevention analyst for the Authority. "We conducted a survey, interviews and clinical observations to assess the implementation of fifty evidence-based infection prevention best practices."

Bradley added that the first-time study was conducted using the Authority's Long-Term Care Best Practice-Assessment Tool, which is based on best-practice strategies selected from current guidelines that have been shown in the research literature to deliver better quality and provide better outcomes.

"The Authority's tool helped us measure the level of implementation of best practices such as implementing hand hygiene protocols and preventing urinary tract infections," Bradley says. "Overall, the nursing homes with high HAI rates did not implement these best practices as well as those nursing homes with low HAI rates."

Specifically, the Authority's tool helped measure the level of implementation in seven domains: hand hygiene, environmental, urinary tract infection (UTI), respiratory tract infection (RTI), gastrointestinal (GI) and multidrug-resistant organism (MDRO) infection, skin and soft-tissue infection (SSTI) and outbreaks.      

"Overall, the scores for both high HAI and low HAI nursing homes were lowest in full implementation of hand hygiene best practices," Bradley says. "The highest overall scores for the nursing homes with low rates were in implementation of SSTI prevention practices. Meanwhile, the nursing homes with high rates did best in implementing strategies for preventing GIs and MDROs."

Bradley added that compared with nursing homes with high rates, nursing homes with low rates scored better in full implementation of best practices in five of the seven assessment domains. However, the nursing homes with high rates scored better than nursing homes with low rates in individual secondary categories for implementation of a plan, goals education, documentation, monitoring and assigned accountability for outbreak control.           

"We conducted this study in response to the limited evidence available to evaluate the effectiveness or level of adoption of specific basic infection control measures to minimize infections in nursing homes," Bradley says. "This assessment provides a targeted focus for follow up educational programs for nursing homes whether they have a high or low score, to improve infection rates in their individual facilities."

For more information about the nursing home assessment and barriers in implementing best practices for preventing infections, go to the September Patient Safety Advisory article, "Impact of Implementation of Evidence-Based Best Practices on Nursing Home Infections" on the Authority's website at

The Authority's 2012 September Advisory also contains other clinical articles with strategies to improve patient safety and updated educational toolkits. Highlights include:

- The Breadth of Hospital-Acquired Pneumonia: Nonventilated versus Ventilated Patients in Pennsylvania: Patients at risk for ventilator-associated pneumonia (VAP) are easily identified because they require an endotracheal tube or tracheostomy, require life support, and are commonly admitted to specific areas of the hospital. However, Pennsylvania data shows that mortality rates for patients with nonventilator-hospital-acquired pneumonia (NV-HAP) are comparable to mortality rates for patients with VAP. Using Pennsylvania data, Authority analysts have also determined that NV-HAP affects more people than VAP and is as lethal as and more costly than VAP. Furthermore, NV-HAP is a safety issue that is on the rise in patients in the conventional ward, and it is likely to be underreported. Data suggests in this article that if VAP prevention is a focus at a facility, perhaps NV-HAP prevention should also share the spotlight. An educational toolkit is also available with this article.

Update on the Prevention of Retained Surgical Items: Surgical items such as sponges, sharps, and instruments may be retained following surgery and lead to serious patient harm. In June 2009, the Authority reported that the prevention of retained foreign objects, now commonly referred to as retained surgical items (RSIs), requires application of a multidisciplinary, consistent approach using current best practices. Ongoing analysis of events reported to the Authority show that in 2011, Pennsylvania healthcare facilities reported 452 events involving RSIs. During this time, Pennsylvania healthcare facilities also reported 1,930 events involving incorrect counts of needles, sponges, or equipment. Since the June 2009 Advisory article, the Association of periOperative Registered Nurses published updated guidelines for preventing RSIs. The Authority discusses these and other strategies in this article. An educational toolkit is also available with this article.

Quarterly Update on Preventing Wrong-Site Surgery: The wrong-site surgery reports this quarter matched the third-lowest number of reports in a quarter since statewide reporting began June 28, 2004. During the second quarter of 2012, Pennsylvania operating rooms wentfor the third time--for more than a month (32 days) without any reports of wrong-site surgery. During this past academic year (July 2011 through June 2012), there were 47 reports of wrong-site surgery, which is below the historical average of 63 and the lowest yearly total since data collection began in mid-2004. The two-year rolling average (51 per year) is also the lowest since reporting began. The implementation of the 21 principles to prevent wrong-site surgery appears to be working. Continuing the work to prevent wrong-site surgeries, this article highlights several near miss reports during this quarter that facilities can learn from to prevent a harmful wrong-site surgery event. An updated educational toolkit is also available with this article. 

Source:  Pennsylvania Patient Safety Authority


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