AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention

Facilitator Training—Additional Exercises (continued)

Trigger Summary Report Information Exercises

Objective: Facilitators will understand criteria and rules that determine information that displays on the Trigger Summary Report.

Exercise #1: Resident-Level Report: Risk Criteria and Rules

Please choose the best answer to the questions.

  1. The Trigger Summary Report is based on 8 triggers from nursing assistant documentation associated with risk for pressure ulcer development.
    1. True
    2. False
  2. Residents must meet at least 2 triggers during the report week to display on the report.
    1. True
    2. False
  3. All information on the report is captured from nursing assistant documentation, except for pressure ulcer information.
    1. True
    2. False
  4. The report displays a 4-month trend of each trigger for each resident.
    1. True
    2. False
  5. If a resident has incomplete documentation of meals during the report week, the following will display:
    1. Cells in each Wt Loss column (30, 90, and 180 day) will be blank
    2. Cells in 2 Meals ≤50% in 1 Day and Weekly Meal Intake Average <50% columns will be blank
    3. Cells in 2 Meals ≤50% in 1 day and Weekly Meal Intake Average <50% will display a dash (-)
    4. a & b
    5. None of the above
  6. The following is true if a resident who displays on the Trigger Summary Report has incomplete bladder or urinary documentation during the report week.
    1. Daily urinary incontinence column will be blank
    2. Daily urinary incontinence column will display a dash (-)
    3. A resident having incomplete documentation for any one trigger used for the report cannot display on the report
    4. None of the above
  7. There are three views of the Trigger Summary Report information: (1) Resident-Level View, (2) View by Specific Trigger, and (3) Unit-Level View.
    1. True
    2. False

Answers

  1. a
  2. b
  3. b
  4. b
  5. c
  6. b
  7. b

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Exercise #2: Prioritize Residents for Followup

Using the sample Trigger Summary Reports below, select the residents in each report you would consider highest priority. These are both resident-level reports.

Sample Trigger Summary Report #1

Name Room # Wt Loss ≥5% Prior 30 Days Wt Loss ≥7.5% in Prior 90 Days Wt Loss ≥10% in Prior 180 Days 2 Meals ≤50% in 1 day Weekly Meal Intake Average <50% Daily Urinary Incont >3 Days Bowel Incont Foley Catheter Current Pressure Ulcer # of Triggers Last Week # of Triggers This Week
Res1 0001 X X X X       X X 3 6
Res2 0002 X     X X   X X   5 5
Res3 0003 X   X   X X X     2 5
Res4 0004       X X X X     3 4
Res5 0005 X X X - - X X     1 5
Res6 0006 X   X     X X     0 4
Res7 0007     X   X X X     2 4
Res8 0008   X     X X X     3 4
Res9 0009       X   - X X   4 3
Res10 0010       X       X X 0 3

Answers: All residents are at risk. Residents 1-7 and 10 would be prioritized for followup. Generally, residents are identified as at highest risk based on having 4 or more triggers in the current week and/or an increase of 2 triggers from prior week to current week. 

Sample Trigger Summary Report #2

Name Room # Wt Loss ≥5% Prior 30 Days Wt Loss ≥7.5% in Prior 90 Days Wt Loss ≥10% in Prior 180 Days 2 Meals ≤50% in 1 day Weekly Meal Intake Average <50% Daily Urinary Incont >3 Days Bowel Incont Foley Catheter Current Pressure Ulcer # of Triggers Last Week # of Triggers This Week
Res1 0001 X X X X         X 4 5
Res2 0002 X   X - - X X     3 4
Res3 0003   X   X X X X     2 5
Res4 0004       X X X X     0 4
Res5 0005       X X X X     2 4
Res6 0006 X   X     X       2 3
Res7 0007   X X X X         0 4
Res8 0008         X X     X 1 3
Res9 0009         X - X   X 0 3
Res10 0010             X X X 0 3

Answers: All residents would be considered at risk. Residents 1-5 and 7-10 would be prioritized for followup.

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Exercise #3: Resident-Level Data

Using Trigger Summary Report #1

  1. How many residents appear to have incomplete CNA documentation in at least one area?
  2. Is Resident 2 at higher risk than Resident 6? If yes, why? Why not?

Answers:

  1. 1 (#5)
  2. Resident 2 may be at higher risk because of the sustained number of risk factors (5) for 2 consecutive weeks. Resident 6 is also at risk because of the recent increase to 4 factors. This is a case where clinical judgment and knowledge of the residents is required to look beyond the numbers in the report.

