Pressure Injuries: Prevention That Works

Pressure Injuries: Prevention That Works Joyce Pittman PhD, ANP-BC, FNP-BC, CWOCN Indiana University Health Indianapolis, IN jpittma3@iuhealth.org Ann N. Tescher, APRN CNS, CCRN, CWCN, FCCM Clinical Nurse Specialist Surgical/Trauma/CV Surgery ICU, Hyperbaric Therapy, Vascular Wound Center Mayo Clinic, Rochester MN tescher.ann@mayo.edu 2017 National Pressure Ulcer Advisory Panel www.npuap.org Pressure Injuries: Prevention That Works Disclosures: Joyce Pittman AACN grant recipient- Research Impact grant Unavoidable pressure injuries in critical care Smith & Nephew- consultant JWOCN Deputy Editor Ann Tescher None 1

Objectives Describe components of a sustainable pressure injury program. Name 2 exemplars of successful Pressure Injury prevention programs. Describe innovative methods to incorporate into your PIP program. Essentials Components of Pressure Injury (PI) Prevention 1. Pressure injury admission assessment 2. Daily pressure injury risk assessment 3. Daily (routine) skin assessment 4. Moisture management 5. Maximize nutrition 6. Minimize pressure Educate staff, provider, patient, family 2

Essential Components of PI Prevention 1. Evaluate the individual s clinical condition and pressure ulcer risk factors 2. Define and implement interventions that are consistent with individual needs, goals and recognized standards of practice 3. Monitor and evaluate the impact of the interventions 4. Revise the approaches as appropriate (NPUAP, 2010; CMS) SWOT Model Strengths Weaknesses Opportunities Threats 3

Structure- Process- Outcomes To achieve and sustain the lowest possible HAPI rates, you should ask: 1. What structure needs to be in place 2. What process should be implemented and monitored 3. How should outcomes be measured and reports Pressure Injuries: Prevention That Works STRUCTURE- PROCESS- OUTCOMES 4 Magnet Model Domains: 1. Transformational leadership 2. Structural empowerment 3. Exemplary professional practice 4. New knowledge; innovation and improvement. Successful implementation of these elements yields measurable positive outcomes (W. V. Padula, Mishra MK, Makic MB, Valuck RJ, 2014 Apr). 4

Transformational Leadership Key leader stakeholder (VP) appointed to facilitate/support PIP initiatives PIP clinical program facilitator appointed/designated Sets clear expectations for benchmarking, outcomes, and accountability. Removes barriers Transformational Leadership Clear reporting structure and bidirectional communication for the PIP program in the nursing organizational framework identified. Board level (Safety and Risk Board) Nurse Executive Council PPS committee WOC/PIP committee Facility PPC Facility PIP Unit Time and resources for group meetings and projects is supported Supports use of FTE to do the work- system facility unit, and communicates those expectations to all levels. Supports interdisciplinary team development. 5

Structural empowerment PIP Team established: system, facility, unit level, multidisciplinary Bi-directional reporting/ accountability Multidisciplinary: WOC, CNS, RN, RT, PT, RD, Risk, Social Work, Educator (staff/patient), Ethics, Supply Chain, IT Continuum of care:- Acute care, Home Care, Long term care, LTAC Recognition of excellence- system, facility, unit, individual PIP Member role/responsibilities/expectations was established and approved by NEC PIP Education expectations/opportunities- Embedded annual/orientation staff education/competencies, WTA program CAP Conference presentations/attendance Exemplary professional Practice Evidence-based PIP protocol, plan of care, order sets developed and embedded into EMR. PIP is hard-wired into care at the bedside but also ancillary areas- OR, ED, transportation- safe handoff, order sets, triggers, etc.. HAPI prevalence/processes benchmarking Monthly rather than quarterly. Transparent at unit level. PI integration into IT- quality data reports, triggers, e-measures EMR design triggers specific nursing interventions based on risk assessment EMR generates daily/real time PU occurrences Moving toward meaningful data- incidence rather than prevalence Culture of Safety through standardized Root Cause Analysis process NPUAP RCA template Avoidable versus unavoidable HAPI 6

