Gerontological Advanced Practice Nurses Association (GAPNA) 32nd Annual Conference

September 18-21, 2013; Chicago, IL

Clinical Practice Guidelines for Individualizing Behavioral Interventions in Long-Term Care Patients With Dementia

Patient-centered behavioral treatment has taken center-stage in the effort to decrease the use of antipsychotics in long-term care (LTC) patients with dementia. As unnecessary use of antipsychotics is being phased out due to the high rates of adverse effects and death in elders, many healthcare providers are turning to clinical practice guidelines for methods of behavioral management. However, many of these guidelines do not take into account residents’ individual needs and their applicability to environment, according to Nanette Lavoie-Vaughan, MSN, APRN-C, DNP, clinical assistant professor, College of Nursing, East Carolina University, Greenville, NC. Lavoie-Vaughan reviewed five sets of clinical practice guidelines: the American Psychiatric Association (2010), the American Geriatric Society (2011), the Group Health Cooperative (2009), the University of Iowa Gerontological Nursing Intervention Research Center (2005), and AMDA—Dedicated to Long Term Care Medicine (AMDA; 2012). After finding that these guidelines lack specific information about behavioral interventions for dementia, Lavoie-Vaughan collaborated with a clinical team comprised of a psychiatrist and two psychiatric nurse practitioners to develop new clinical practice guidelines that address these deficiencies. Lavoie-Vaughan presented the results of her project during a poster session at the GAPNA conference.

Lavoie-Vaughan and colleagues modified the existing AMDA guidelines by adding a three-pronged conceptual framework with the goal of developing targeted interventions that individually address the relationships between stress, environment, and behavior in dementia patients, Lavoie-Vaughan explained.

The first prong is Wiedenbach’s Helping Art of Clinical Nursing, a concept that emphasizes a patient-centered approach to nursing and asserts that whatever an individual does at any given moment represents the best available judgment for that person. “Wiedenbach’s model is the basis for assessment and treatment of behavioral problems, as it outlines the need to find the trigger or antecedent [and] explore the possible causes,” said Lavoie-Vaughan in an interview with Annals of Long-Term Care^®. The second and third prongs are the Progressively Lowered Threshold (PLT) model and Boltz’s six essentials of care. The PLT model entails that with disease progression, individuals experience increasing vulnerability and a lower threshold to stress and external stimuli; thus, this concept is integral for targeting environmental, social, and modifiable conditions that contribute to behavioral problems. Boltz’s six essentials are as follows: (1) maximize safe function by reducing stimuli, anticipating needs, and establishing consistent routines (eg, relaxation therapies); (2) provide unconditional positive regard to residents by training staff in communication skills; (3) use behavior to gauge activity and stimulation; (4) teach caregivers to listen to behaviors by educating them on communication and techniques for interaction; (5) modify the environment to create home-like living; and (6) provide ongoing caregiver support by frequently re-evaluating how interventions and/or education can be improved.

Lavoie-Vaughan said she will make the clinical practice guidelines accessible on her Website in early 2014. “As the number of persons with dementia continues to grow and the burden on LTC staff to provide safe and quality care increases, evidence-based data must be used to develop individualized plans of care,” Lavoie-Vaughan said. “The nurse practitioner plays a pivotal role in this process by disseminating information, doing research, and assisting staff in formulating care plans. Although it may be difficult to individualize every plan, an evidence-based guideline may make the process easier for the practitioner.”—Allison Musante

An Evidence-Based Curriculum to Prevent Diabetic Foot Problems in Frail Nursing Home Residents

One of the most common complications of diabetes mellitus is diabetic peripheral neuropathy (DPN), which may lead to diabetic foot ulcers (DFUs) and lower extremity amputation (LEA). Guidelines developed and published by the American Diabetes Association and other organizations advocate for annual diabetic foot examinations in the preventive care of diabetic foot complications. Nurse practitioners (NPs) are often the ones providing care to older adults in long-term care (LTC) settings, so adherence to these guidelines is important given the high prevalence of comorbidities, frailty, cognitive impairment, and complex medication regimens in these patients.

According to a literature review by Gail M. Prothe, DNP, APRN, BC-FNP/GNP, Arizona State University, and Optum Post Acute Services, the best strategy for diagnosing DPN and DFUs to prevent LEA is an annual diabetic foot examination using a 10-g monofilament, which includes education of the healthcare team and reminder systems. The results of Prothe’s literature review provided the basis for her original evidence-based curriculum (EBC) for NPs who provide care to LTC patients. Prothe tested the EBC in a group of adult, family, and geriatric NPs providing point-of-care services to frail and older adults residing in LTC facilities in metropolitan Phoenix and Tucson, AZ. Annals of Long-Term Care^® (ALTC) interviewed Prothe about the three major outcomes of her EBC study—cost, NP knowledge, and guideline compliance. Prothe presented the results of her EBC project in a poster session at the GAPNA conference, but those interested in the content and methods of her EBC can obtain a copy by e-mailing Prothe at gail_m_prothe@optum.com.

