Maryland Patient Safety Center s Call for Solutions Submission. Organization: Atlantic General Hospital

Transcription

1 Maryland Patient Safety Center s Call for Solutions Submission Organization: Atlantic General Hospital Solution Title: Using the Evolution of Data Collection Methods 2 Drive Revolution in the Reduction of Hospital Acquired Pressure Ulcers Program/Project Description, including Goals: What was the problem to be solved? How was it identified? What baseline data existed? What were the goals how would you know if you were successful? A review of Nursing Quality Indicators by researchers suggests about 8% of hospital patients are at risk for developing a pressure ulcer and that the prevalence of hospital acquired pressure ulcers (HAPUs) ranges from % nationally. Additionally, 16.7% of patients entering the hospital with a pressure ulcer developed at least one new pressure ulcer during their hospitalization (NDNQI, 2010). In 2011, Atlantic General Hospital (AGH) was outperforming these published NDNQI benchmarks for HAPU prevalence and was meeting the clinical outcome standards of American Nurses Credentialing Center s Magnet Recognition Program. Administrators and nurse leaders were caught off guard in late 2011 when Maryland released their Potentially Preventable Conditions (PPC) report, which identified that AGH patients were experiencing a higher than expected incidence rate of developing HAPUs. The subsequent analysis of our HAPU data demonstrated the need to move from focusing on HAPU prevalence data to actual incidence. HAPU prevalence data proved that on the day of the month we surveyed all our patients, we found very few HAPUs. What prevalence data failed to reveal is all the other days that same month where a patient could have suffered through the incidence of just one HAPU. Despite outperforming national benchmarks in HAPU prevalence and meeting Magnet standards, our analysis exposed an incidence rate of HAPUs Stage II & Above per 1000 Patient Days in our Critical Care Unit and an incidence rate of 1.58 on our Med/Surg Units. No longer was it good enough for AGH to just outperform what we thought were the most robust published benchmarks available for HAPUs. Instead, we chose a patient-centered approach by focusing on each and every HAPU incidence. Our goal was to reduce the incidence of unit acquired pressure ulcers (UAPUs) as evidenced by three consecutive months without incidence of UAPUs on Critical Care and Med/Surg units by December 31, Process: What methodology or process was used to develop the Solution? An interdisciplinary Skin Wound Assessment Taskforce (SWAT) met monthly and included nurse leaders, direct care nurses and techs, as well as support staff from dietary, risk 1

2 management, medical records, imaging, and respiratory. Leadership of the SWAT was shared by a direct care nurse serving as the Chair, a certified wound nurse serving as a consultant, and a nurse administrator serving as the data analyst. After completion of the team s charter, the SWAT leaders initially met weekly to research evidence-based practices in the reduction of HAPUs and to develop an action plan using a framework for implementation that was provided by the Advisory Board (2007) titled Putting Perfection into Practice. AGH would be remiss not to include credit to Sandra Murray, who presented at the Maryland Patient Safety Conference in 2012, and clearly, concisely and cogently defined in her presentation the need to use both a family of measures and run charts to accurately determine if there is actual performance improvement when analyzing data. From there, AGH recognized that our HAPU data collection needed to evolve from focusing on prevalence, to incidence, then to rare event. Solution: What solution was developed? How was it implemented? The SWAT first assessed all the current HAPU data collection methods and benchmarks. We started with our most accurate data collection method at the time which was the team s monthly HAPU prevalence studies and began creating the appropriate run charts needed for improvement analysis. Although we no longer placed value in the NDNQI prevalence benchmarks when it came to measuring our performance improvement for this initiative, we also knew that current incidence data was dependent upon direct staff completing a system improvement report. An automated report capturing all HAPUs coded by Medical Records was written and was disseminated monthly to risk management staff and the wound care nurse. Risk management staff then validated each coded HAPU against the system improvement reports that were generated by front line staff to assure that we were capturing each and every incidence, allowing us to begin analyzing our performance improvement against actual incidence. Through the collaboration of SWAT members from quality, risk management, and medical records, as well as nursing, we revised the systems improvement reports for HAPUs to include hard stops on certain data fields, which required direct care staff to input the data we would need for further analyze each incidence. Mini root cause analysis (RCA) forms were then completed by risk management staff on every incidence and SWAT members kept looking for additional opportunities for improvement, beyond the published evidence-based practices we had already implemented and the traditional methods used to reduce pressure ulcers in healthcare. One such example included the discovery that 5 out of 6 patients experiencing Deep Tissue Injuries while in our care had all been transported to our imaging department for CT scans. Through further analysis and collaboration with SWAT members from imaging, we identified the risk of harm from delayed CT scans where high-risk patients were left on specialty mattress 2