Using Trigger Summary Report #2

  1. How many residents had an increase of 2 or more triggers from the previous week?
  2. How many residents appear to be getting worse from the previous week?
  3. How many residents appear to be improving from the previous week?
  4. How many residents appear to be unchanged from the previous week?
  5. How many residents are likely to be new admissions?
  6. How many residents are likely to display on the Medium-Risk Nutrition Report?
  7. How many residents may have been admitted with a pressure ulcer?
  8. For all residents on the report, which triggers are occurring most often?

Answers:

  1. 7
  2. 10
  3. None
  4. None
  5. 4 (#4, #7, #9, and #10)
  6. 5 (#1, #3, #4, #5, and #7)
  7. 2 (#9 and #10)
  8. Weekly Meal Intake Average <50%; >3 Days Bowel Incontinence; Daily Urinary Incontinence

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Exercise #4: Unit-Level Data

In reviewing triggers for a specific nursing unit over a 4-week period:

  1. Which triggers are worsening?
  2. Which triggers are improving?
  3. Which triggers have the highest prevalence?
  4. How would you facilitate discussion?
Sample Trigger Summary Report: Unit Level
Pressure Ulcer Triggers Week 4
5/10/14
Week 3
5/17/14
Week 2
5/24/14
Week 1
5/31/14
Wt Loss ≥ 5% in prior 30 Days (ANY) 1 (3%) 2 (6%) 1 (3%) 1 (3%)
Wt Loss ≥ 7.5% in prior 90 Days 1 (3%) 1 (3%) 1 (3%) 1 (3%)
Wt Loss ≥ 10% in prior 180 Days 1 (3%) 2 (6%) 1 (3%) 2 (3%)
2 Meals ≤50% in 1 Day 5 (14%) 4 (11%) 4 (11%) 7 (20%)
Weekly Meal Intake Average <50% 3 (9%) 3 (9%) 2 (6%) 3 (9%)
Daily Urine Incontinence 2 (6%) 3 (9%) 3 (9%) 5 (14%)
>3 Days Bowel Incontinence 5 (14%) 4 (11%) 3 (9%) 7 (20%)
Foley Catheter 8 (23%) 7 (20%) 5 (14%) 8 (23%)
Current Pressure Ulcer 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Answers:

  1. 2 Meals ≤50% in 1 Day, Daily Urine Incontinence, >3 day Bowel Incontinence
  2. None, but weight loss is minimal and there are no pressure ulcers
  3. Foley Catheter, >3 Days Bowel Incontinence, 2 Meals ≤50% in 1 Day, Daily Urine Incontinence
  4. Ask the group if this information fits their clinical picture of this unit. Ask these questions:
    • Have there been any changes to explain the triggers that have worsened?
    • Which triggers would they like to address first?
    • How would they approach this task?
    • What will be the next steps?
    • Who will lead the effort?

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Exercise #5: Report Calculations

Please choose the best answer to the questions about report calculations.

  1. Which of the following weights are used in weight loss calculations?
    1. Daily weight
    2. Highest weekly weight
    3. Lowest weekly weight
    4. Monthly weight
  2. The 30-day weight loss calculation (≥5% in ≤30 days) and 180-day weight loss calculation (≥10% in ≤180 days) are based on MDS calculations.
    1. True
    2. False
  3. If a weight value is not available at 30 days prior to weight being used in the report, then the following weight is used:
    1. Most recent weight, weight closest and prior to report date
    2. All weights 25-35 days prior to report date are checked; use weight with date closest to 30-day date
    3. No weight loss is recorded since there is no weight value at 30 days prior to report date
  4. Which of the following are true for computing 180-day weight loss?
    1. All weights that occur in the range of 170-190 days prior to weight being used in report are checked and the weight closest to 180 days from report weight is used
    2. If two weights are the same distance from 180 days (e.g., 175 days and 185 days), then select the lowest weight for calculation
    3. a and b
    4. None of the above
  5. Which of the following are true for calculation of any weight loss within 30 days?
    1. There may be multiple occurrences of weight loss during the 30-day period
    2. Week 4 weight is subtracted from Week 3 through Week 1 weights; all weight losses are recorded
    3. Week-3 weight is subtracted from Week 2 through Week 1 weight; all weight losses are recorded
    4. Week 2 weight is subtracted from Week 1 weight; weight loss is recorded
    5. All of the above
    6. None of the above
  6. If a resident has at least one episode of urinary incontinence each day during the report week, then 7 will display in the Daily Urinary Incontinence column for that resident.
    1. True
    2. False
  7. Which of the following is used to determine >3 days bowel incontinence during the report week?
    1. Resident had at least one episode of bowel incontinence for 3 different days during the report week
    2. Resident had three episodes of bowel incontinence for at least 1 day during the report week
    3. Resident had nine consecutive shifts of bowel incontinence during the report week
    4. None of the above
  8. Presence or absence of Foley catheter is generated from which data source? (Circle all that apply)
    1. CNA daily documentation
    2. Physician orders
    3. Nurse assessment
    4. MDS assessment
    5. All of the above
  9. Weekly meal intake average <50% uses the same calculations used in the Nutrition Risk Report to determine average intake.
    1. True
    2. False
  10. For a resident, the value for # of triggers last week and # of triggers this week is determined by counting the total number of X's in each column.
    1. True
    2. False
  11. On the Nursing Unit Level view of the Trigger Summary Report: (choose all that apply)
    1. Weekly 4-week view of overall prevalence and trends of PrU triggers display
    2. Monthly 4-month view of overall prevalence and trends of PrU triggers display
    3. Data display for a single nursing unit
    4. None of the above
  12. On the Nursing Unit Level view of the Trigger Summary Report, number of residents and percentage of total census who meet each trigger display.
    1. True
    2. False

