Pressure Injuries: Moving from Reporting to Healing Patricia Neal Rehabilitation Center Knoxville, TN Mary Dillon, MD, Medical Director Addie Lowe, MSN, BSN, RN, CNRN, CRRN Nurse Manager Anne Teasley, MS, Certified PPS/Quality Coordinator FIM is a trademark of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. 1 Patricia Neal Rehabilitation Center Opened in 1978 First inpatient rehabilitation center in East Tennessee Named after Academy Award winning actress and stroke survivor Patricia Neal 2 1
Patricia Neal Rehabilitation Center 73-bed CARF accredited facility 10 CARF accreditations Diagnosis specific inpatient programs Stroke, Brain Injury, Spinal Cord Injury Amputee, Ortho, Trauma, Cancer, Neuro, Pediatrics Unique outpatient programs Comprehensive, interdisciplinary outpatient program Custom seating, Augmentative Communication, Assistive Technology Comprehensive Driving Evaluations and Training Neuropsychology IRC Innovative Recreational Cooperative 3 Patricia Neal Rehabilitation Center Located in Fort Sanders Regional Medical Center 541-bed tertiary acute hospital 24-bed Transitional Care Unit 35-bed Long-term Care Unit TJC Comprehensive Stroke Center > 600 physicians in 45 specialties Member of Covenant Health Not-for-profit health system Serving over 26 counties in East Tennessee 9 acute care hospitals Largest private employer in the region (>10,000 employees) > 1,500 physicians Among America s Best Employers in Forbes magazine 2016 for best in large and mid-size employers 4 2
Learning Objectives 1. Describe skin/wound assessment components of IRF-PAI reporting 2. Explain education process for nursing staff, therapist, physicians, and hospital administration for new skin assessment and management program 3. Discuss outcomes and results of new skin assessment and management program 5 CMS Pressure Ulcer Definition A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with a shear and/or friction. 6 3
Pressure Injuries: Moving from Reporting to Healing Background The high cost of treating hospital-acquired pressure injuries (HAPI) and the associated risks to the patient resulted in the addition of required reporting of new/worsened pressure ulcers to CMS IRF Quality Reporting Program, effective 10/1/2012 The cost for a hospital-acquired pressure injury patient averaged $129,248 (stage IV). 7 Pressure Injuries: Moving from Reporting to Healing Background In addition to the financial impact of caring for HAPIs, patients who develop pressure injuries while in a healthcare facility are at risk for a longer length of stay and hospital readmission. Higher mortality rates have also been reported. Approximately 50% of stage II and 95% of stage III and stage IV pressure injuries do not heal within 8 weeks. 8 4
Pressure Injuries: Moving from Reporting to Healing Background Patients with pressure ulcers may demonstrate significantly impaired physical and social function, self care, and mobility. CMS implemented public reporting for IRFs in December 2016. Facilities will want to ensure that reported data accurately represents facility performance. 9 October 2012 October 2014 October 2016 December 2016 Began mandatory report of Stage II IV Pressure Injuries (Data Collection Period) Added voluntary reporting of Stage I, Unstageable, & Suspected Deep Tissue Injuries Change in the IRF-PAI (6 pages to 18 pages) Public Reporting Began (Stage II IV) 10 5
CMS IRF Compare https://www.medicare.gov/inpatientrehabilitationfacilitycompare/ 11 CMS IRF Compare https://www.medicare.gov/inpatientrehabilitationfacilitycompare/ 12 6
Learning Objective #1 Describe skin/wound assessment components of IRF-PAI reporting 13 Admission IRF-PAI 14 7
Discharge IRF-PAI 15 Discharge IRF-PAI 16 8
Discharge IRF-PAI 17 Discharge IRF-PAI 18 9
