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Documentation of preventive nursing measures in the elderly trauma patient: potential financial impact and the health record.

Elderly trauma patients have higher complication and mortality rates compared with younger victims with similar injuries. Nursing measures to prevent hospital-acquired complications are generally mandated by nursing policy and are required documentation in hospital record systems. In this study, gaps in the nursing documentation of measures intended to prevent hospital-acquired complications in elderly trauma patients may be related to the documentation of these measures not being required entries in the system used by the facility. Since hospital-acquired complications are not reimbursed by Medicare, failure to provide reminder prompts in the documentation system may result in preventive measures not being documented or even performed.


In 2010, approximately 13% of the total U.S. population was comprised of older adults (those 65 years of age and older) (Administration on Aging, 2010; U.S. Census Bureau, 2010). Studies have shown hospital-acquired complications in older adults to be as high as 36%, significantly higher than in those who are younger (Aitken, Burmeister, Lang, Chaboye, & Richmond, 2010; Rowell, Nghiem, Jorm, & Jackson, 2010; Soop, Fryksmark, Koster, & Haglund, 2009). Hospital-acquired complications are a contributing factor to increased costs, with some reports attributing an additional 9.6% to overall costs (Fuller, McCullough, Bao, & Averill, 2009). As of 2008, the Centers for Medicare & Medicaid Services (CMS) no longer reimburse for costs associated with particular hospital-acquired complications (e.g., catheter-associated urinary tract infections, and stage 3 and 4 pressure ulcers) because approximately 70% of all hospital-acquired complications are considered preventable (Soop et al., 2009). CMS clearly states in much of its literature that these hospital-acquired conditions "could reasonably have been prevented through the application of evidence-based guidelines" (CMS, 2012). The quality and fiscal impact of these findings have spurred the current urgency to address hospital-acquired complications, particularly in the elderly who demonstrate higher rates of these complications.

In the 1999 report, To Err is Human: Building a Safer Health System, the Institute of Medicine disclosed that up to 98,000 deaths per year, in all age groups, were attributed to health care errors (e.g., adverse drug events) and to preventable complications (e.g., falls, pressure ulcers, inadequate nutrition, incontinence, and delirium) costing as much as $29 billion in health care related expenses. Robust literature reports the higher risk in older adults for hospital-acquired complications than in younger patients (Rowell et al, 2010). Particular hospital-acquired complications (e.g., falls, functional decline, delirium, and pressure ulcers) occur with enough frequency to be widely reported within the context of "geriatric syndromes" (Francis & Lahaie, 2012). A recent report prepared for CMS found the cost of hospital-acquired complications to be $205 million (Kandilov, Dalton, & Coomer, 2012).

Recent data link older trauma patients (those 65 and older), in particular, with higher complication rates, higher mortality, greater use of resources (such as intensive care and diagnostic testing), longer lengths of stay, and lower return to pre-hospital levels of functioning compared to younger victims with similar injuries (Bradburn, 2012; Keller, Sciadini, Sinclair, & O'Toole, 2012; O'Neill, Brady, Kerssens, & Parks, 2012). Older adults have more co-morbidities and routinely take more medications than do the younger, complicating their responses to injury and treatment (Cutugno, 2011; Evans et al., 2011). Disproportionate to their numbers in the population (13%), those 65 and over account for more than 25% of all trauma hospital admissions (American College of Surgeons, 2012; Campbell, DeCalla, Fallon, & Rader, 2009). By 2050, estimates indicate 40% of all trauma patients will be over 65 with a predictable impact on health care costs that will parallel their increasing numbers in the United States (Blumenthal, Plummer, & Gambert, 2010).

