Do Practices Make Perfect?

Part Twelve of a Series on the Survey Process

by Steven Levenson, MD, CMD

We would like to think that the OBRA regulations have helped promote better care in the nursing home population by clearly identifying and reinforcing good practice. But, that is only occasionally true. In fact, current nursing home practice is a mix of competent geriatrics and a lot of myth, habit, and unsubstantiated opinion. In many ways, the survey process and various other forces have fostered or permitted questionable care instead of encouraging good practice.

Processes and practices are two major, potentially improvable elements of nursing home care (see "LTC Regulations: Devil in the Details" and "Simple Fixes for the OBRA Regulatory Process" in the August and December 2001 issues, respectively, of Caring). Processes are the steps that are followed, and practices are the specific evaluations or interventions taken at those steps. For example, process steps for addressing pressure ulcers include evaluating risk factors and removing dead tissue from the wound. Related practices involve using a risk assessment instrument and choosing a debridement method.

OBRA regulations and guidelines have provided the bare framework of a care process. They tell surveyors to see if facilities have followed "professional standards of practice." But they offer no substantive guidance as to what those are and how to evaluate compliance with them.

The result: much talk in nursing home care about "best practices." But, reflecting the limited scope of the OBRA regulations, the discussions often focus on specific assessments and interventions--for example, pain management or pressure ulcer prevention. Often overlooked are vital underlying principles, such as the following.

Not Doing Harm There are two main approaches to managing individuals with chronic illnesses and disabilities. One focuses on doing things; the other focuses on avoiding harm by not doing certain things.

Nursing home residents often benefit from thoughtful, relevant interventions. But they also suffer from complications of otherwise beneficial treatments when inappropriate things are done or when interventions are selected without regard to their potential to interact dangerously with other interventions.

Additionally, many tests and treatments are irrelevant or offer little or no substantial benefit for the time and resources that they require. For example, pre-albumin is expensive and rarely pertinent to managing nutrition in nursing home patients; formal swallowing studies may be beneficial for individuals with a new stroke, but are rarely indicated routinely for other individuals who are not eating well.

Our health care system heavily emphasizes treatment for everything; this approach suggests that, given a choice, it is better to treat despite attendant risks than to wait or not treat. Clearly, some remediable conditions and preventable problems in nursing home patients have not been managed adequately. But, although the notion of not doing harm is a central tenet in all of medicine, it is increasingly becoming lost in the rush to treat the nursing home patient.

Treatment Advocates Nursing home care and the survey process have become profoundly influenced by treatment advocates, who say that aggressive treatment of various conditions is both desirable and a fundamental "right"--for example, the right to be free of pain.

Disease management--use of specific protocols and interventions (especially medications) to address specific illnesses or conditions--is a growing trend. Sometimes, aggressive disease or symptom management can be beneficial. But the impact of treating a condition often depends, among other factors, on whether the condition is isolated or appears in conjunction with other problems.

Trouble is, nursing home patients rarely have isolated conditions, and symptoms often overlap. Treating one condition often affects other conditions or risk factors. Under such circumstances, trying to treat every condition may be futile or problematic.

For example, aggressive management of heart disease, hypertension, Parkinsonism, and pain may be good individually. But there's a good chance that adverse drug reactions will lead to injurious falls or change in mental status or appetite in the frail older patient who is being treated for all four conditions simultaneously. The rush to treat pain symptomatically by prescribing narcotics means the need for careful symptom description and consideration of the causes may be overlooked.

So, best practice is not just about treating specific symptoms, diseases, or conditions; it is about demonstrating why specific patients are likely to benefit from specific interventions, and how those interventions are being monitored to ensure that they are not causing additional problems. Although the survey guidance alludes to this more balanced approach, the survey process often undermines it.

Experts Our health care system has become populated with specialists and consultants who purport to set standards for acceptable care. In nursing homes, generous reimbursement and regulatory pressures have led to a vast industry of people retained by nursing home owners and managers to tell staff and practitioners how to take care of patients. The rationale given for the use of such consultants is that they will help facilities meet regulatory requirements.

However, many consultants don't evaluate the whole patient. Despite their skill in managing discrete conditions, they may not recognize basic geriatric principles--for example, that all body systems interact, and that a symptom of a problem in one body system is often due to a problem somewhere else. And, they may not be around or acknowledge responsibility if their recommendations backfire.

The OBRA guidelines were written at a time when many significant treatable conditions were often undertreated. Therefore, they often steer surveyors toward investigating if specific disciplines are involved in patient care.

The regulations do not force facilities to use all these consultants. Yet, misinterpretation of the survey process (by both by facility staff and surveyors) has led to promotion of the notion that specific disciplines must be consulted for specific symptoms or categories of problems--and this, in turn, has made habits into de facto requirements. But these habits should not be confused with best practices.

Quantity & Quality The survey process focuses excessively on how much facility staff have done or how quickly they have done something. Often, facility staff are more likely to be cited for not doing "enough" things fast enough, or for doing the right thing improperly, than they are for having done too many irrelevant or inappropriate things that actually miss the root cause of a problem or increase subsequent risks for the patient.

But more is not necessarily better, and may sometimes be worse. It is acceptable practice to institute therapeutic trials, one at a time. If one approach fails, it is okay to move on to another. They don't all have to be done simultaneously. In fact, if several interventions are done at once, it may be impossible to tell which one was effective and which ones were just incidental. This may then lead to continuing unnecessary interventions.

Sometimes, the causes of nursing home patients' problems and symptoms are not readily discernible or correctable. Additionally, symptoms in the elderly often are nonspecific and nursing home patients often cannot give a good history. At such times, it may be beneficial to initiate treatment without fully evaluating the situation. For example, it may help to treat sepsis in elderly patients with antibiotics without waiting for culture results or identifying the source of the infection right away.

Or, sometimes it may be necessary to institute general fall-prevention measures because specific risk factors (for example, residual weakness from a previous stroke) cannot be corrected. But symptoms such as swallowing difficulty, change in behavior, or weight loss may require a detailed analysis of the whole patient before interventions are chosen.

In one situation, facility staff had identified that an individual was falling because of his stooped posture and unbalanced gait. But the resident refused therapy interventions that would probably have helped to correct the problem. So, the staff tried other interventions, including shoe changes and a low bed; not surprisingly, these were unsuccessful in stemming the falls. Even though the staff explained that the resident had refused the primary intervention that was most likely to address the problem, a surveyor cited them for "not doing enough" to try to prevent falls.

Yet, the concept of differential diagnosis--knowing how to distinguish different causes of similar symptoms based on patterns and relationships to other findings--is central to all effective patient care. Cause identification is not just a medical concept; it applies to all aspects of care. However, many nursing home management and staff disdain this process as being "too clinical," and some physicians disregard these tenets by quickly authorizing orders to address nurses' reports of symptoms.

Key Attributes of Best Practice

In short, "best practice" respects basic geriatric tenets: consistently do the few things that have been shown to make a difference in outcomes, and don't do things that make matters worse than they already are. Not doing harm is often preferable to risking questionable interventions without recognizing potential adverse consequences.

Best practice promotes the elements of the care-delivery process: correct problem and risk definition, effective cause identification, treatment in context that considers preventable risks and potentially correctable causes, and effective monitoring, including recognition of treatment complications.

Best practices are not diagnosis specific--that is, they don't require doing the same thing for everyone just because they have a given diagnosis. For example, not everyone with a fall risk needs physical therapy or a low bed; not everyone with a diagnosis of chronic obstructive pulmonary disease needs pulse oximetry testing or multiple inhalers daily; and not everyone with a diagnosis of diabetes needs a podiatrist to trim their toenails.

Relatively few interventions in the chronically ill produce a significant change in results for the patient. Most of the ones that do involve basic measures such as maximizing mobility and addressing major risk factors caused by illness and impaired function. Even when irrelevant care is not directly harmful, it often wastes scarce resources and time.

Time for Change

The result of all the above is that nursing home care has become a strange mixture of superb care and a potpourri of habit, opinion, and interesting but misguided speculation and practices. It's time for some basic changes in order to improve the situation.

First and foremost, the OBRA survey process should shift its focus from judging practices to assessing process performance. Without explicit criteria for determining the correctness of practices, it is not feasible for most individuals to evaluate whether a practice was correct or whether it conforms with "professional standards." But it is appropriate for surveyors to ask facility staff to justify their management of specific symptoms and conditions, and to challenge the absence of a plausible explanation.

The survey process should promote, not undermine, essential geriatrics and care process principles. It should reflect--not propose or promote--specific care practices and rely primarily on evidence-based approaches that have been identified by multiple reputable professional organizations.

The survey process should not allow surveyors to confuse their personal beliefs and opinions with best practices. State agencies should have written protocols for what surveyors can and cannot say about specific approaches that are not required under the regulations--for example, recommending certain lab tests, consultations, or interventions. And, federal surveyors (i.e., from CMS regional offices) should not change citations based on their own peculiar personal interpretations and opinions about what facility staff should have done differently.

Nursing home staff should refocus on basic, competent care-delivery processes. They should use evidence-based protocols to tell their primary care providers (nurses and physicians) how to care for patients, rather than relying on consultants. As has been noted many times in this series, nursing home staff should stop trying to practice "regulatory geriatrics"--doing unnecessary or inappropriate things just to try to avoid citations.

Finally, political influences on care practice should be tightly restrained. In an often desperate attempt to influence care without understanding the root causes of care problems, legislators and members of Congress have weighed in with laws and regulations that allegedly reflect best practices.

Regrettably, they often miss the mark badly. In fact, politicizing nursing home care sometimes leads to pressure not to use potentially beneficial treatments--for example, misguided perceptions about "chemical restraints" often results in the undertreatment of acute psychosis with ineffective anti-anxiety agents.

When these important changes occur, then nursing home residents may finally get the "best possible" care.

Dr. Levenson is a Multi-Facility Medical Director in Baltimore and Chair of Caring's Editorial Board.

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