Learning Objective #2 Explain education process for nursing staff, therapists, physicians, and hospital administration for new skin assessment and management program. 19 Pressure Injuries: Moving from Reporting to Healing Challenges PNRC is located within FSRMC, and has access to the hospital wound care team; however this team was not consistently available during the 3-day admission assessment period required for reporting by CMS. Differing definitions (CMS vs. NPUAP) contributed to inaccuracy of reporting (when using non-rehab staff). The pressure ulcer staging definitions used in the IRF-PAI Training Manual have been adapted from those recommended by the National Pressure Ulcer Advisory Panel (NPUAP) 2007 Pressure Ulcer Stages. IRFs may adopt the NPUAP guidelines in their clinical practice and documentation. However, because CMS has adapted the NPUAP guidelines for IRF-PAI purposes, the definitions do not perfectly correlate with each stage as described by the NPUAP. Therefore, IRFs cannot use the NPUAP definitions to code the IRF-PAI. (IRF-PAI Training Manual) 20 10
Pressure Injuries: Moving from Reporting to Healing Challenges The lack of a clearly defined and consistent process for assessment and documentation of skin findings within the medical record resulted in failure to identify wounds that were present on admission. Variable knowledge and skill level was present regarding and staging of pressure ulcers among team members. o Physiatrists o Consulting physicians and APPs o Hospital wound care nurses o PNRC RNs/LPNs o CNAs o Therapy staff 21 Pressure Injuries: Moving from Reporting to Healing PNRC s Response to Quality Reporting for Pressure Injuries September, 2014: PNRC creates Wound Care RN position (no additional FTE) CMS adapted NPUAP definitions CMS requires skin assessment within 3 days of admit Coordination of care between physician and nursing staff; as well as patient/family education Budget neutral staff position Current FTE employee moved into the position Absorbed a PRN FTE Shift leader on nights pulled into staffing 22 11
Pressure Injuries: Moving from Reporting to Healing Goals Implement an interdisciplinary approach to pressure injury identification and treatment Accurately identify and stage pressure injuries or other problems related to patient skin integrity present on admission (POA). Create a unique plan of care for each patient with loss of skin integrity. Create a skin care education plan to provide nursing staff with a standardized skill set. 23 Pressure Injuries: Moving from Reporting to Healing Goals Interval skin re-assessments completed throughout rehab stay Monitor patients throughout the rehabilitation stay and provide preventative care to avoid loss of skin integrity. Treat developing conditions immediately and aggressively. Accurately assess pressure injuries for discharge reporting 24 12
Pressure Injuries: Moving from Reporting to Healing Now Heal This! 25 Pressure Injuries: Moving from Reporting to Healing PNRC Wound Care RN completes full body skin assessment during 3-day admission assessment period (usually on day of admit) Rehab physician responsible for completing admission and discharge documentation with staging Care plan developed in conjunction with medical staff and interdisciplinary team Care plan carried out by staff nurses under direction of Wound Care RN and medical staff throughout rehab stay 26 13
Pressure Injuries: Moving from Reporting to Healing Patient and family receive education on maintaining skin integrity during rehab stay New nursing staff receive education with Wound Care RN during orientation PNRC Wound Care RN completes full body skin assessment within three days of discharge Root Cause Analysis of all new/worsened pressure injuries 27 Pressure Injuries: Moving from Reporting to Healing Education Plan Key team leaders viewed the CMS Wound Staging presentation, presented at a CMS IRF Provider Training by Dr. Elizabeth Ayello, PhD, RN, ACNS-BC, CWOM, EN, MAPWCA, FAAN in Baltimore, Maryland May 12, 2014 on YouTube. PNRC nursing staff completed the University of Washington School of Nursing Wound Academy, a 14.5-hour online course. Physicians received education through monthly physician meetings and webinars 2016 CMS Provider Training by Ann Spenard, MSN, RN-BC 2017 PNRC nursing staff trained in Covenant Health s Pressure On to Take Pressure Off program 28 14