ALTC: What were the key findings of the cost analysis?

Prothe: By being able to diagnose DPN and detect DFUs earlier, the diabetic foot exam provides quality cost-effective healthcare to frail and older adults living in LTC facilities. A healed DFU can cost $8,000, but a DFU with an infection can cost $17,000. When a DFU doesn’t heal and/or develops an infection that requires LEA, the cost increases to $45,000. In contrast, the cost of developing and presenting the EBP curriculum was $4,031 total (about $80 per NP). A diabetic foot exam costs only $10 per exam. The usual care of a person with diabetes mellitus is $20,496 per patient, compared with the diabetic foot exam plus the EBC project curriculum cost of $8,432 per patient.

Did NP knowledge improve as a result of the project?

At our practice, the completion of health guidelines are documented in the electronic medical records (EMRs) on a health maintenance summary form that includes vaccinations, tuberculosis testing, and diabetic foot exam. A clinical indicator quarterly report devoid of individual patient information provided a total summary of guideline completion per NP. For the project, I compared the results both pre- and post-curriculum presentation.

There was no statistically significant change in NP knowledge regarding the diabetic foot exam after the presentation of the EBC curriculum. Out of 11 questions, the mean score for the pre-test was 9.8387 and the mean score for the post-test was 9.7647. Many of the demographic factors may have influenced the lack of statistical significance between the pre-test and post-test scores and the higher-than-average rate of completed diabetic foot exams. The majority of the NPs had less than 5 years of experience (38.5%) with the next largest group (32.2%) having between 6 and 10 years of experience. Family NPs made up 47.7% of the group, with adult NPs at 29.2%. The patient population managed by the group was over the age of 65 years, but only 12% were geriatric NPs, only 7.7% were wound-care certified, and no one was diabetic-certified. 

Did compliance with guidelines improve as a result of the project?

The frequency of completion of diabetic foot exams pre-curriculum (56%) and post-curriculum (57%) did not demonstrate increased compliance. However, when compared with other similar studies, our group had higher rates to start (0%-79%), but similar studies have reflected better improvement post-curriculum (40%-94%). The high scores on the pre-test and the post-test and the high rate of completion of annual diabetic foot exams are the likely result of a culture that promotes quality patient care at the project site. This includes multiple educational opportunities to enhance compliance with the Healthcare Effectiveness Data and Information Set; and the health maintenance record on the EMR gives a reminder to providers to complete the annual diabetic foot exam.—Allison Musante

Quality Improvement Project Led by Nurse Practitioners Reduces All-Cause Readmissions

According to a statement earlier this year from the Centers for Medicare & Medicaid Services (CMS), the rate of 30-day, all-cause readmissions is estimated to have dropped in October 2012 to 17.8%, after an average of 19% for the past 5 years. This drop represents approximately 70,000 fewer admissions in 2012. Although incentivizing care appears to be having a beneficial effect on healthcare cost and patient outcomes, many facilities continue to struggle with implementing processes for reducing avoidable readmissions. After observing a pattern of high hospital readmissions among residents of two skilled nursing facilities (SNFs) in Wisconsin, Dana Beyers, GNP-BC, and Deborah Kwasneske, ACNS-BC, APNP, Aurora Health Care, designed a quality improvement pilot project using an advanced practice nurse (APN) model to see if the number of readmissions could be reduced to 10% or less. The results of their project were presented in a poster at the GAPNA conference.

The project included all-cause readmissions for patients aged 65 years and older who were discharged from either of the two pilot site hospitals and admitted to either of the two pilot site SNF facilities. During the 6 months of study, 126 patients were admitted from SNF 1 (mean age, 84.6 years), and 103 patients were admitted from SNF 2 (mean age, 81.9 years).

The project employed two nurse practitioners (NPs) whose role was to closely monitor medications, review test results, and address acute changes in patients, as well as provide support and education to nursing staff in carrying out care plans. Over the course of 6 months, the NPs conducted standard assessments for each patient, which included review of code status, advance directives, decision-making capacity and identification of in-hospital consults, verification of primary care physician, medication review, physical assessment, follow-up care on any physician orders as needed, and need for family collaboration. Visits by NPs were scheduled daily for the first 3 days. For the following 30 days, visits were weekly and as needed.

After making a total of 732 visits to SNF 1 and 397 visits to SNF 2, the NPs had created a database of patient information that was used in the analysis. The results showed that the APN model reduced readmissions to the hospital in SNF patients. SNF 1 had fourteen 30-day readmissions, and the rate of readmissions decreased from 24% in the first month of the project to 11.5% in the sixth month. At SNF 2, there were ten 30-day readmissions, and the rate of readmissions decreased from 18% in the first month to 8.5% in the sixth month.

In their poster, Beyers and Kwansneske noted important aspects of the project’s design and protocol. The model includes a steering committee that meets monthly, and an operations team that meets weekly and with the SNF team as needed. They emphasized that the NP does not bill for services and does not take the place of physicians.—Allison Musante