Answers:

  1. c
  2. b
  3. b
  4. c
  5. e
  6. b
  7. c
  8. a, b, c
  9. a
  10. b
  11. a, c
  12. a

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Trigger Summary Report Implementation Exercises

Objective: Facilitators will understand how to coach teams on implementation of report use. The data that display on the sample Trigger Summary Reports are representative of report results encountered in actual clinical settings. Sample report results will be used to discuss the various ways to interpret report results. Facilitators will be prepared to respond to a variety of questions from clinical teams implementing the Trigger Summary Report for the first time.

Exercise #6: Implementation: Key Points

Please choose the best answer to the questions.

  1. A resident who triggers for 2 meals ≤50% in one day will always be on the Medium-Risk Nutrition Report if which of the following are true? (Circle all that apply)
    1. The Nutrition Report is generated for the same report week
    2. There is no weight loss
    3. There is ≥1.0 pound weight loss
  2. Weekly Meal Intake Average ≤50% also displays on the High-Risk Nutrition Report.
    1. True
    2. False
  3. Recent admissions will never display on the Trigger Summary Report if admit date occurs during the report week.
    1. True
    2. False
  4. The Trigger Summary Report validation exercise is beneficial for which of the following reasons?
    1. Teams begin to see report data match clinical picture of residents
    2. Teams begin to use report data to target proactive measures for residents at risk
    3. Teams are more motivated to use and see value in using report data
    4. All of the above
    5. None of the above
  5. Completing the exercise to compare recent findings from root cause analysis for in-house-acquired pressure ulcers with recent Trigger Summary Report results raises team awareness of how Trigger Summary Report information could have helped target proactive preventive measures for high-risk residents.
    1. True
    2. False
  6. The Trigger Summary Report is beneficial for monitoring risk among new admissions.
    1. True
    2. False
  7. A zero value in the # of Triggers Last Week column usually indicates the resident was discharged during the report week.
    1. True
    2. False
  8. Which of the following are important when implementing any new process improvement using the Trigger Summary Report?
    1. Confirm the process for report use, who uses the report, and when
    2. Identify person or persons responsible to review report data prior to team meetings or huddle
    3. Confirm criteria to be used to determine risk (and followup)
    4. All of the above
    5. None of the above
  9. A recommended strategy to triage residents who display on the Trigger Summary Report includes review of residents having the following (circle all that apply):
    1. 4 or more total triggers for the report week
    2. Increase by 2 or more triggers from prior week
    3. A pressure ulcer
    4. Weight loss ≥10% in 180 days
    5. None of the above
  10. Benefits of using the Trigger Summary Report for process improvement to identify and communicate high-risk residents include which of the following?
    1. Improve identification and communication about residents at highest risk for PrU development to CNAs and multidisciplinary team members
    2. Confirm report results match resident clinical picture, so documentation is accurate
    3. Confirm appropriate intervention strategies are in place
    4. Prompt followup assessment on residents having more triggers from prior week
    5. All of the above
    6. None of the above
  11. Nursing & Rehab use the Trigger Summary Report to support collaborative discussion of residents at potential risk for pressure ulcer development and identify opportunities for rehab intervention.
    1. True
    2. False
  12. A recommended strategy to facilitate implementation of the Nurse/Rehab huddle is to:
    1. Compare residents on Trigger Summary Report with Rehab list of residents currently being followed
    2. Compare residents on Trigger Summary Report with Rehab list of residents recently discharged from Rehab care
    3. Compare list of residents with pressure ulcers with Rehab list of residents currently being followed
    4. All of the above
  13. Ideally, Nurse/Rehab huddles are held:
    1. Daily
    2. Weekly
    3. Monthly
  14. Using the Trigger Summary Report: Unit Level enables leadership to analyze specific and overall trends of PrU triggers for a nursing unit to:
    1. See upward or downward trends over a 4-week period
    2. Evaluate impact of new programs or existing quality improvement efforts
    3. Drive new quality improvement initiatives
    4. Compare results across units to understand variances
    5. All of the above
  15. Options to consider when discussing implementation strategies for process improvement to monitor unit-level trends of high-risk residents include:
    1. Incorporate report review into QI meetings
    2. Target facilitywide process improvements
    3. Monitor impact facilitywide and understand unit-level variation
    4. All of the above

Answers:

  1. a, b
  2. b
  3. b
  4. d
  5. a
  6. a
  7. b
  8. d
  9. a, b
  10. e
  11. a
  12. d
  13. b
  14. e
  15. d

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Exercise #7: Implementation: Factors for Success

Please choose the best answer to the questions.

  1. During On-Time team meetings with the Facilitator, it is important to have the following team members present (circle all that apply):
    1. Nursing assistant
    2. Floor nurse
    3. Director of Nursing or administrator
    4. Unit manager
    5. Rehab staff member
    6. Social worker
    7. Dietitian
  2. Which team member takes the lead in conducting the Trigger Summary Report validation exercise?
    1. MDS nurse
    2. Nursing assistant
    3. Unit manager
    4. QI or staff education staff member
    5. Housekeeping
    6. All of the above
  3. Steps in good communication include:
    1. Setting the stage; giving the information; asking for feedback or discussion to confirm information is valid; ending with clear next steps
    2. Making sure supervisor communicates the message
    3. Providing electronic or written communication and checkoff sheet
  4. The reasons for monitoring high risk-triggers weekly are (circle all that apply):
    1. Regulatory requirements
    2. Opportunity to be more proactive in responding to resident needs
    3. More timely than MDS information
    4. Requests from physicians for more frequent updates on residents
    5. All of the above

Answers:

  1. a, b, d, e, g
  2. c
  3. a
  4. b, c

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Exercise #8: Coaching Teams Through Use of Report Information

Scenario: The sample Trigger Summary Report below was generated for a single nursing unit. The team you are facilitating is assembled for a routine meeting.

Sample Trigger Summary Report
Name Room # Wt Loss ≥5% Prior 30 Days Wt Loss ≥7.5% in Prior 90 Days Wt Loss ≥10% in Prior 180 Days 2 Meals ≤50% in 1 day Weekly Meal Intake Average <50% Daily Urinary Incont >3 Days Bowel Incont Foley Catheter Current Pressure Ulcer # of Triggers Last Week # of Triggers This Week
Res1 0001 X X X X X       X 5 5
Res2 0002       X X   X X X 4 5
Res3 0003     X - - X X     3 4
Res4 0004 X     X X X X     2 4
Res5 0005   X X   X X       3 3
Res6 0006       X X     X   2 3
Res7 0007     X X X         3 3
Res8 0008         X X X     3 3
Res9 0009           - X X X 0 3
Res10 0010         X X       0 2
  1. What questions will you ask your core team about the Trigger Summary Report information?
  2. What questions will you ask your core team about interventions for residents?
  3. What questions would you consider asking the team about facility processes?

Answers:

  1. How are you using this report? At which meetings? Who is in attendance? Who leads the meeting? Is the information on the report useful?
  2. Nurse: Have the residents with weight loss and decreased intake been evaluated by the dietitian? Is resident 9 a new admission? Was this resident's pressure ulcer present on admission? What is the reason for his/her Foley catheter? Has this resident been re-evaluated by the wound nurse?

    Restorative Nurse:  Have the residents with bladder and bowel incontinence been evaluated for a restorative bowel/bladder program? Residents 2, 6, and 9 have Foley catheters. What is the diagnosis to support catheter use? Have these residents been evaluated to determine if the Foley catheter could be removed? Are their care plans up to date?

    Wound Nurse:  Residents 1, 2, and 9 have pressure ulcers. What is the status of these ulcers? Are they healing on schedule? Is Resident 9 a new admission? Was this resident's pressure ulcer present on admission? What is the treatment?

    Dietitian: What are the nutritional interventions for the residents with pressure ulcers? Have you evaluated the residents listed with weight loss and decreased intake? What were the recommendations that came out of those meetings? Have the care plans for these residents been updated and any new interventions communicated to the nursing assistants?

  3. Are the Weekly Nutrition Risk Huddles occurring as scheduled? Are the nursing assistants attending? Are the dietitian and nurse manager present? Are the nursing assistants included in wound rounds?

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Page last reviewed April 2016
Page originally created March 2013
Internet Citation: AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention. Content last reviewed April 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/pruprev/addexercises3.html