The purpose of this study was to evaluate documentation, as an indicant of performance, of nursing measures intended to prevent hospital-acquired complications (atelectasis, bacterial pneumonia, falls, pressure ulcers, pain management, and confusion) in trauma patients 65 years of age and older. Nursing documentation was evaluated for measures directed toward the prevention of respiratory atelectasis and falls, the promotion of mobility, the maintenance of skin integrity, the assessment of orientation, and pain management. The performance and documentation of nursing preventive measures are standard of care practices required by all U.S. hospitals. Performing preventive measures at routine intervals is intended to decrease the incidence of hospital-acquired complications in patients of all age groups and is common practice for nurses. Documentation requirements for these measures are stipulated in nursing textbooks and in organizational nursing policies. This documentation is evaluated as assumed evidence of performance by regulatory agencies, such as the Joint Commission. All types of nursing documentation records include specific sections for recording the performance of these measures. Given the incidence of hospital-acquired complications in trauma patients 65 years and older, this study sought to evaluate the documentation of these preventive measures in this group of patients.

Ample nursing literature focused on improving care of elderly patients in general is available, much of it directed at the prevention of complications. Assessment tools and recommended preventive measures in current use include those that address respiratory impairment, problems of immobility, loss of skin integrity, falls, confusion, dehydration, and hospital-acquired infections. Management efforts for "geriatric syndrome" complications are being increasingly addressed (Francis & Lahaie, 2012; Inouye, Studenski, Tinettti, & Kuchel, 2007). Additionally, considerable recent efforts have been directed at measures to maximize pain control due to the proven link between pain and impaired mobility (and, thus, falls), exacerbation of cognitive impairment, and functional loss (Horgas, Yoon, & Grail, 2012).

Despite both practice standards and ubiquitous nursing policies, outcome evidence supporting the efficacy or the recommended frequency of many of the nursing preventive measures in common use is scant. For example, no evidentiary support exists that a patient should be turned, or that coughing and deep breathing or the use of the incentive spirometer is indicated, every 1, 2, or 12 hours. Although known that immobility is a risk factor for the development of pressure ulcers, the frequency of position changes has not yet been established (Ayello & Sibald, 2012). However, strong evidence supporting the association of more hours of nursing care for patients (each nurse taking care of fewer patients) with fewer hospital-related complications exists (Frith et al, 2010; Kane, Shamliyan, Mueller, Duval, & Wilt, 2007). Given the strength of this evidence, it likely indicates more hours of nursing care assessment and intervention, preventive and otherwise, decrease hospital-acquired complications.

Preventable complications negatively impact a patient's quality of life, extend hospital length of stay, and utilize resources that are costly and may not be reimbursed. Both the American Geriatrics Society (2006) and the American College of Surgeons (2006) (who oversee trauma standards in the United States) recommend the prevention and early recognition of complications in the management of older adult trauma patients. This study sought to evaluate nursing measures intended to prevent hospital-acquired complications in older trauma patients by conducting a retrospective review of the medical records.


A descriptive design was used in this study. Documentation compliance for preventive measures was determined relative to the requirements of the nursing policy of the hospital, which are based on current standards of care (Nettina, 2010). The study was conducted at a large inner-city Level II trauma center in New Jersey. The emergency department receives approximately 130,000 patient visits per year with an average of 1,000 trauma admissions per year. Institutional review board (IRB) approval was obtained from a college and the medical center. Waivers of informed consent were also obtained from both IRBs based on the availability of only de-identified data to the principal investigator, who was not a member of the hospital's nursing department. All patient data were stored safely and were accessible only to the investigators.


Admissions to the surgical trauma unit of the hospital were determined from the unit admission log. From this information, the health records of patients who met the study inclusion criteria of age and trauma diagnosis were reviewed. The sample period began June 2010 and ended September 2011 when the determined sample size (100 elderly trauma patient records) was reached. The inclusion criteria were 65 years of age and older, male or female, and admitted to the general surgery-trauma unit with a traumatic injury diagnosis (e.g., fractured hip, ruptured spleen, liver laceration). Older adult trauma patients admitted to the surgical intensive care unit (SICU) were excluded from the study due to the higher acuity (e.g., traumatic brain injury, spinal cord injury, gunshot wound to the abdomen) and the nursing requirements for ICU patients which are notably different (e.g., frequency of assessment, amount and detail of documentation) from those for the general surgery-trauma patients. Based on care and documentation requirements, ICU nurses generally manage two patients. Nurses on the general surgery-trauma unit generally care for 6-7 patients.

