Reducing Potentially Avoidable Hospitalizations of Nursing Home Residents: Results of a Pilot Quality Improvement Project
Reducing Potentially Avoidable Hospitalizations of Nursing Home Residents: Results of a Pilot Quality Improvement Project
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DOI：
10.1016/j.jamda.2009.07.001
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发表时间：
2009-11-01
影响因子：
7.6
通讯作者：
Lamb, Gerri
中科院分区：
文献类型：
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作者：
Ouslander, Joseph G.;Perloe, Mary;Lamb, Gerri
目标：住院会使疗养院 (NH) 居民面临护理中断、医源性事件和相关发病率，并导致医疗保健费用过高。研究表明，很大一部分住院治疗是可以避免的，并且减少此类住院治疗可以节省医疗保险资金，这些资金可以重新投资于提高美国NHs的护理质量。该项目的目标是试点测试工具和策略，旨在帮助 NH 专业人员减少可能可以避免的住院治疗。设计：由佐治亚州医疗保健基金会、佐治亚州医疗保险质量改进组织 (QIO) 开展的为期六个月的前瞻性质量改进计划。参与的 NH 获得了旨在帮助减少可能避免的住院治疗的沟通和临床实践工具和策略，以及由高级执业护士提供的现场和电话支持。设施工作人员对急症护理转移进行了回顾性审查。将结果数据与 15 个月基线期间回顾性收集的测量结果进行比较。背景：根据自愿参与的高住院率选择了佐治亚州的三个 NH。测量：在干预期间，每两周由高级执业护士进行现场访问，监测工具和策略的使用情况。住院率的基线数据是使用最小数据集 (MDS) 确定的，专家小组使用结构化隐式记录审查流程将住院评级为可能避免的情况，该流程类似于之前关于 NH 居民住院适当性的研究中使用的流程。确定了 6 个月干预期间的所有住院情况，并由专家小组审查了由 Medicare 报销住院费用的居民的所有住院情况，以确定可能避免的比例。 结果：虽然 NH 工作人员对这些工具持积极态度，但他们在 3 个机构中对这些工具的使用情况各不相同，没有一个机构完全实施了所有工具。尽管仅部分实施，但与基线相比，质量改进举措在 6 个月的干预期内使总体住院率降低了 50%。被评为可能可避免的住院治疗的比例也降低了 36%，从基线时的 77% 降至干预期间的 49%。 结论：该试点项目中测试的质量改进策略和工具显示出协助 NH 减少可能可避免的住院治疗的希望。必须谨慎解释结果，因为这不是一项对照研究，并且仅在 3 个精心挑选的 NH 中进行。正在完善工具和实施策略，并在更大、更多样化的 NH 样本中进行测试。 (J Am Med Dir Assoc 2009；10：644-652)
Objectives: Hospitalizations expose nursing home (NH) residents to disruptions in care, iatrogenic events and related morbidity, and result in excess health care costs. Research has shown that a substantial proportion of these hospitalizations may be avoidable and that reducing such hospitalizations could save Medicare dollars that could be re-invested in improving the quality of care in US NHs. The objective of this project was to pilot test tools and strategies designed to assist NH professionals in reducing potentially avoidable hospitalizations.Design: Six-month prospective quality improvement initiative conducted by the Georgia Medical Care Foundation, the Medicare Quality Improvement Organization (QIO) for Georgia. Participating NHs were provided with communication and clinical practice tools and strategies designed to assist in reducing potentially avoidable hospitalizations, and on-site and telephonic support by an advance practice nurse. A retrospective review of acute care transfers was conducted by facility staff. Outcome data were compared to measures collected retrospectively over a 15-month baseline period.Setting: Three NHs in Georgia selected based on high rates of hospitalization that volunteered to participate.Measurements: Use of the tools and strategies were monitored every 2 weeks during the intervention with on-site visits by the advance practice nurse. Baseline data on hospitalization rates were determined using the Minimum Data Set (MDS), and hospitalizations were rated by an expert panel as potentially avoidable using a structured implicit record review process similar to that used in a previous study of the appropriateness of hospitalizations of NH residents. All hospitalizations during the 6-month intervention were ascertained, and all hospitalizations of residents whose hospital stay was reimbursed by Medicare were reviewed by the expert panel to determine the proportion that was potentially avoidable.Results: Although NH staff viewed the tools favorably, their use of them in the 3 facilities varied and none of the facilities fully implemented all of the tools. Despite only partial implementation, the quality improvement initiative was associated with a 50% reduction in the overall rate of hospitalizations during the 6-month intervention period compared to baseline. The proportion of hospitalizations rated as potentially avoidable was also reduced by 36%-from 77% at baseline to 49% during the intervention.Conclusion: The quality improvement strategies and tools tested in this pilot project show promise for assisting NHs in reducing potentially avoidable hospitalizations. The results must be interpreted cautiously because this was not a controlled study, and was conducted in only 3 highly selected NHs. Refinement of the tools and implementation strategies and testing in a larger and more diverse sample of NHs is under way. (J Am Med Dir Assoc 2009; 10: 644-652)