Pressure Ulcer Prevention Do No Harm through Elimination of Hosptial Acquired Pressure Ulcers Yes Assess skin Document POA within 24 hrs Complete Braden risk and skin assessment Braden < 18 or POA Implement skin/ wound interventions/ orders based on risk Initiate Phase 1 and 2 of skin care prevention PPOC Evaluate skin based on implemented interventions Risk or skin integrity changed No Continue skin plan of care No Surface selection Initiate Phase 1 and 2 of skin care prevention PPOC Yes Keep turning Evaluate skin Incontinence/ moisture management Risk or skin integrity changed Nutrition No Continue PU prevention plan of care Process Measures: 1. 100% skin assessment completed and documented POA within 24 hours 2. 100% accuracy with wound order set completion based on risk Standard Work Requirement (discussed in huddles/bedside report, etc) 1. Skin wound orderset included in admission packet and placed on every chart 2. Assess risk with Braden and anytime change in status 3. Complete skin wound orderset based on risk 7

Save our SKIN! 3/11/2017 Did you know? HAPU care can cost up to $70,000 Patients with a HAPI have a 2-6 times greater mortality risk 70% of pressure ulcers occur in patients over 70 years of age BUNDLE these pieces together When completed TOGETHER, they are more effective! Document your skin assessment on admission and every shift. Assess your patient s Pressure Injury Risk by documenting their BRADEN SCORE within 4 hours of admission and every shift. 1) Braden Risk completed on admission & every shift 2) Skin assessment on admission & every shift Revise interventions according to patient condition N Nutrition Addressed S Surface Appropriate K Keep turning Q2hrs includin g devices I Incontinence Management (Breathable pads &/or moisture barriers) Commit to putting ALL of the pieces together to prevent HAPI Data- Communicating Results 8

New knowledge; innovation and improvement Research activities- WOCN grant recipient x 3- BMS RCT, BMS translation into practice, PIPI Device-related HAPI- AACN grant recipient/webinar Nov 2014 Soft silicone dsg as prevention- cost savings of $271,000- $1,972,100 WOC Team redesign- IUH Quality award Supports EBP projects to improve PIP- WTA program EBP projects PIP and linen use PIP and progressive mobility PIP and Braden risk assessment PIP and support surface Supports publication of clinical work- journal articles, abstract submissions, poster presentations, podium presentations. Recognizes innovation- standing agenda item (tests of change) Promotes PIP beyond organization, into the community- WTA Community Program Greetings from Mayo Clinic Rochester 9

One Size Does NOT Fit All Structure Elements Stability of Clinical Staff Experts near the Front Lines Presence and Sophistication of Electronic Health Record Materials Management and Purchasing Department Administrative Support Legal Department liaison 10

Process Elements Assessment CWOCN/CWCN/CNS Wound Therapy Technicians Expert Staff Nurses Skin Savers Teams on the Units Availability of Educational Offerings Physical Therapy Wound Specialists (CWS) Staging (Are we all speaking the same language?) Process Elements Communication Electronic Notifications through the EHR Types of Notifications Braden Scores for high risk patients Certain types of skin alterations Clinical Cameras Data security Technical expertise Accessibility Multidisciplinary Team Notification 11

Process Elements Materials Management and Purchasing Contracts Nursing Supply Value Analysis Committee Multi-disciplinary Administrative Support Resource Commitment (It Takes a Village) Pressure Ulcer Prevention Work Group Event Analysis Personnel Support for Education Process Elements Interventions Skin Care Bundles for Prevention Risk and skin assessments Progressive mobility Moisture management Nutrition Treatment Algorithms Process Measures Monitoring Standardized but customizable care plans Follow up compliance reports 12

Process Elements Interventions Evidence Based Practice (the never-ending story) Dressings Silicone border Bed Surfaces Support Surface Standards Initiative (S3I) Building the Body of Evidence Non-Contact Ultrasonic Mist Therapy Turning schedules and reminders Process Elements Event Data Analysis Medical Device Related Pressure Injuries Compression Wraps Continuous Positive Airway Pressure (CPAP) masks Cervical Collars Translational Research 13

Research and QI: Pay it Forward Cervical Collars Tescher AN, Rindflesch AB, Youdas JW, Jacobson TM, Downer LL, Miers AG, Basford JR, Cullinane DC, Stevens SR, Pankratz VS, Decker PA. Range-of-motion restriction and craniofacial tissue-interface pressure from four cervical collars. J Trauma. 2007 Nov; 63(5):1120-6. PMID:17993960. DOI:10.1097/TA.0b013e3180487d0f. Braden Scale Scores Tescher AN, Branda ME, Byrne TJ, Naessens JM. All at-risk patients are not created equal: analysis of Braden pressure ulcer risk scores to identify specific risks. J Wound Ostomy Continence Nurs. 2012 May-Jun; 39(3):282-91. PMID:22552104. DOI:10.1097/WON.0b013e3182435715. Anti-Shear Technology CPAP Masks Pre-hospital Transport Anti-Shear Technology CPAP Masks 14