3 surfaces that were unplugged while they waited for their procedure. We were also able to address the potential of skin shearing during the transfer of patients to the imaging table. Another example of discovered opportunities through incidence analysis was based on patient length of stay data. The mini RCA data on every incident revealed that over 70% of our HAPUs were occurring on patients with an average length of stay greater than 4 days. While both common sense and evidence-based practice told us that co-morbid and more acutely ill patients had a higher risk of developing HAUPs, we now had evidence that enabled us to address a targeted patient population. We put a process in place for the wound care nurse to daily work with direct care staff to assess the need for a specialty mattress surface for any patient with a length of stay greater than four days. Measurable Outcomes: What are the results of implementing the Solution? Provide qualitative and/or qualitative results to the data. (Please include graphs, charts, or tools.) By December 31, 2012, we had met our goal for both our Critical Care and our Med/Surg units and had reduced the incidence of unit acquired pressure ulcers (UAPUs) as evidenced by three consecutive months without incidence of UAPUs. The evolution of our data collection methods, combined with the implementation of evidence-based practices, drove us 2 revolution in the reduction of HAPU and we can now say that HAPUs are now rare events at AGH. 3

4 4

5 Sustainability: What measures are being taken to ensure that results can be sustained and spread? Performance data on HAPUs continues to be monitored at the incidence level and continues to be validated through automated reports released through Medical Records and AGH s incidence reporting system, as well as through Maryland s quarterly PPC report. In the rare event that an acquired wound does occur, nurse leaders are to complete a mini root cause analysis and are held accountable through monthly review at a meeting focused on quality outcomes specific to patient care services. This incidence review is then included in a quarterly bottom line report from patient care services to our Organizational Quality Committee and on to our Board Quality Committee. AGH continues to participate in prevalence studies at least quarterly, not because AGH considers the data as demonstrating our performance improvement, rather because AGH desires to contribute and include our performance data in national databases publishing future HAPU benchmarks. Expanding beyond the reduction of acquired pressure ulcers in acute care, AGH has now joined a pilot program with Healogics to implement a robust model to improve wound outcomes across the care continuum and mirror the Clinical Practice Guidelines of our outpatient wound management program. Desired outcomes of this model will include not only the sustainment of our reduction in the incidence of acquired pressure ulcers, but also a reduction in the average length of stay and readmission rates for patients with any wound type. Role of Collaboration and Leadership: What role did teamwork and collaboration play in the Solution? What partners and participants were involved? Was the organization s leadership engaged and did they share the vision for success? How was leadership s support demonstrated? Collaboration between support departments such as imaging, respiratory, quality, risk management and direct care staff has led to the evolution of HAPU data collection methods and a successful performance improvement in this incidence-based and patient-focused approach. The VP of Patient Care Services provided vision and directive to SWAT leadership and the nurse leaders empowered direct care staff to be engaged in the SWAT and provided the resources and support needed to implement interventions based upon evidence-based practices and data analysis. Specifically, the VP of Patient Care Services routinely met with SWAT leadership to review the action plan, address barriers and re-define processes as needed. One such example was during the review of our mattress surfaces. The VP of Patient Care Services reviewed the cost analysis of our mattress surfaces and overlays and the SWAT recommendation to buy all new mattress surfaces and then gained the necessary approval through our Board Finance Committee to purchase the recommended mattress surfaces. This collaboration of the SWAT with nursing 5

6 leaders enabled AGH to re-allocate the $40,000 annual spend on mattress overlays to purchase all new mattress surfaces, assisting us in reducing the potential for patient harm from HAPUs. Innovation: What makes this Solution innovative? What are its unique attributes? While many healthcare organizations participate and contribute to national databases on HAPU prevalence, very few have evolved from using prevalence to using incidence data collection methods to successfully drive the revolution in the reduction of HAPUs. Additionally, AGH remains on the cutting edge of improving wound outcomes across the care continuum and looks forward in participating in a pilot program to further expand our success in the reduction of readmission rates and average length of stay for our patients with any type of wound. Related Tools and Resources: Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers, Murray, S., Using Data for Improvement: Make it real, keep it simple. Maryland Patient Safety Center s Annual Conference, April National Database of Nursing Quality Indicators (NDNQI) 2010 Pressure Ulcer Surveys, which included data from 1,419 hospitals and 710,626 patients. The Advisory Board Company Nursing Executive Center. Putting Perfection into Practice: Achieving and Sustaining Zero-Defect Quality Goals, The Advisory Board Company Nursing Executive Center. Safegaurding Against Nursing Never Events: Best Practices for Preventing Pressure Ulcers and Patient Falls, American Hospital Association, Coding Clinic: Fourth Quarter 2008, pp , Contact Person: Jeanette Troyer, MSN, RN, NE-BC Title: Performance Management Coordinator & Data Analyst jtroyer@atlanticgeneral.org Phone: