On-Time Implementation (continued)

On-Time Quality Improvement Manual for Long-Term Care Facilities

Step 3: Implement Process Improvements Using Nutrition and Weight Summary Reports

This section explains how the Nutrition and Weight Summary Reports can be used to identify residents at nutritional risk and therefore at risk for pressure ulcer development. The reports can be used to ensure that appropriate interventions are in place to prevent weight loss from occurring and pressure ulcers from forming. The reports can also ensure that interventions are communicated among disciplines and that a well-defined followup plan is in place.

The Nutrition and Weight Reports can be used separately or in tandem for daily, weekly, or monthly meetings or specific process improvement initiatives. Since they often are used together, the Nutrition and Weight Reports will be discussed together in this section.

This section provides:

  • An orientation to the Nutrition and Weight Summary Reports.
  • Examples of process improvements that use Nutrition and Weight Summary Report information to identify residents at potential nutritional risk.
  • Implementation tips from nursing homes that have integrated the Nutrition and Weight Summary Reports into daily practice.
  • Frequently asked questions about using the Nutrition and Weight Summary Reports.

Orientation to the Nutrition and Weight Summary Reports

Nutrition Report

The Nutrition Report provides the dietitian, nurse manager, wound nurse, and MDS (Minimum Data Set) nurse an overall portrait of resident nutrition status. This report can be used in preparation for team briefings and followup with frontline staff prior to care planning.

 

The Nutrition Report displays weekly nutrition information, meal intake, and weight at a resident level and by nursing unit. The report sorts residents into high and medium nutritional risk categories and displays average meal intake for each of the last 4 weeks. It also indicates any weight change in pounds. Select Table 3.1 for a sample Nutrition Report.

Grouping the residents by high and medium risk helps the team focus on specific residents and target followup questions for staff. Trended data provide dietitians and nurses with an opportunity to spot subtle upward or downward trends that may not be apparent during shift or daily review. A downward trend in resident meal intake is an early warning signal of potential nutrition decline and triggers further investigation by the clinical team to confirm that appropriate interventions are in place.

Residents are included in the report if they have at least one of two nutritional risk factors for the report week: decreased food intake or weight loss. Decreased meal intake is defined as meal consumption at 50 percent or less for two meals in one day at least one time during the report week. Weight loss refers to any weight loss during the report week and is determined by subtracting the current week's weight from the most recent weight.

Residents meeting both nutrition risk criteria are considered at high nutritional risk; residents meeting one of the two nutrition risk criteria are at medium nutritional risk. Residents at high risk and medium risk display on separate report tables.

This report is used with other clinical information about the identified residents to answer the following questions:

  • How many residents trigger for high risk?
  • How many residents trigger for medium risk?
  • Is report information consistent with resident clinical picture?
  • Is the resident with poor meal intake also receiving tube feedings?
  • Is there a downward trend in average meal intake over the past 4 weeks? Upward trend?

Weight Summary Report

The Weight Summary Report is typically used by the dietitian and provides a profile of resident weight history, including indicators of weight loss over a 30- to 180-day period. The information can be reviewed together with the Nutrition Report for early detection of trends or associations between meal intake and weight values. In addition, the Weight Summary Report is a useful tool for MDS nurses when preparing MDS assessments.

 

The Weight Summary Report displays 4 weeks of trended weight information for each resident, calculates weight changes, and displays whether there has been significant weight loss (more than 5 percent, more than 10 percent) in the past 30 and 180 days. Select Table 3.2 for a Weight Summary Report.

The Weight Summary Report is used to answer the following questions:

  • How many residents had weight loss during the report week?
  • How many residents had 5 percent or greater weight loss within the last 30 days?
  • How many residents had 10 percent or greater weight loss within the last 180 days?

Process Improvements Using Nutrition and Weight Summary Reports

Once a team is familiar with the Nutrition and Weight Summary Report definitions, they agree to a timeline for implementing process improvements: Certified Nursing Assistant (CNA) 5-minute standup meeting and supplemental weight monitoring.

5-Minute Standup Meeting

The objective of the CNA 5-minute standup meeting is to integrate the use of the Nutrition Report into clinical practice, facilitate communication across disciplines, and include CNA staff in discussions with nursing and dietary staff. While a facility may already have a similar briefing process in place, the On-Time standup is distinctive in being a weekly meeting that is brief, focused, and data driven. The meeting has several objectives:

  • Elicit CNA feedback on resident eating habits and preferences that may provide insights for dietitian and nurse followup.
  • Confirm that appropriate care plan interventions are in place and establish followup plans with frontline staff.
  • Promote CNAs as an integral part of team discussions and key informants to licensed staff.

The recommended steps for implementing the CNA 5-minute standup meetings are:

  1. Identify meeting facilitators and participants. Team participants include CNA staff, nurse manager, and dietitian. Ad hoc participants include assistant director of nursing, MDS nurse, staff educator, social workers, and rehab staff.
  2. Establish meeting schedule. Select a day and time to conduct weekly meetings. It is important to elicit input from CNA staff when selecting a meeting time that is least disruptive to their daily routine.
  3. Plan meeting. Facilitators typically print the reports, scan the list of residents who trigger for high and medium risk, and, using clinical judgment, select residents for discussion.
  4. Follow meeting discussion format:
    • Confirm that report results are accurate and reflect resident clinical condition. Do residents with poor meal intake match what CNA staff observe during mealtimes? If not, why?
  5. Review list of residents who trigger for high nutritional risk:
    • Can CNAs provide insights into poor meal intake (e.g., food preferences, changes in resident eating habits)?
    • Confirm that appropriate interventions are in place. Are changes to care plan needed? Are consults needed? What is the responsibility of each team member? What is to be reported on, when, and to whom? Ensure that the team understands the action plan and followup.
    • Review list of residents who trigger for medium nutritional risk and repeat the process listed above for high nutritional risk.
  6. Implement and refine the process. Implementation of 5-minute standup meetings typically occurs in a staged approach. First, try the process on one or two nursing units. Second, refine the process as needed. Determine plan to include evening shift.
  7. Implement facilitywide. After a trial of 5-minute standup meetings on one or two units is complete, determine the rollout plan for facilitywide implementation. Consider identifying internal mentors to help facilitate implementation.

Implementation tips follow:

  • Consider starting the 5-minute standup meetings on nursing units having the highest number of pressure ulcers.
  • Avoid scheduling the meeting during a shift change. Often, CNAs are hurrying to finish outstanding work or complete documentation at the end of their shift and cannot focus on a meeting.
  • Forge strong relationships with Dietary and Nursing. A strong Dietary and Nursing collaboration results in more effective meetings. It is recommended that dietitians take the lead in facilitating the meeting with the nurse manager/coordinator as cofacilitator. Dietitians can make changes immediately to diet and food preferences and make timely recommendations for referrals during meetings.
  • Follow the structured meeting format focusing on resident meal intake. If the meetings cover too many topics, CNAs may lose interest or meetings may take too long. Keep the discussion focused around Nutrition Report results so that meetings are brief and on track. Also, adhering to a standard meeting format helps the CNA team prepare for the meetings.
  • Conduct meetings weekly. Some teams made decisions to hold meetings less frequently but learned that holding the meetings weekly is important for timely communications and keeping CNAs engaged. Teams that reduced meeting frequency eventually reinstituted weekly meetings.
  • Consider implementing on evening shift once the process is refined. This allows CNAs on different shifts to have a voice. In addition, dietitians have found that CNAs on evening and night shifts provide feedback about resident intake that is unique to their shift.
  • Ask unit managers and team members that have implemented the 5-minute meetings to serve as mentors to other facility units.

"CNAs are enthusiastic about the meetings, really feeling like part of the team now."

— Director of Nursing

"The On-Time process increases CNA awareness of how their documentation is used by licensed staff in resident care planning."

— Assistant Director of Nursing

"Standup meeting increased motivation by CNAs to improve completeness and accuracy of daily documentation."

— Director of Nursing

"Because of the 5-minute meetings, CNAs are more comfortable approaching dietitians throughout the day to communicate issues."

— Dietitian

"CNAs watch for small subtleties in their residents' eating patterns and they are picking up on eating issues earlier."

— Dietitian

Supplemental Weight Monitoring

Dietitians use the Weight Summary Report as a complementary tool to support existing processes for resident weight management; the process varies by facility and dietitian. Dietitians frequently report gaining efficiencies by using the report since monitoring resident weight trends is often a manual effort.

"Weight trend information is the most helpful. Previously, we did our own calculations using current weight and previous weight."