Anti-Shear Technology Pre-Hospital Transport There s got to be a pony in here somewhere 15

Conclusion An effective and sustainable PIP program can be developed using the four Magnet Model domains of: Transformational leadership Structural empowerment Exemplary professional practice New knowledge; innovation and improvement. Successful implementation of these elements yields measurable positive outcomes.(w. V. Padula, Mishra MK, Makic MB, Valuck RJ, 2014 Apr) References Agency for Healthcare Research and Quality (AHRQ). (2011 July). AHRQ toolkit helps to prevent hospital-acquired pressure ulcers: Research Activities. Rockvill, MD: AHRQ. Berwick, D. M., Calkins DR, McCannon CJ, Hackbarth AD. (2006 Jan). The 100,000 lives campaign: setting a goal and a deadline for improving care quality. JAMA, 295(3), 324-327. Black, J. M. (2005). National Pressure Ulcer Advisory Panel: Moving toward consensus on deep tissue injury and pressure ulcer staging. Adv Skin Wound Care, 18, 415. Clark, M. L. (2006 Jun). The Magnet Recognition Program and evidence-based practice. J Perianesth Nurs, 21(3), 186-189. Creehan, S.; Cuddigan,J.; Gonzales, D.; Nix, D.; Padula, W.; Pittman,J.; Pontieri-Lewis, V.; Walden, C.; Wells, B.; Wheeler, R. The VCU Pressure Ulcer Summit-Developing Centers f Pressure Ulcer Prevention Excellence: A Framework for Sustainability. J Wound Ostomy Continence Nurs. 2016;43(2):121-128 Donabedian, A. (1992). Quality assurance. Structure, process and outcome. Nurs Stand, 7(11 Suppl QA), 4-5. Duncan, K. (2007). Preventing Pressure Ulcers: The Goal is Zero. The Joint Commission Journal on Quality and Patient Safety, 33(10). Kelleher, A. D., Moorer, A., & Makic, M. F. (2012). Peer-to-peer nursing rounds and hospitalacquired pressure ulcer prevalence in a surgical intensive care unit: a quality improvement project. J Wound Ostomy Continence Nurs, 39(2), 152-157. doi: 10.1097/WON.0b013e3182435409 LeMaster, K. (2007). Reducing Incidence and Prevalence of Hospital-Acquired Pressure Ulcers at Genesis Medical. The Joint Commission Journal on Quality and Patient Safety, 33(10). Lyder, C. H., Grady J, Mathur D, Petrillo MK, Meehan TP. (2004). Preventing pressure ulcers in Connecticut hospitals by using the plan-do-study-act model of quality improvement. Jt Comm J Qual Safe, 30(4), 205-214. Morton, A., Mengersen K, Waterhouse M, Steiner S. (2010). Analysis of aggregated hospital infection data for accountability. J Hosp Infection, 76(4), 287-291. National Database of Nursing Quality Indicators; Pressure Injury Training Modules, version 5; Retrieved February 9, 2017. https://members.nursingquality.org/ndnqipressureulcertraining/ 16

References National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009. Padula, W. V., Mishra MK, Makic MB, Sullivan PW. (2011 Apr). Improving the Quality of Pressure Ulcer Care with Prevention: a cost-effectiveness analysis. Med Care, 49(4), 385-392. Padula, W. V., Mishra MK, Makic MB, Valuck RJ. (2014 Apr). A Framework of Quality Improvement Interventions to Implement Evidence-Based Practices for Pressure Ulcer Prevention. Adv Skin Wound Care, (In Press). Padula, W. V., Mishra MK, Weaver CD, Yilmaz T, Splaine ME. (2012 Jun). Building Information for Systematic Improvement of the Prevention of Hospital-acquired Pressure Ulcers with Statistical Process Control Charts and Regression. BMJ Quality & Safety, 21(6), 473-480. Padula, W. V., Wald, H. M., & Makic, H. M. (2013). Pressure ulcer risk assessment and prevention. Ann Intern Med, 159(10), 718. doi: 10.7326/0003-4819-159-10-201311190-00016 Pappas, S. (2008). The Cost of Nurse-Sensitive Adverse Events. JONA, 38(5), 230-236. Ratliff, C. R., Bryant DE. (2003). Guideline for prevention and management of pressure ulcers WOCN clinical practice guideline; no. 2 (Vol. 2, pp. 52). Glenview, IL: Wound, Ostomy, and Continence Nurses Society (WOCN). Ratliff, C. R., & Tomaselli, N. (2010). WOCN update on evidence-based guideline for pressure ulcers. J Wound Ostomy Continence Nurs, 37(5), 459-460. doi: 10.1097/WON.0b013e3181f17cae Centers for Medicare and Medicaid Services (CMS). Overview of hospital-acquired conditions (present on admission indicator). Retrieved 3/13/2012 from: http://www.cms.gov/hospitalacqcond/01_overview.asp#topofpage References Armour-Burton, T., Fields, W., Outlaw, L., Deleon, E. The Healthy Skin Project: Changing Nursing Practice to Prevent and Treat Hospital-Acquired Pressure Ulcers. Critical Care Nurse. June 2013. 33(3): 32-40. Bergstrom, N., Horn, S., Rapp, MP, Stern, A., Barrett, R., Watkiss, M. Turning for Ulcer ReductioN: A Multisite Randomized Clinical Trial in Nursing Homes. JAGS. October 2013. 61(10):1705-1713. Call, E., Pedersen, J., Bill, B., Black, J., et al. Enhancing Pressure Ulcer Prevention Using Wound Dressings: What are the Modes of Action?. INT WOUND J. Aug2015; 12(4):408-413. Chaboyer, W., Gillespie, BM. Understanding nurses views on a pressure ulcer prevention care bundle: a first step towards successful implementation. Journal of Clinical Nursing. February 2014. 23, 3415-3423, doi:10.1111/jocn.12587. Chou, R., Dana, T., Bougatsos, C., Blazina, I., et al. Pressure Ulcer Risk Assessment and Prevention. Annals of Internal Medicine. 2 JUL 2013. 159(1): 28-39. Coyer, F., Gardner, A., Doubrovsky, A., Cole, R., et al. Reducing Pressure Injuries in Critically Ill Patients by Using a Patient Skin Integrity Care Bundle (InSPiRE). American Journal of Critical Care. May 2015. 24(3): 199-210. Crawford, B., Corbett, N., Zuniga, A. Reducing Hospital-Acquired Pressure Ulcers: A Quality Improvement Project Across 21 Hospitals. J Nurs Care Quality. 29(4):303-310. Dellefield, ME, Magnabosco, JL. Pressure Ulcer Prevention in Nursing Homes: Nurse Descriptions of Individual and Organization Level Factors. Geriatric Nursing. 35 (2014) 97-104. Gillespie, BM, Chaboyer, W., Sykes, M., O Brien, J., Brandis, S. Development and Pilot Testing of a Patient-Participatory Pressure Ulcer Prevention Care Bundle. J Nurs Care Qual. 29(1): 74-82. Hopper, MB, Morgan, S. Continuous Quality Improvement Initiative for Pressure Ulcer Prevention. J WOCN. March/April 2014;41(2):178-180. 17

References Olsho, LEW, Spector, WD, Williams, CS, et al. Evaluation of AHRQ s On-Time Pressure Ulcer Prevention Program: A Facilitator-assisted Clinical Decision Support Intervention for Nursing Homes. Mecal Care. March 2014;52(3):258-266. Padula, WV, Makic, MB, Mishra, MK, et al. Comparative Effectiveness of Quality Improvement Interventions for Pressure Ulcer Prevention in Academic Medical Centers in the United States. Joint Commission Journal on Quality and Patient Safety. June 2015;41(6):246-256. Padula, WV, Valuck, RJ, Makic, MB, Wald, HL. Factors Influencing Adoption of Hospital- Acquired Pressure Ulcer Prevention Programs in US Academic Medical Centers. J WOCN. July/August 2015;42(4):327-330. Santamaria, N., Gerdtz, M., Sage, S., McCann, J., et al. A Randomized Controlled Trial of the Effectiveness of Soft Silicone Multi-layered Foam Dressings in the Prevention of Sacral and Heel Pressure Ulcers in Trauma and Critically Ill Patients: The Border Trial. INT WOUND J. 2015; 12:302-308. Tayyib, N., Coyer, F., Lewis, PA. A Two-Arm Cluster Randomized Control Trial to Determine the Effectiveness of a Pressure Ulcer Prevention Bundle for Critically Ill Patients. Journal of Nursing Scholarship. 2015;47(3):237-247. Yap, TL, Kennerly, SM, Simmons, MR, et al. Multidimensional Team-Based Intervention Using Musical Cues to Reduce Odds of Facility-Acquired Pressure Ulcers in Long-Term Care: A Paired Randomized Intervention Study. JAGS. 2013;61(9):1552-1559. Prevention That Works 18