Long-Term Care Survey Alert

Published on Wed Sep 24, 2003 PDF

 Avoid these 5 common mistakes.

They say the best defense is a good offense, and in long-term care, a good offense includes clinical practice guidelines, or CPGs.
 
CPGs help a facility improve its care and offer up a solid, evidence-based argument that staff did the right thing for a resident who suffered a negative outcome.
 
That's all quite true, but CPGs can work against a patient - and a facility - unless you avoid these five common mistakes in selecting and implementing them:
 
1.  Don't select or stick with guidelines that are too out of date and/or not right for the facility's patient population. You want guidelines based on the latest developments and current evidence, advises Jean Slutsky, acting director for the Agency for Healthcare Research & Quality's Center for Outcomes and Evidence. So check to see if an organization has updated its guidelines, and make sure you get the most recent version. Also select CPGs that you think provide the best fit for your patients. "The guidelines should identify their scope," Slutsky advises.
 
Tip: The summary of each set of guidelines posted by the AHRQ-sponsored National Guideline Clearinghouse at www.guideline.gov has a field that captures the scope of the guidelines. For more advice on how to select CPGs, see "Select the Best CPGs For Your Facility".
 
2.  Don't apply the guidelines in a "one size fits all" fashion. "You have to keep sight of the individual patient and realize that patients come in many sizes and with many different comorbidities," Slutsky reminds facilities. "So make sure the guidelines address your particular patient."
 
3.  Don't refuse to abandon the blueprint. Guidelines are a good reference and starting point, says Kathy Hurst, a nursing consultant and attorney in Chino Hills, CA. "But providers have to switch gears if a CPG protocol isn't producing the expected outcome in a particular case - for example, if a resident's wound isn't healing," she emphasizes.
 
4.  Don't fail to evaluate and remove obstacles to implementation. The American Medical Directors Association's guideline for guidelines implementation cites numerous reasons why the facility or staff doesn't implement the CPGs effectively. These include training issues, lack of resources, or staff perceptions. For example, some caregivers may think their way is better or believe the CPG won't work or will lead to negative consequences.
 
5. Don't follow a CPG that's less stringent than the local standard of care. Facilities will be held to a more stringent local standard in a malpractice battle, Hurst notes. For example, the regulations and most CPGs require facilities to identify patients at risk for pressure ulcers and to care plan for those risks. But Hurst notes that a lot of nursing homes in her area are starting to implement an across-the-board prevention program irrespective of the resident's risk, which is a higher standard (see the lead story in the September 2003 Long-Term Care Survey Alert, p. 78).