— Dietitian

Monitor Progress

The Nutrition Report Tracking Form is used in conjunction with the report. Facility teams use the tools for the initial 4 to 8 weeks of implementation to monitor team progress during 5-minute standup meetings. Once teams are comfortable with the meeting format and process, the tracking tool is completed every 3 to 6 months to confirm that processes are maintained.

 

The tracking form is used to record meeting information for 6 weeks. Information tracked includes number of high- and medium-risk residents who trigger reports and number of interventions each week. The tracking form is helpful early in On-Time implementation to help teams see trends in number of residents who trigger and why, as well as the recommended interventions. Dietitians typically take the lead in completing the tracking form but this may vary by facility. Select Table 3.3 for a sample tracking form.

Frequently Asked Questions

Question: Will review of Nutrition Report help us to improve accuracy of our CNA documentation?

Answer: Consistent review by dietitians and nurses of resident meal intake averages and weight information prompts more frequent followup with CNA staff to confirm accuracy of data entry. As documentation issues are identified, educational inservices can be used to focus on these issues and to address problems. With this focused approach to training, CNAs are more receptive and engaged in improving daily documentation. The result is better understanding by CNAs of proper documentation of meal consumption and weights, resulting in improved report data for clinician use.

Question: Should we review both the high- and medium-risk residents during the meeting?

Answer: Many teams start by reviewing the high-risk residents, but dietitians have provided feedback that included residents who triggered as medium nutritional risk. This practice has led to earlier identification of nutritional needs.

Question: The Nutrition Report does not provide our nurses with all of the information needed to care for their residents. Shouldn't the report provide more information?

Answer: The Nutrition Report is not intended to provide a comprehensive clinical picture of the resident (e.g., respiratory or cardiac condition, new medications, pain, infection). The report is intended to summarize CNA daily documentation for the past week and alert clinicians to residents who may be at nutritional risk. This information, along with other assessment data, may provide insights into residents' overall clinical condition.

Question: We have a resident listed as medium nutritional risk but the dietitian notes that he should be high risk; nothing displays in the weight loss column and he has lost weight.

Answer: Residents not weighed last week (during the report week) cannot display as high risk since recent weight loss is a criterion for inclusion on this list. Thus, if your facility policy is monthly weights, then the high-risk list will be computed only the week when weights are recorded and for residents on weekly weights.

Question: Why isn't the most recent weight displayed on the high- and medium-risk Nutrition tables? It would be helpful to see the most recent weight.

Answer: The Weight Summary Report displays weight values for the past 30, 90, and 180 days. The information that displays on the Nutrition high risk and medium risk lists represents a summary of information based on the most recent week: meal averages and weights. The goal is to focus on recent resident changes. If a previous weight were to display (perhaps a weight from 3 weeks prior), the clinician might incorrectly assume the weight value links to the current meal intake information. In addition, previous weight values were likely acted upon during previous report reviews. Therefore, the weight change in pounds is based on a weight recorded during the week the report was generated and reviewed.

Question: How are meal averages computed for residents who are NPO (nothing by mouth) or have refused meals? Will their meal averages be lower than actual?

Answer: If an option of Refused Meal or NPO is selected, the value used in the meal average calculation is zero.

Question: Our dietitians prefer their process to review meal intake information with the CNA staff and do not want to implement the 5-minute standup meeting. What should we do?

Answer: It is common for dietitians to feel they are on top of residents' nutrition status and risk and they typically have well-defined processes to work with CNA staff and nurses. The 5-minute standup meeting is not designed to interfere with existing processes. It is meant to encourage structured communication among dietitians, CNA staff, and nurses to elicit CNA feedback about resident meal intake patterns and to contribute to a multidisciplinary team approach. The meetings are focused on Nutrition Report results and provide an opportunity to elicit feedback from the staff who spend the most time with the residents, the CNAs. Dietitians typically embrace the process after one or two meetings and describe positive experiences regarding interactions with CNAs and information shared. On-Time facilitators highly recommend a trial implementation of the process on at least one nursing unit to overcome preconceived notions or resistance.

Question: Our staff prefer holding the weekly meetings during shift changes; it is too difficult for our CNAs to leave the units to attend meetings.

Answer: It is not uncommon for teams to initially shy away from holding meetings with CNA staff at times other than existing meeting times; shift change is often the easiest time to hold the meetings. Conducting 5-minute standups with CNAs at shift change is highly discouraged because of distractions (end of shift rush to complete work, finish documentation, and leave for the day). Teams discover after one or two meetings that CNAs are highly enthusiastic about participating in the meetings and sharing knowledge of their residents with clinicians. Teams report that CNAs are often the first to arrive to meetings and express concern when meetings are delayed or canceled.

Question: We just started our 5-minute standups and are having trouble keeping the meetings to 5 minutes; they often last 30 minutes or longer. How can we shorten the meetings?

Answer: All teams report meetings lasting longer than anticipated when initially implemented. Once dietitians are familiar with report information and CNAs are clearer about the meeting's purpose, meetings are often completed in less than 10 minutes. Dietitians and nurses report that CNAs come prepared to discuss their residents and are aware of information to share with clinicians after one or two meetings.

Summary of Key Points

  • Using the Nutrition and Weight Summary Reports motivates CNAs to document completely and accurately and engages them in the quality improvement process.
  • Using a structured meeting format and team discussion driven by report results leads to collaboration and good use of time for the entire team.
  • The 5-minute standup meeting:
    • Highlights the importance of the CNA role in team communications and the CNA as key informant to licensed staff.
    • Enhances multispecialty communication in a team format.
    • Identifies opportunities for nutritional interventions earlier.
    • Detects documentation issues and fosters targeted training to improve accuracy.

Return to Contents

Step 4: Implement Process Improvements Using the Pressure Ulcer Trigger Summary Report

This section describes the On-Time report, Pressure Ulcer Trigger Summary Report (Trigger Summary Report) and how it may be used to identify residents at potential risk for pressure ulcer development. The report information helps staff focus on high-risk residents to determine if they need additional followup, such as referrals, tests, or changes in the care plan. The nurse, wound nurse, physical therapist, and other members of the multidisciplinary quality improvement team can use the report to monitor residents weekly.

This section provides:

  • An orientation to the Trigger Summary Report.
  • Examples of process improvements using Trigger Summary Report information to identify when additional preventive interventions or further assessments are needed.
  • Implementation tips from nursing homes that have integrated the Trigger Summary Report into daily practice.
  • Frequently asked questions about using the Trigger Summary Report.

Orientation to the Trigger Summary Report

The Trigger Summary Report provides a weekly snapshot of a resident's risk for pressure ulcer development. Risk is based on eight triggers associated with pressure ulcer development. These triggers are derived from Certified Nursing Assistant (CNA) documentation and are described below. The report lists residents with at least one trigger, which triggers are present, and total number of triggers for each resident for the report week.

The report information is displayed in two sections: Resident Level and Nursing Unit Level.

 

The resident-level view (Table 4.1) displays residents with at least one trigger activated during the report week. Each trigger is marked and the total triggers for the current and previous week are displayed. The report displays residents in descending order of total number of triggers for the report week, providing clinicians with information to help them easily focus on the highest risk residents and confirm that appropriate interventions are in place. The side-by-side comparison of the sum of current and previous week's triggers makes it easier to detect upward or downward trends in total number of triggers for a 2-week period.

The Pressure Ulcer Trigger Summary Report: Resident-Level Section answers the following questions:

  • How many residents have at least one trigger?
  • How many residents have more then 3 triggers for current week? 4 triggers?
  • For residents with the highest number of triggers, which triggers are present?
  • How many residents had an increase in the number of triggers by two or more from the previous report week?
  • How many residents had a decline in the number of triggers from the previous week?

 

The unit-level section of the report (Table 4.2) is used to monitor the overall prevalence and trends of pressure ulcer triggers on a specific nursing unit. This information may be useful for program monitoring and planning or identifying inservice needs of staff. The unit-level view displays the number of residents (and percentage of total nursing unit census) who meet each trigger; a 4-week trend displays.

The Pressure Ulcer Trigger Summary Report: Unit-Level Section indicates how many residents:

  • Are experiencing ≥5% weight loss in ≤30 days? ≥10% in 180 days? Is the number of residents losing weight improving or worsening?
  • Have a weekly meal intake average less than 50%? What percentage of total unit census does this represent? Is this improving or worsening over the 4-week period?
  • Have daily urinary incontinence? What percentage of total unit census does this represent? Is this trending upward or downward over the 4-week period? Is it staying the same?
  • Have more than 3 days of bowel incontinence each week? What percentage of total unit census does this represent each week?
  • Have Foley catheters?
  • Overall, what are unit trends for pressure ulcer triggers? Are they stable? Getting worse? Getting better?

