Evaluation of AHRQ's On-time Pressure Ulcer Program

Pressure ulcers and injurious falls have serious health and economic consequences for elderly residents in nursing homes. Although substantial research has documented that preventing pressure ulcers and falls is possible, these problems persist across health care settings. The On-Time Quality Improvement for Long-term Care project was funded by AHRQ in part to assist nursing homes to implement best practice guidelines in pressure ulcer care through workflow redesign and process improvements integrated into the daily work of front-line caregivers. While the On-Time program had demonstrated success in early testing, a formal evaluation examining the effectiveness of this unique approach in reducing pressure ulcer incidence was needed as wide-spread dissemination had been considered. In response to this need, AHRQ funded a rigorous evaluation of the On-Time Pressure Ulcer program. 

The objects of the project were to:

• Evaluate the effect of the On-Time Pressure Ulcer program by comparing 12 New York nursing homes that have implemented the program with 13 control nursing homes.
• Design the tools and establish the foundation for a fall prevention implementation effort using an approach similar to the On-Time Pressure Ulcer Prevention program, including standardized documentation data elements that can be integrated into everyday practice, actionable reports of resident fall risk factors, and tracking tools.
• Develop an evidence-based systems approach for identifying, managing, and monitoring multiple risk factors for hospitalizations and ED visits.
• Develop the On-Time Train-the-Trainer and TeamSTEPPS for long-term care curricula.

Lessons from the On-Time Pressure Ulcer program informed the development of an On-Time Fall Prevention module, which uses documentation data elements, actionable reports, and tracking tools to address residents’ fall risk factors. The module provides resources to support nursing home staff to develop timely interventions for at-risk residents to reduce the incidence of falls. A year-long process of meetings informed the standardization of fall documentation and the development of tools to guide clinical decisionmaking for fall prevention. In addition, several facilities participated in a series of teleconference calls to develop health information technology specifications based on the final set of fall prevention tools. The project team worked with facilities to develop a feasible implementation plan to integrate these tools into daily practice.

A review of literature and analysis of national data was conducted to identify residents in nursing homes who should be targeted for prevention protocols to reduce hospital and emergency department (ED) visits. A training curriculum for the On-Time Pressure Ulcer program was developed and tested. The Team Strategies and Tools to Enhance Performance & Patient Safety (TeamSTEPPS) program was modified for use with nursing home staff. TeamSTEPPS is a training system designed to help health care professionals provide higher-quality, safer patient care and create a culture of safety within their teams. New materials, including the production of three videos, were designed to be relevant and meaningful to the staff at nursing homes. 

The study team found a statistically significant reduction in pressure ulcer incidence associated with the joint implementation of four core On-Time components. Impacts vary with implementation of specific component combinations. On-Time implementation was associated with sizeable reductions in pressure ulcer incidence, implying significant improvements in health outcomes and substantial cost savings.