Demographic data, including gender and race or ethnicity, were collected (see Table 1). All patients were 65 and older; 74/100 were female. A determination of "race" was not offered by 19 of the patients. The medical literature suggests race, gender, and age bias affect the likelihood certain procedures will be performed or processes followed (Chang, Bass, Cornwell, & MacKenzie, 2008; Lehmann, Beekley, Casey, Salim, & Martin, 2008). Therefore, multiple linear and logistic regressions were conducted to determine if these factors predicted the likelihood the preventive measures were performed or omitted.

Instrumentation and Data Collection

A data collection tool (see Figure 1) was developed based on the specific documentation requirements for nursing preventive measures in the hospital's nursing policies. The Lippincott Manual (Nettina, 2010) was the reference used as the practice standard for the policies and included performance and frequency standards for patient assessment, intervention, and evaluation. Where specific frequencies were not specified in the nursing policy, time frames for the data collection tool were determined from the Nettina text. The tool developed included all elements required (either by policy or Nettina text) for the specific preventive measures evaluated (mobility, respiratory management, skin integrity, fall prevention, confusion assessment, and pain management).

Data collection was completed by two registered nurses, each with more than 10 years experience in surgical trauma nursing, who were involved in the development of the tool. The nurses reviewed the nursing documentation of the health records for performance of the nursing preventive measures during the patient's hospital stay. The documentation was determined to be "complete" if all daily entries were present as required by the hospital's nursing policy. It was determined "incomplete" if any nursing policy required entry was missing from the patient's record.

Data Analysis and Results

Descriptive statistics were obtained using SPSS software. Only frequencies were determined for each element of the preventive measures since some of the data elements were obtained only on patient admission and other data were to be documented each shift or even every 2 hours (as with turning). The percentage of complete and incomplete documentation for each preventive measure for the 100 records was determined. No association was found for documentation compliance with the patient demographics of gender or race.

Gaps in the required documentation of some respiratory, mobility, and pain preventive measures were noted (see Table 2). The respiratory preventive measures assessed were coughing and deep breathing, the use of the incentive spirometer, and the performance of provider-ordered respiratory treatments. The documentation compliance for hourly coughing and deep breathing was 16%; for hourly incentive spirometer, 51%; and for ordered respiratory treatments, 87%.

The preventive measures assessed for promotion of mobility were for the patients to be out of bed to the chair and out of bed walking, if indicated by provider order or patient condition. This preventive measure had no discrete policy standard for frequency. The nurse investigators reviewed the records for mobility documentation on each shift, which the investigators determined to be the minimum requirement. The documentation compliance for out of bed to the chair was 81% and for up walking was 54%. The required measures for pain were assessment on admission, assessment and reassessment according to policy, and pain treatment as per policy. The documentation compliance for assessment on admission was 100%; for assessment according to policy, 82%; for reassessment per policy, 41%; and for treated per policy, 100%. Other assessed measures were well documented (see Table 2).


A notable finding in the study was that the patient documentation system used by the facility did not include all of the policy-mandated preventive measures as required entries. The most time-efficient patient charting forms are "flow sheets," which include all required patient data and, as such, provide "prompts" for patient management and documentation. These types of forms serve as a reminder to nurses of what needs to be assessed and documented and only require that the appropriate value be entered or the item be checked as completed. In this study, those measures not required as entries were also those with the lowest documentation compliance (coughing and deep breathing, use of the incentive spirometer, out-of-bed walking, and pain reassessment). Because documentation of these measures were not mandatory entries in the system utilized, compliance would have required nurses to write narrative notes instead of just checking off the measure as performed. Scripting narrative notes would have added considerable time for documentation.

These findings highlight the importance of the relationship between nursing documentation requirements and the system (most often, but not necessarily, electronic) used for the expedient documentation of nursing care. Nursing department policies mandate the type and frequency of preventive measures (and their documentation) and the electronic health record utilized should reflect those policy requirements. Lack of documentation "prompts," and the resultant need for more time-consuming narrative notes, may have contributed to the missing documentation found.

The findings regarding the documentation system were unanticipated by the investigators and may be prevalent in other institutions, as well. This finding may have broader implications for patient outcomes and reimbursement and may be relatively simple to rectify. Making changes in the documentation system, even for institutions still using paper systems, may alone improve the compliance.

Limitations. The study had a number of limitations. First, inter-rater reliability for the patient record monitoring tool was not rigorously established prior to the study. Because the indicators were taken directly from the nursing policy and the documentation was either complete or incomplete, the researchers determined that inter-rater reliability was unnecessary in this instance. The preventive measures evaluated were those dictated by the institution's nursing policies and the investigators agreed to determine documentation to be complete or incomplete based on these requirements. Second, the results are based on the assumption nursing documentation is reflective of performance but that may not be accurate due to a number of factors. Documentation may, or may not, reflect actual performance due to unit acuity level, staffing levels, individual performance, or a host of other reasons.

Future research. Future qualitative studies may be able to determine if, and to what extent, nurses perform procedures but do not document these, or other, actions. Can it be determined if complete documentation is related to the health record itself, or to unit acuity, or to staffing, or to as yet undetermined reasons? Future studies may also be able to establish the outcome value of performing and documenting these or other nursing preventive measures. Considering the time devoted to these measures, the benefit to patients should be established unequivocally if these practices are to continue. Given the projected financial and quality-of-life costs of hospital-acquired complications in the older adult trauma population, additional studies are needed to examine how these complications can be minimized and patient outcomes improved in this group.

In addition, robust data link higher nursing care hours and lower hospital-acquired complications. Because of the CMS directive eliminating reimbursement for hospital-acquired complications, additional studies are needed to examine the real costs of providing more nursing hours. Some data indicate these costs to be significantly offset by reductions in lengths of stay and the elimination of the additional financial burdens normally associated with hospital-acquired complications (Kane et al., 2007; Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2006).

In this study, researchers examined preventive nursing measures directed at decreasing hospital-acquired complications in trauma patients 65 and older. While made more expedient with well-designed documentation systems, documentation of these measures is not the outcome of real importance. Nursing preventive measures are time intensive and currently inadequate evidence exists for the need for their performance when patient outcomes are evaluated. Future nursing research is needed to determine the nursing role in preventing complications in a growing elderly population prone to injury and particularly vulnerable to costly and potentially preventable complications.


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CHRISTINE CUTUGNO, PhD, RN, NEA-BC, is Assistant Professor, Hunter-Bellevue School of Nursing, New York, NY.

MARYANN HOZAK, MSN, RN, NEA-BC, is Director, Innovative Nursing Practice and Quality Outcomes, St. Joseph's Regional Medical Center, Paterson, NJ.

DEBRA L. FITZSIMMONS, MSN, RN, CCRN, ACNP-BC, is Advance Practice Nurse, Medical Intensive Care Unit, St. Joseph's Regional Medical Center, Paterson, NJ.