Process Improvements Using Trigger Summary Report

Once a team is familiar with the Trigger Summary Report definitions and layout of information, teams implement a series of process improvements described below:

  • Report Validation Exercise: Root Cause Analysis of Facility-Acquired Pressure Ulcers.
  • Identification and Communication of High-Risk Residents.
  • Rehabilitation Focus on High-Risk Residents.
  • Monitoring of Unit-Level Trends of High-Risk Triggers.

Report Validation Exercise: Root Cause Analysis of Facility-Acquired Pressure Ulcers

Report validation helps motivate the team to see the value of the information and consider ways to use the report in one or more process improvements. In this exercise, findings of root cause analysis for recent in-house acquired ulcers are compared to Trigger Summary Report results. Did the resident who developed an ulcer also appear on the Trigger Summary report in the 2 to 3 months leading up to ulcer development? If so, how many times did the resident appear on weekly Trigger Summary Reports? How many triggers were activated each week? In most cases, the team will find that residents who developed a pressure ulcer were on the Trigger Summary Report prior to ulcer development.

This exercise emphasizes how the Trigger Summary Report could have raised team awareness and targeted pressure ulcer prevention before the resident developed an ulcer. Staff often gain a new perspective about the value of report results after completing this exercise, paving the way for clinician adoption of this and other reports to support clinical decisionmaking and care planning

Recommended steps follow:

  1. Select two nursing units with recent development of in-house pressure ulcers and for the same 2- to 3-month period:
    • Review findings of pressure ulcer root cause analysis.
    • Review Trigger Summary Reports for these residents.
  2. During this review, consider the following questions:
    • How many residents who developed an ulcer also displayed on the Trigger Summary Report?
    • For residents who developed an ulcer and also displayed on the report:
      • How many report weeks did each resident display?
      • Are there patterns in total number of triggers among residents? For example, did all residents have four or more triggers activated?
      • Were the same triggers activated or did they vary by resident? Were any patterns noted?
    • From the root cause analysis:
      • What contributing factors were found to be associated with pressure ulcer development (e.g., steroid use, contractures, refusal of care, specific behaviors)?
      • Are the findings from the Trigger Summary Report and root cause analysis similar? If not, what were the differences?
    • Are there opportunities for improved prevention using the Trigger Summary Report?
  3. Review findings with the team and answer these questions:
    • How could the Trigger Summary Report information have been used to be more proactive in prevention efforts?
    • Using findings from the review, establish facility-specific criteria to identify residents at risk using the Trigger Summary Report, such as:
      • Residents having 3 or more triggers.
      • Residents with an increase in number of triggers by 2 or more; for example, resident trigger count increases from 1 to 3 or 2 to 4.

Implementation tips follow:

  • Some teams found it helpful to conduct the review on nursing units having the highest number of in-house acquired pressure ulcers.
  • The wound nurse or quality improvement analyst typically leads this effort with nurse manager involvement.
  • In the root cause analysis, several teams discovered factors beyond CNA documentation linked to pressure ulcer development, such as hospice, resident refusal of care, and steroid use. A team can consider developing a list of additional risk factors, based on findings, to use in conjunction with the Trigger Summary Report to identify residents at risk on a weekly basis.

Frequently Asked Questions

Question: We have a resident who developed a pressure ulcer but did not show up on the Trigger Summary Report. Why not?

Answer: Not all of the risk factors for pressure ulcer development are provided on the Trigger Summary Report. The triggers are based on CNA documentation. It is possible that a resident who developed a pressure ulcer in-house did not show up on the Trigger Summary Report. However, On-Time team experience supports that a resident with several triggers on the report is at high risk for developing a pressure ulcer.

Identification and Communication of High-Risk Residents

The Trigger Summary Report can be used to improve communication about residents at highest risk to CNAs or existing multidisciplinary teams. Using the Trigger Summary Report, the team members can focus discussion on residents with a high number of triggers or an increased number of triggers, assess appropriateness of interventions, and monitor interventions for residents with improvement from the previous week.

Recommended steps follow:

  1. Identify existing interdisciplinary meetings or rounds to use Trigger Summary Report, such as:
    • Wound Management or Skin Integrity meetings.
    • Weekly care planning meetings.
    • Incontinence Management meetings.
    • Behavior Management meetings.
    • Prep for Wound Rounds.
  2. Review Trigger Summary Report and identify high-risk residents each week, using criteria determined by team, such as:
    • A resident with 3 or more triggers this week OR
    • An increase in triggers by 2 or more from previous week; for example, resident trigger count increases from 1 to 3 or 2 to 4.
  3. Discuss high-risk residents during forum identified in step 1. Possible questions include:
    • Are report results consistent with resident's clinical picture? If no, why not? Is there a documentation issue?
    • Are interventions in place for triggers that are activated?
    • Are number of triggers increasing or decreasing from the previous week?
    • How many residents are new admissions? Does the report provide insight on new admissions?
    • Do team members need to follow up?
  4. Establish a unitwide communication strategy for high-risk residents. For example:
    • Post resident names on 24-hour report and for discussion at morning meetings.
    • Post the weekly reports in nursing station.
    • Note on CNA assignment sheet if a resident has, for example, 4 or more triggers to indicate high risk.
  5. Establish a plan to implement on all nursing units and agree to a timeline.

Implementation tips follow:

  • Review existing interdisciplinary meetings and determine the best way to incorporate the Trigger Summary Report into those meetings. This report is often used in conjunction with other On-Time or facility reports.
  • Do not expect or rely on the Trigger Summary Report to drive the entire process (keep in mind that other information will be used such as lab results, vital signs, other assessment findings). But the report will help keep the teams focused week after week and increase awareness of the importance of CNA input and documentation.

Frequently Asked Questions

Question: The Trigger Summary Report does not provide our nurses with all of the information needed to identify residents at high risk for pressure ulcer. Shouldn't the report provide more information?

Answer: The Trigger Summary Report is not intended to provide a comprehensive picture of the risk factors for pressure ulcer development. The report is intended to summarize CNA daily documentation items related to pressure ulcer development for the past week and alert clinicians to residents who trigger. This information, along with other risk assessment data, such as the Braden scale, should identify the highest risk residents but may not catch everyone.

Question: Do we need to adhere to the recommended high-risk criteria: ≥3 triggers and increase by 2 or more in total triggers from previous week?

Answer: Using 3 or more triggers or an increase of 2 or more triggers is a suggested place to start. As a team gets familiar with the report, it is often helpful to provide an easy way to start reviewing the report information and help focus on a subset of residents. Many teams expand the focus as they gain experience using reports in process improvements. The experience of teams is that pressure ulcers are more likely to form earlier in residents with multiple risk factors.

Question: Should we expect all new admissions to show up on the Trigger Summary Report?

Answer: No. Only new admissions with triggers will show up on the report. On-Time teams have reported that the Trigger Summary Report is a valuable tool to monitor risk factors for new admissions. The team can use trigger information to discuss patterns and confirm appropriate care plan interventions are in place.

Question: Is it unusual to see the same residents show up on the report week after week?

Answer: No. On-Time teams report that a resident with several triggers typically shows up on the report each week. The goal is to improve proactive team communication and coordination of care. It is important to identify that the resident is at high risk for pressure ulcer development, confirm that preventive interventions are in place, and discuss alternative strategies based on CNA input.

Question: What do we do if we disagree with report results? For example, one resident on the report triggered for daily urinary incontinence and this is not accurate.

Answer: Similar to the Nutrition Report, consistent review by nurses of resident meal intake averages, weight information, and continence trends prompts more frequent followup with CNA staff to confirm accuracy of data entry. As documentation issues are identified, educational inservices can be used to focus on these issues and to address problems.

Question: We currently use the EQUIP program to identify residents at high risk. How does the Trigger Summary Report differ?

Answer: The EQUIP reports use MDS (Minimum Data Set)iii data, which are mostly quarterly data. The On-Time Trigger Summary Report uses CNA data from the most recent week; On-Time report data are more recent.

Question: Is there a way to involve our wound nurse?

Answer: Here is a process many teams use. The wound nurse meets weekly with nurse managers to discuss residents with 3 or more triggers on the Trigger Summary Report. These residents are discussed, the charts are reviewed, and other clinical factors that the team found to be associated with in-house ulcers are discussed.

