Can Standardization Improve Care in LTCFs?

The benefits of increasing the consistency of care, such as through the use of protocols, clinical practice guidelines, and clinical pathways, have been widely demonstrated across multiple care settings. Such standardization of care practices can be used to improve clinical outcomes, reduce costs, and enhance the quality of care. The articles in this issue highlight clinical issues commonly encountered in long-term care (LTC) settings that may benefit from more consistent, evidence-based guidance regarding best practices.

In LTC facilities, residents with chewing and swallowing difficulties may struggle with eating, which often leads to poor nutrition. Furthermore, they may be at increased risk of choking on or aspirating their food. To address these problems, facilities often provide modified-texture foods, such as puréed foods and thickened beverages, to such residents to make it easier for them to safely consume adequate nutrients.

In their previous research, Wendy J Dahl, PhD, RD, FDC, and Amanda L Ford, MS, found a wide degree of variability in how modified-texture foods are prepared, as well as whether they are prepared on site by the facility or are purchased by a third-party provider. This variability introduces the possibility of inadequate quality control in preparation practices.

To investigate this issue further, the researchers conducted a survey of 682 LTC facilities in Florida regarding their modified-texture food preparation practices. Survey results indicated that, while in-house preparation of puréed foods is the current norm in Florida LTC facilities, use of standardized protocols for preparing these foods is limited. Surveyed facilities also reported a lack of quality control procedures to ensure optimal texture and acceptability of these foods to support safe and adequate food intake of LTC residents with chewing and swallowing problems. These findings suggest an opportunity for improved quality of care for such residents through greater standardization of modified-texture food preparation practices. 

Many LTC residents receive warfarin to reduce the risk of cerebrovascular accidents. Because warfarin has a narrow therapeutic index, routine international normalized ratio (INR) monitoring is required.

Within their network of skilled-nursing facilities, Casey V Fowler, DNP, MSN, NP-C, ARNP, identified that sub-optimal warfarin monitoring practices were leading to an influx of INR-related calls after hours, at which time only one nurse practitioner (NP) was on duty to respond to the calls. Recognizing that this after-hours line congestion could potentially cause delays in care for other patients, the researchers conducted a quality improvement project with the goal of reducing the number of INR-related calls made after hours.

A key component of this quality improvement project was standardizing the warfarin-monitoring practices of NPs in the skilled-nursing facilities. NPs were trained to follow an evidence-based warfarin dosing protocol for adjusting warfarin and ordering follow-up INRs; use the CHA2S2-VASc to determine appropriateness of warfarin therapy; and order routine INRs for set days early in the week, so that NPs can order follow-up INRs before the weekend if needed. There was a statistically significant reduction in INR calls after this intervention, suggesting that the implementation of evidence-based dosing protocols and time management measures by NPs can reduce the volume of after-hours INR-related calls, potentially improving care quality and continuity of care.

Infection prevention in LTC settings is a fundamental challenge for care providers. Barbara I Braun, PhD, and colleagues suggest that high reliability organizations may serve as a model for how infection control may be improved in LTC settings. High reliability is characterized by core processes including preoccupation with failure, reluctance to simplify, sensitivity to operations, deference to expertise, and commitment to resilience. The authors assert that incorporating these practices into LTC infection prevention initiatives could improve success rates.

Dr Braun and coauthors provide examples of how core processes of high reliability are already being applied to LTC and review the existing literature on the implementation and outcomes of these programs. The authors identified that, in order for a health care organization to become highly reliable, there must be a commitment among leadership, a supportive organizational culture, and tools for robust process improvement. The implementation of protocols and standard practice guidelines are consistent with these aims and may offer an opportunity for LTC providers to improve all aspects of the care provided to their residents.