August Pressure Ulcers A Never Event

Transcription

1 August 2010 Pressure Ulcers A Never Event Pressure ulcers (PU) have recently evolved on the local and national scene to include much more than the historical decubitus ulcers of old. They have come to include all pressure mediated skin and underlying tissue injuries, including those caused by devices. Importantly, they are usually considered to be preventable; the inference, therefore, is that PU presence is a patient safety concern. The state of California, for instance, has included acquired high stage PU (Stage 3 and 4) as a Never Event, which is reportable to the CDPH. The scope of the problem is large, as evidenced by PU being the most commonly reported Never Event by CHCA hospitals (see Figure below), not to mention all hospitals in California. CHOC over the past year has developed a comprehensive skin assessment and treatment program, designed to detect (including risk) and treat PU, beginning at admission. Preexisting PU are not reportable events for the detecting institution. We just concluded a CHCA Collaborative to develop and share best practices among children s hospitals across the U.S. There has been extensive training of nursing staff and physical therapists. Five additional nurses and physical therapists have been formally trained in PU evaluation and management, and a specialized skin care team with daily availability is in formation. The CUBS team now monitors daily all reports of skin breakdown, for quick intervention. Numerous equipment and treatment options are either in place or undergoing evaluation, while many ineffective treatment choices of old have been discarded. Skin breakdown risk is objectively assessed for all inpatients; unfortunately the tool is specific but not sensitive, and thus a more comprehensive risk tool is in development at CHOC. From a physician perspective, Dr. Dan Jaffurs of Plastic Surgery has become the point person, evaluating patients with potential deep i.e., full thickness, or Stage 3 or 4 PU, and providing education to the residents and hospital staff. Expanded education to the Medical Staff and outside physicians is in planning, including an upcoming Grand Rounds. In the near future, an additional Link will be placed in PowerChart with PU resource documents. As a CHOC physician, be aware that nursing will notify you if there is a suspected PU in your patient; however, it is not the expectation that you are the expert. The appropriate personnel to assess and care for the patient will be engaged. One of the most important things we can do is to assess for and document all skin breakdowns present at admission (POA) to the institution, including outpatient evaluations. Documentation of POA must occur with 24 hours. Working collaboratively with the bedside team, most PU can be prevented and/or treated to prevent progression. 1 of 5

2 Family Activated RRT Effective June 2nd, the CHOC Rapid Response Team program added an additional patient safety upgrade by implementing family activation of the Rapid Response Team. Upon admission to non ICU areas, families are educated that, should usual escalation through the healthcare team prove unsatisfactory in resolving the patient s perceived clinical deterioration or concern, they can call the CHOC Operator via a dedicated phone number (x5433) to request an RRT. The Operator confirms the clinical nature of the request, and an RRT is paged overhead. This program completes the comprehensive inpatient program of patient deterioration recognition started with the RRT and enhanced by the Pediatric Early Warning System (PEWS). It is in keeping with the Institute of Medicine (IOM) quality domain of Patient centered (family centered in Pediatrics) care. Please direct questions to Nicole Ryan RN, BSN, CPN; Neuroscience Unit Manager, x of 5

3 SRS Shortcut on PowerChart Links Tab As requested by the Medical Staff, easy access to the electronic Safety Reporting System (SRS) has been implemented as the latest shortcut under the Links tab on Power Chart (above). When signed in to PowerChart, clicking on Links, then clicking on the SRS icon links you directly to the SRS input page (see above, which is the current array of extremely helpful and efficient PowerChart Links shortcuts). Recall that although SRS reports can be filed anonymously, there naturally can be no follow up input provided in that format. As always, safety concerns can be telephonically generated by calling x3222 and leaving a message. The SRS system also remains accessible via PAWS, under Web Tools, without having to log in to PowerChart. CA BSI status July 30, 2010 CHOC continues its vigilant quest to reduce and/or eliminate catheter associated bloodstream infections (CA BSI). The results above demonstrate a new organizational best, by CVICU, of 241 days between infections, and counting. The PICU is not far behind at 208 days, approaching its all time best performance. The CA BSI program emphasizes the three major components of 1) Ideal sterile central line placement; 2) Strict line management and 3 of 5

4 maintenance protocols; and 3) Central line discontinuation as soon as clinically appropriate. Regarding the latter, a CDPH (and common sense) requirement is a daily discussion amongst health care team members as to the need for continued central line access, which is documented in the medical record (medical or nursing). Another related initiative has been monitoring of chlorhexidine gluconate (CHG) skin prep use in the OR during placement of surgical central lines (i.e., Broviacs), which is identified as best practice. The Figure below demonstrates the significant progress in this relatively new focus area by the Pediatric Surgeons. Congratulations to all. CA Medical Board Notice to Consumers Regulation Effective June 27, 2010, a new regulation, mandated by Business and Professions Code Section 138, went into effect requiring physicians in California to inform their patients that they are licensed by the Medical Board of California, and include the Board's contact information. The information must read as follows: NOTICE TO CONSUMERS Medical doctors are licensed and regulated by the Medical Board of California (800) The purpose of this new requirement (Title 16, California Code of Regulations section ) is to inform consumers where to go for information or with a complaint (or compliment Ed.) about California medical doctors. Physicians must make this information available to patients/families by using signage, signed attestation, or including in commonly used documentation, like History assessments, Conditions of Treatment, or Discharge Instructions. This applies to all physicians settings, notably including private practice offices. 4 of 5

5 At CHOC, signage containing the above language is visible in all Outpatient Clinic and Admission areas (if you see such an area where it is lacking, please let us know). Earlier this summer, we sent an electronic version of the above content for use in private practice signage to all Medical Staff members. 5 of 5