"The report helped to identify additional factors linked to pressure ulcer development and alerted management that weekend followup practices were inconsistent and an area for improvement."

— Nurse Manager

"The change from week to week is very good; the information helps the team see what is going on when you are not there, and provides a different picture."

— Wound Nurse

Rehabilitation Focus on High-Risk Residents

Members of the rehabilitation team can use the Trigger Summary Report to prompt communication with nursing and dietary team members and to confirm that interventions for pressure ulcer prevention are in place for high-risk residents.

Recommended steps follow:

  1. Assign member of rehabilitation team to review Trigger Summary Report.
  2. Set criteria to identify residents at highest risk (e.g., presence of 3 triggers).
  3. Review weekly reports and identify high-risk residents.
  4. Review existing care plans for high-risk residents and determine if there are or need to be rehabilitation interventions in place with these residents, such as positioning devices.
  5. Meet with nurses and CNAs to confirm that interventions are understood and provided.
  6. Determine timeline for followup with nurses and CNAs.

On-Time teams typically identify one unit to pilot this process with the rehabilitation team.

"Report has been helpful in flagging residents to be considered for more indepth review by rehab and closer monitoring by nursing."

— Director of Rehabilitation

Monitoring of Unit-Level Trends of High-Risk Triggers

A team may consider using the Trigger Summary Report: Unit-Level Section to monitor unit trends in high-risk triggers.

Recommended steps follow:

  1. Assign responsibility for evaluating and monitoring unit trends.
  2. Review weekly trends and answer these questions:
    • What are the most frequent triggers?
    • Is there an increase in triggers unitwide that indicate a need for process improvement interventions or staff inservice?
    • Is there a decrease in triggers unitwide that indicate improvement? If yes, what worked?
  3. Communicate and discuss findings with nursing unit team. Identify team members, meeting forum, and meeting frequency.
  4. Determine followup actions:
    • Reinforce existing process improvements: Are current prevention strategies affecting one or more of the eight risk factors? For example, is a new bladder training program reducing the percentage of residents with daily urinary incontinence?
    • Identify new process improvements: Consider targeting one or more negative trends to improve and develop an implementation plan.
    • Prioritize targeted process improvements. For example, areas that have greater than 50 percent prevalence or a monthly increase of more than 20 percentage points may take priority over other initiatives.

Frequently Asked Questions

Question: Who uses the unit-level section of the report the most?

Answer: Upper management and quality improvement staff use the Nursing Unit-Level Section. Directors of Nursing, nurse managers, quality improvement nurses, and special project teams can review and analyze specific and overall trends of pressure ulcer triggers for the entire nursing unit and see upward or downward trends over a 4-week period. Impact of new programs or existing quality improvement efforts, such as bowel or bladder training programs, can be evaluated for effectiveness. New strategiesto reduce Foley catheter use, for example, can be monitored using this report. Unanticipated unit trends or an increase in specific risk criteria can drive new quality improvement initiatives or focused staff inservices.

Trigger Summary Tracking Form

The Trigger Summary Tracking Form is used to help the team monitor their use of the report information and track progress. The tracking form helps teams track:

  • Number of residents who trigger each week.
  • Associated resident characteristics, such as tube fed, bedfast, wheelchair bound, experiencing a decline in activities of daily living, or hospice care.
  • Number of recommended interventions.

 

Select Table 4.3 for the Trigger Summary Tracking Form.

Summary of Key Points

  • The Trigger Summary Report can be used by multiple disciplines to meet discipline-specific objectives. In On-Time, one report can be used for multiple process improvements.
  • The Trigger Summary Report can be used as a complementary tool for existing processes such as root cause analysis of in-house acquired pressure ulcers.
  • The process improvements using Trigger Summary Report:
    • Engage multiple disciplines in using information based on weekly CNA documentation.
    • Improve timely identification of residents at risk for pressure ulcer development.
    • Increase proactive communication among multidisciplinary team members regarding high-risk residents.

iii The Minimum Data Set is maintained by the Centers for Medicare & Medicaid Services.


Page last reviewed January 2011
Internet Citation: On-Time Implementation (continued): On-Time Quality Improvement Manual for Long-Term Care Facilities. January 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/ontimeqimanual/qimanual4a.html