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 Case Reports Better in Preventing Falls than Charting, Duke Study Says

A new study in JAMDA says, “clinical vignettes,” or case reports, completed by the staff of skilled nursing facilities (SNFs) are better at preventing repeat falls by residents than the traditional chart abstraction process measures. Authors of “Resident Vignettes for Assessing Care Quality in Nursing Homes” compared traditional resident chart abstractions with vignettes to assess fall rates for quality improvement purposes.

JAMDA is the journal of AMDA – The Society for Post-Acute and Long-Term Care Medicine.

Chart abstraction means that a trained staff member (usually a nurse) reads through a patient’s chart or electronic medical record to determine what care has been provided. “In our case they looked for what fall prevention care was done; for example, decreasing risky medicines or starting physical therapy,” says Cathleen Colon-Emeric, MD, a geriatric medicine specialist at the Duke University School of Medicine and one of the report’s authors.

But as part of the study, SNF staff were asked to complete two clinical vignettes before and right after a falls quality improvement intervention, for a maximum of four vignettes over three months. “Vignettes were derived from resident stories constructed by demographic characteristics and the presence or absence of fall-related risk factors, such as prior falls,” the JAMDA report said.

The vignettes are included in a standardized form allowing clinicians to tell the story of the patient involved, as well as to rank on a scale of 0 to 10 the care given for a resident. For example, the form asks if there was a blood pressure measurement taken of the resident while he or she was lying down, sitting down, or standing to see if the reading dropped, or if a bed or chair alarm is in use. Other rankings asked if the resident’s shoes or socks are safe, or if the bed was lowered to a mat placed next to the bed.

Duke researchers discovered that two of four fall prevention process measures assessed by clinical vignettes, specifically environmental modification and comorbidity management, explained 7 percent to 10 percent of the variation in resident- and facility-level recurrent fall rates.

“The authors concluded that clinical vignettes offer a promising alternative to chart abstraction for measuring nursing home quality. Not only were they acceptable to staff, but they were simple to administer and analyze,” the report said.

Beyond those factors, the report said chart abstraction was time-consuming and required many resources. Vignettes, on the other hand, use standardized patient examples, eliminating the need to adjust for different risk factors that are necessary for chart abstraction.

This could result in vignettes being especially cost-effective for complex conditions that require multiple process measures and case-mix adjustment.

“It would be useful to determine whether vignette measures can distinguish differences in care quality between nursing units within the same facility so that quality improvement efforts can be targeted to those with lower performance,” the authors said, noting more study needs to be completed before that question is answered.

Still, researchers concluded that clinical vignettes completed by nursing center staff were more feasible than traditional chart abstraction process measures.

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