Dossier n. 188/2010 [Abstract] Prevention and control measures for infections and pressure ulcers in residential facilities for elderly. Results from an improvement project

In recent decades in Italy, several demographic and social factors have led to a significant increase of elderly living in residential facilities and to a growing interest in the health issues related to this specific target.

In 2001-2002 a survey was conducted in 49 nursing homes of the Emilia-Romagna Region to estimate the prevalence of two adverse events such as infections and pressure ulcers. The study underlined several areas which needed improvements, concerning in particular prevention and control. The improvement project started in 2003 was thus implemented as an intervention strategy for preventing endemic and epidemic infections among both guests and health workers, and for controlling pressure ulcers. It involved 19 nursing homes of 3 Local Health Authorities (LHA), voluntarily selected among the 49 facilities that had participated in the prevalence surveys. Aims of the project were: to reduce the frequency of infections and pressure ulcers, to increase attention through the implementation of control programs, to test an intervention for care quality improvement that can afterwards be applied in other regional care facilities.

The intervention components were: creation of improvement groups, training programs for health workers, implementation of clinical care audit, resource raising to implement the necessary organizational changes. The improvement groups identified 17 macro actions and defined 44 actions that represented the goals of the project (32 for the project on infections and 12 for that on pressure ulcers).

At the beginning of the project a survey was conducted among practitioners, in order to describe knowledge and practice levels and the organizational climate in the facilities. Throughout the whole period of intervention (before, during and after), outcome indicators were collected through repeated prevalence surveys. At the end of the intervention, each facility was visited by a professional of the Regional Healthcare and Social Agency to complete a check list for collecting results from process indicators.

Results

Organizational climate

The average profile for professionals working in the involved facilities is:

• woman, 40 years old, coming from Northern Italy, married with one or more children, who has been working for 11 years, employed in the structure since more than 6 years, has previously worked in other sectors providing care to elderly;
• rarely reads scientific articles or participates in training courses;
• would like to receive more supervision and support during daily duties;
• reads only protocols concerning his/her profession;
• is satisfied to work in the structure, but complains about the insufficient information flows and the lack of recognition for the results obtained;
• identifies the following as critical issues that negatively affect job satisfaction: meetings, forms to be filled in, lack of continuing education, little career opportunities, insufficient wage, difficulties in reconciling work with family, lack of free time and holidays, little social prestige.

Infections

All professionals involved in the project and who participated in the initial audit showed a modest level of knowledge and a low degree of compliance to practice for the aspects investigated by the questionnaire. On 4,872 guests involved in six prevalence surveys, 562 were identified as infected for a total of 607 infections. The mean prevalence of infected guests and infections was equal to 11.5% and 12.5%, respectively. The most frequent infection sites were the lower respiratory tract, the urinary tract and conjunctivitis.

Prevalence rates have not substantially decreased during the project period, although significant variability due to seasons and differences in facilities’ case-mix and types of infection were detected, thus making it difficult to evaluate the overall time trend. The final evaluation of improvement actions implemented in each structure was positive: almost all the aims were - at least partially - achieved by all facilities.

Pressure ulcers

The initial audit showed a higher level of knowledge and practice in physicians when compared to other professionals. Out of 2,585 residents studied, 724 presented one or more pressure ulcers on the day of survey. During the project, no substantial reduction of the prevalence was observed, probably due to a gradual increase in stage I pressure ulcers detected over time. The prevalence of pressure ulcers of higher stages (II, III and IV) remained constant or slightly decreased. The final evaluation of improvement actions was partially successful: only 4 actions out of 12 were completed by all the eight facilities.

At the end of the project, the facilities have developed their own tools for continuous surveillance, thus consolidating and reinforcing the results already obtained. At the beginning of this surveillance the frequency of pressure ulcers was equal to 15%, but it was then gradually reduced and in May 2008 it reached a value of 10%.

Satisfaction for participation in the project

Professionals who participated in the intervention for controlling pressure ulcers expressed a higher degree of satisfaction compared to those who participated in the intervention for preventing infections. Aspects which were referred as improvable in the project were: level of involvement of social and health workers, communication on the different phases of the project, participation of the facility coordinator and nurses coordinators. Professionals in the participating facilities reported to have actually observed changes in their working place, such as using more accurate tools for adverse events registration, more frequent trainings, an increasing attention to the issues of prevention and treatment of infection and pressure ulcers.

Strengths and weaknesses of the project

Project strengths were: promotion of an increased awareness to the two targeted adverse events, development of prevention and treatment protocols based on scientific evidence, more frequent adoption of devices for prevention and treatment, agreement on the importance of conducting a continuous surveillance.

The main weakness was represented by an insufficient involvement of Local Healthcare Authorities: human resources necessary for an efficacious governance of the improvement project at local level were not always guaranteed.