Toward a National Health Information Infrastructure: A Key Strategy for Improving Quality in Long-Term Care. APPENDIX A. ACOVE Indicators

Pressure Ulcers
Risk Assessment IF a vulnerable elder is admitted to an intensive care unit or a medical or surgical unit of a hospital and cannot reposition himself or herself or has limited ability to do so, THEN risk assessment to pressure ulcers should be done on admission.
Preventive Intervention IF a vulnerable elder is identified as at risk for pressure ulcer development or a pressure ulcer risk assessment score indicates that the person is at risk. THEN a preventive intervention addressing repositioning needs and pressure reduction (or management of tissue loads) must be instituted within 12 hours.
Nutritional Intervention IF a vulnerable elder is identified as at risk for pressure ulcer development and has malnutrition (involuntary weight loss of >10% over 1 year or low albumin or prealbumin levels,) THEN nutritional intervention or dietary consultation should be instituted.
Evaluation IF vulnerable elder presents with a pressure ulcer, THEN the pressure ulcer should be assessed for location, depth, and stage, size, and presence of necrotic tissue.
Management IF a vulnerable elder presents with a clean full-thickness pressure ulcer and has no improvement after 4 weeks of treatment, THEN the appropriateness of the treatment plan and the presence of cellulitis or osteomyelitis should be assessed.

IF a vulnerable elder presents with a partial-thickness pressure ulcer and has no improvement after 2 weeks of treatment, THEN the appropriateness of the treatment plan should be assessed.

Debridement IF a vulnerable elder presents with a full-thickness sacral or trochanteric pressure ulcer covered with necrotic debris or eschar, THEN debridement by using sharp, mechanical, enzymatic, or autolytic procedures should be done within 3 days of diagnosis.
Cleaning IF a vulnerable elder has a stage 2 or greater pressure ulcer, THEN topical antiseptic should not be used on the wound.
Systemic Infection IF a vulnerable elder with a full-thickness pressure ulcer presents with systemic signs and symptoms of infection, such as elevated temperature, leukocytosis, confusion, and agitation, and these signs and symptoms do not have another identified cause, THEN the ulcer should be debrided of necrotic tissue within 12 hours

IF a vulnerable elder with a full-thickness pressure ulcer presents with systemic signs and symptoms of infection, such as elevated temperature, leukocytosis confusion, and agitation, and these signs and symptoms do not have another identified cause, THEN a tissue biopsy or needle aspiration sample should be obtained and sent for culture and sensitivity testing within 12 hours.

Topical Dressing IF vulnerable elder presents with a clean full-thickness or a partial-thickness pressure ulcer, THEN a moist-healing environment should be provided with a topical dressing.

 

Pain Management
Screening for Pain ALL vulnerable elders should be screened for chronic pain during initial evaluation period.

ALL vulnerable adults should be screened for chronic pain every 2 years.

Target History and Physical Examination IF a vulnerable adult has a newly reported chronic pain condition, THEN a targeted history and physical examination should be initiated within 1 month.
Addressing Risks of NSAIDs IF a vulnerable adult ahs been prescribed a cyclooxygenase nonselective NSAID for the treatment of chronic pain, THEN the medical record should indicate whether he or she has a history of peptic ulcer disease and, if a history is present, justification of the NSAID should be documented.
Constipation with Opioid Use IF a vulnerable elder with chronic pain is treated with opioids, THEN he or she should be offered a bowel regimen, or the medical record should document the potential for constipation or explain why bowel treatment is not needed.
Treating Pain IF a vulnerable elder has a newly reported chronic painful condition, THEN treatment should be offered.
Reassessment of Pain Control IF a vulnerable elder is treated for a chronic painful condition, THEN he or she should be assessed for a response within 6 months.
Related Indicators Evaluate depression in patients with chronic pain.

Palliative care.

Educate concerning side effects of new medication.

Avoid meperidine.

Assess pain and function annually for osteoarthritis.

Acetaminophen use for osteoarthritis.

NSAID use for osteoarthritis.

 

Urinary Incontinence
Initial Evaluation ALL vulnerable elders should have documentation of the presence or absence of urinary incontinence during the initial evaluation.
Annual Evaluation ALL vulnerable elders should have annual documentation of the presence or absence of urinary incontinence.
Targeted History IF a vulnerable elder has a new urinary incontinence that persists for more than 1 month or urinary incontinence at the time of a new evaluation, THEN a targeted history should be obtained that documents each of the following: (1) characteristics of voiding, (2) ability to get to the toilet, (3) previous treatment for urinary incontinence, (4) importance of the problem to the patient, and (5) mental status.
Targeted Physical Examination IF a vulnerable elder has new urinary incontinence that persists for more than 1 month or urinary incontinence at the time of a new evaluation, THEN a targeted physical examination should be performed that documents (1) rectal examination (2) a genital system examination (including a pelvic examination for women).
Diagnostic Tests IF a vulnerable elder has a new urinary incontinence that persists for more than 1 month or urinary incontinence at the time of a new evaluation, THEN a dipstick urinalysis and post-void residual should be obtained.
Discussion of Treatment Options IF a vulnerable elder has a new urinary incontinence or urinary incontinence at the time of a new evaluation, THEN treatment options should be discussed.
Behaviorial Therapy IF a cognitively intact vulnerable elder who is capable independent toileting has documented stress, urge, or mixed incontinence without evidence of hematuria or high post-void residual, THEN behavioral treatment should be offered.
Urodynamic Testing IF a vulnerable elder undergoes surgery or periurethral injections for urinary incontinence, THEN subtracted cystometry should be performed before the procedure.
Surgery for Stress Incontinence IF a female vulnerable elder has documented stress urinary incontinence caused by isolated intrinsic sphincter deficiency or intrinsic sphincter deficiency with coexistent hypermobility, and she undergoes surgical correction, THEN a sling or artificial procedure should be used.
Catheter Use IF a vulnerable elder has clinically significant newly discovered overflow urinary incontinence and indwelling urethral catheterization is used, THEN there should be documentation that the patient is not a candidate for alternative interventions as a result of severe physical or mental impairments or does not want to alternative interventions.

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