Innovations to Stop Pressure Ulcers among Patients at Critically High Risk for Pressure Ulcer Development a Multidisciplinary Approach

Transcription

1 Innovations to Stop Pressure Ulcers among Patients at Critically High Risk for Pressure Ulcer Development a Multidisciplinary Approach October

2 Disclosures The speakers have nothing to disclose. Amy Bratta, PT, DPT Julie Rece, MSN, RN, CRRN, CWOCN Marci Ruediger, PT, M.S. Holly Stevens, RD, LDN, CNSC 2

3 Acknowledgements The Pressure Ulcer Prevention Leadership Team Amy Bratta, PT, DPT Christopher Formal, M.D. Robert Kautzman, BSN, Ph.D. Deborah Long, MSN, RN, CRRN Julie Rece, MSN, RN, CRRN, CWOCN Marci Ruediger, PT, MS Other Key Players Patricia Barker, RHIT, CDIP Paul Buttner, RN, BSN, CWON Naoko Otsuji-Miwa, RN, BSN, CRRN, CWOCN Evelyn Phillips, MS, RD, LDN, CDE Pamela Thompson, IT Clinical Systems Manager Skin Champions 3

4 Objectives Participants will be able to: describe a bundle of best practices to prevent pressure ulcers in rehab patients at highest risk. describe methods for safely mobilizing and feeding patients who are at highest risk for pressure ulcers 4

5 About Magee 96 Bed Inpatient Acute Rehab Hospital 5

6 How we got started 6

7 Baseline efforts Strong collaboration - wound care and nutrition High quality tube-feeding supplements Advanced seating capabilities Everyone turned and shifted 7

8 Nursing-Specific Actions Head to toe assessment by RN, WOCN, MD Head of bed WOC Team Weekly full body assessment with photos Shift of WOCN hours 8

9 Foam Barriers for Skin Protection Ointments ph balanced skin cleanser 9

10 Supplies Liberal use of barriers - protect intact skin exposed to stool Elimination of plastic from bed pads and briefs 10

11 Nursing-Specific Communication Staff education Wound care formulary Supply guidelines 11

12 Equipment 12

13 Poop in a Group Nursing supervisor General Rehab Nutrition Nurse manager - SCI Therapy Seating Specialist WOCN Physician Pharmacy Director Front-line nurse BI/stroke 13

14 Physician-Specific Actions Physician champion Assess skin at admission Engage nursing assistants Work with WOCN to identify and stage ulcers 14

15 What is malnutrition? Consensus statement by the Academy of Nutrition and Dietetics & American Society of Enteral and Parenteral Nutrition in 2012 Risk Factors Insufficient energy intake Weight loss Loss of muscle mass Loss of subcutaneous fat Localized or general fluid accumulation Decreased functional status Inflammation present? No Yes Starvation- Related Malnutrition (anorexia nervosa) Acute Disease or Injury- Related Malnutrition (trauma, burn, major infection, TBI) Chronic Disease- Related Malnutrition (renal disease, cancer, Sarcopenic obesity) Jensen GL, Bistrian B, Roubenoff R, Heimburger DC. Malnutrition syndromes: A conundrum vs. continuum. JPEN J Parenter Enteral Nutr. 2009; 33 (6):

16 Statistics on Malnutrition Approximately 30-50% of patients admitted to acute hospitals are malnourished If left untreated, ~2/3 of these malnourished patients will experience a further decline in their nutrition status Malnutrition is associated with a % higher risk for developing a pressure ulcer among other conditions Coats KG, Morgan SL, Bartolucci AA, Weinsier RL. Hospital-associated malnutrition: a reevaluation. J Am Diet Assoc. 1992:93: Giner M et al. In 1995 a correlation between malnutrition and poor outcome in critically ill patients still exists. Nutrition. 1996:12: Braunschweig C, Gomez S, Sheean PM. Impact of declines in nutritional status on outcomes in adult patients hospitalized for more than 7 days. J Am Diet Assoc. 2000; 100: ; quiz IHI.org. Whittington K, et al. J WOCN. 2000;27: Banks M, Bauer J, Graves N, et al. Nutrition. 2010;26: Thomas DR, et al. Am J Clin Nutr. 2002;75: Schneider SM et al, Br J Nutr 2004; 92:

17 Rate of Malnutrition on Admission to Magee Approximately 52% of all Magee patients present with malnutrition & 51% of those patients have at least 1 pressure ulcer reported on admission. 17

18 Clinical Nutrition Innovations - Assess for malnutrition on admission and initiate support - Use tube feeding formulas with liquid modular proteins - Meet at least 80% of protein at admission - Review medications - Other risk factors

19 Nutrition Take-Aways Consult registered dietitian Initiate enteral feeding within first hours Consider PEG tube if unsafe swallow or unable to meet nutrient needs as per dietitian s assessment 19

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21 Skin Peers 21

22 Therapy Innovations 22

23 Therapy Innovations 23

24 Interdisciplinary Innovations 24

25 Collaboration with other providers Bracelets for transported patients Brain-storming with providers from a cardio-thoracic ICU PA Hospital Engagement Network 3 - year collaborative 25

26 Leadership 26

27 Culture Change Moisture dermatitis as stage 0 Sense of urgency related to prevention of skin breakdown Principles of Just Culture applied 27

28 Results to Date Serious Pressure Ulcers per 1000 Patient Days FY 12 FY 13 FY 14 FY 15 28

29 Why did it take so long? 29

30 The Challenge of Wicked New challenges with devices Problems Staff turn-over New patient challenges 30

31 Replication of Process Interdisciplinary work Iterative process Innovation creating solutions Not accepting failure 31

32 Lessons We Learn Again and Again Leadership and accountability matter. Without these - > much work and no improvement Things get unfixed without constant vigilance. Over-communication is a necessity. 32

33 Having Fun While Raising Awareness 33

34 References Carson, D, Emmons K, Falone W, and Preston AM. Development of Pressure Ulcer Program across a University Health System. J Nurs Care Qual. 2011; Vol. 00, No. 00, pp Coleman S, Nixon J, Keen J, et al. A New Pressure Ulcer Conceptual Framework. Journal of Advanced Nursing. 2014; 70(10), Cox, J., and L. Rasmussen. "Enteral Nutrition in the Prevention and Treatment of Pressure Ulcers in Adult Critical Care Patients." Critical Care Nurse 34.6 (2014): Web. DeJong G, Hsieh CJ, et al. Factors Associated with Pressure Ulcer Risk in Spinal Cord Injury Rehabilitation. Am J Phys Med Rehabil 2014; 00:1-16. Edsberg LE, Langemo D, Baharestani MM, et al. Unavoidable Pressure Injury: State of the Science and Consensus Outcomes. J Wound Ostomy Continence Nurs. 2014; 41 (4):

35 References (continued) Hoffer, L. J., and B. R. Bistrian. "Appropriate Protein Provision in Critical Illness: A Systematic and Narrative Review." American Journal of Clinical Nutrition 96.3 (2012): Web. McClave SA, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society Critical Care Medicine (SCCM) and American Society of Parenteral and Enteral Nutrition (ASPEN). JPEN 2016;40(2): National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals: SECOND EDITION: Administrative and financial support provided by Paralyzed Veterans of America Tappenden, K. A., B. Quatrara, M. L. Parkhurst, A. M. Malone, G. Fanjiang, and T. R. Ziegler. "Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition." Journal of Parenteral and Enteral Nutrition 37.4 (2013): Web. 35

36 THANK YOU! BELIEVE MAGEE Rehabilitation if there s a way a will Hospital back Julie Rece, MSN, RN, CRRN, CWOCN jrece@mageerehab.org Marci Ruediger, PT, M.S. mruediger@mageerehab.org Holly Stevens RD, LDN, CNSC hstevens@mageerehab.org