HULYA ERTOGAN, RN, is Staff Nurse, Medical-Surgical ICU, St. Joseph's Regional Medical Center, Paterson, NJ.
Table 1.
Patient Demographics *

                                          Valid    Cumulative
Gender             Frequency   Percent   Percent    Percent

Valid   Female         74         74        74         74
        Male           26         26        26        100

        Total         100        100       100

                                          Valid    Cumulative
Race/Ethnicity     Frequency   Percent   Percent    Percent

Valid   White          65         65        65         65
        Black           9          9         9         74
        Hispanic        7          7         7         81
        Unknown        19         19        19        100

        Total         100        100       100

Table 2.
Documentation of Nursing Preventive Measures
(N = 100 patients)

                                 Documentation   Documentation
Preventive Measure                 Compliant     Noncompliant


Cough and deep breath                 16              84
Incentive spirometer                  49              47
Respiratory treatments                13               2


Out of bed: Chair                     72               2
Out of bed: Walking                   39              32


Assess on admission                   100              0
Pressure ulcer on admission            4               0
                                  (present on
Pressure ulcer worsened                2               0
Skin assessed daily                   97               0
Reassessed per policy                 48               3
Turned Q2 hours                       77              14
Risk/Ulcer treated per policy          9               3
Falls assessment                      100              0
Risk measures                         100              0


Assessment on admission               100              0
Orientation daily                      9               2


Assessed on admission                 100              0
Assessed per policy                   82              18
Reassessed per policy                 41              59
Treated per policy                    98               2

                                    Not         Total       Percent
Preventive Measure               Applicable   Compliance   Compliance


Cough and deep breath                0          16/100        16%
Incentive spirometer                 4          49/96         51%
Respiratory treatments               85         13/15         87%


Out of bed: Chair                    10         72/90         81%
Out of bed: Walking                  29         39/71         54%


Assess on admission                  0         100/100        100%
Pressure ulcer on admission          96        100/100        100%
                                 (absent on
Pressure ulcer worsened              2         100/100        100%
Skin assessed daily                  3          97/97         100%
Reassessed per policy                49         97/100        97%
Turned Q2 hours                      9          77/91         85%
Risk/Ulcer treated per policy        88          9/12         75%
Falls assessment                     0         100/100        100%
Risk measures                        0         100/100        100%


Assessment on admission              0         100/100        100%
Orientation daily                    0          98/100        98%


Assessed on admission                0         100/100        100%
Assessed per policy                  0          82/100        82%
Reassessed per policy                0          41/100        41%
Treated per policy                   0          98/100        98%

Figure 1.

Geriatric Trauma Documentation Review

Assigned patient log number --
Patient's age -- Gender -- Race --
Admission date -- Admission time -- Location admitted from --
Unit admitted to -- Unit discharged from --
Unit admission time -- Unit assessment time -- Day of the week --
Date of discharge -- Location discharged to --
Primary diagnosis(es) on admission --
Secondary diagnosis(es) on admission --
Pre-existing diseases on admission --

Documentation Of Preventative Measures as Per Policy:

                                           Complete   Incomplete   N/A


1. Cough and deep breathing
2. Incentive spirometer
3. Respiratory treatments


1. Out of bed: chair
2. Walking

Skin Integrity

1. Assessed on admission
2. Pressure ulcer present on admission
3. If present on admission, did it
   worsen during stay?
4. Assessed daily
5. Assessed with change in condition
6. Turning Q 2 hours if immobile
7. Pressure ulcer treated per policy

Prevention of Falls

1. Falls assessment
2. Risk measures in place

Assessment of Orientation

1. Assessment on admission
2. Daily assessment

Pain Control

1. Assessed on admission
2. Reassesses as per policy
3. Treated as per policy


1. Assessed on admission
2. Reassesses as per policy
3. Treated as per policy

Hydration Status

1. Assessed on admission
2. Assessed every 8 hours
3. Plan of care if indicated


1. Documented if present
2. Plan of care if indicated

Foley Catheter

1. Need assessed every shift
2. Catheter care performed

Name of reviewer (print)          Date

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Author:Cutugno, Christine; Hozak, MaryAnn; Fitzsimmons, Debra L.; Ertogan, Hulya
Publication:Nursing Economics
Article Type:Report
Date:Jul 1, 2015
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