Pressure Injuries: Moving from Reporting to Healing PNRC Wound Care RN Roles and Responsibilities Stay current on wound care assessment, documentation and reporting Head to toe (nooks and crannies) skin assessment on admission and discharge Detailed documentation of all pertinent skin issues, including charting and photographing Development of treatment plan for any issues involving skin integrity Interval skin reassessments and revisions to skin plan of care Liaison among nursing, physicians, consultants, therapists, case managers, patients, families, and PPS Coordinator Education of new staff Skin resource nurse (rehab and acute hospital units) Physician wrangler Documentation resource (audits, education, FIM ratings, pain, restraints) PRN shift leader/staff nurse 29 30 15
Learning Objective #3 Discuss outcomes and results of new skin assessment and management program. 31 32 16
Pressure Injuries: Moving from Reporting to Healing PNRC s Status In 2013, 22% of pressure injuries POA healed by discharge. In 2015, 63% of pressure injuries POA healed by discharge. In 2016, 67% of pressure injuries POA healed by discharge. PNRC has not had a new/worsened pressure ulcer since May 2015. 33 Pressure Injuries: Moving from Reporting to Healing CMS Provider Review of PNRC The CMS Provider Review release for January 1-June 30, 2014 reported PNRC s rate for new or worsened pressure ulcers to be 0.885%. The CMS Provider Review for January-December 2015 reported a rate of 0.2% for PNRC, compared with the U.S. national rate of 0.8%. The CMS Provider Review for April 2015-March 2016 reported a rate of 0.2% for PNRC, compared with a U.S. national rate of 0.7%. 34 17
Pressure Injuries: Moving from Reporting to Healing January May 2015: 5 New/Worsened (reported to CMS) Root Cause Analysis completed for all 3 were identified on one patient who came from another facility. RCA revealed patient had SDTI POA that was not documented until day 4. Wound later opened and documented as (3) stage III wounds All PNRC nursing staff completed 14.5-hour wound care education course 1 occurred on medically fragile patient who died soon after (stage 2) 1 caused by device rubbing on skin (stage 2) Device altered for better fit CONFIDENTIAL AND PRIVILEGED Tenn. Code Ann. 68-11-272 and 63-1-150 and 42 U.S.C. 299b-21 et seq 35 **4 th Qtr 2014 Began capturing Stage 1, Unstageable, and SDTI in addition to Stage II IV** 36 18
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39 Big Brother is Watching and So are Your Patients 1.000% 0.900% 0.800% 0.700% 0.600% 0.500% 0.400% 0.300% 0.200% 0.100% 0.000% ** No national comparative 0.885% CMS Provider Review 0.8% 0.2% 0.7% 0.2% Jan1 - Jun 30, 2014 January - December 2015 April 2015 - March 2016 PNRC US National Rate 40 20
And sometimes, results lead to recognition 2016 Covenant Health Performance Excellence Award 41 References Lyder, et. al. Hospital-Acquired Pressure Ulcers: Results from the National Medicare Patient Safety Monitoring System (MPSMS) Study. J AM Geriatr Soc 60:1603-1608, 2012 Gramulich, J.F. et al. Healing Pressure Ulcers with Collagen or Hydrocolloid: A Randomized, Controlled Trial. J AM Geriatr Soc 51:147-154, 2003 Brem, et al. High Cost of Stage IV Pressure Ulcers. Amer J of Surg. 200 (4): 473-477, 2010 Pham, et al. Preventing Pressure Ulcers in LTC: A Cost-Effectiveness Analysis. JAMA Internal Medicine 171 (20): 1839-1847, 2011 Pressure Ulcers in America: Prevalence, Incidence, and Implications for the Future: An Executive Summary of the National Pressure Ulcer Advisory Panel. Adv Skin Wound Care 14 (4): 208-215, 2001 National Pressure Ulcer Advisory Panel: Costs of Pressure Ulcer Prevention: Is it Really Cheaper than Treatment? Barbara Braden, PhD, RN, FAAN 2012 Bergstrom N, Horn SD, Smout RJ, et al. The National Pressure Ulcer Long-Term Care Study: outcomes of pressure ulcer treatments in long-term care. J Am Geratr Soc. 2005 Oct; 53 (10): 1721-1729. Franks PJ, Winterberg, H, Moffatt CJ. Health-related quality of life and pressure ulceration assessment in patients treated in the community. Wound Repair Regen. 2002 May-Jun; 10(3): 133-140 42 21
Mary E. Dillon, M.D. Medical Director mdillon@covhlth.com Questions? Addie Lowe, MSN, BSN, RN, CNRN, CRRN Nurse Manager atomlin2@covhlth.com Anne Teasley, M.S. Certified PPS/Quality Coordinator ateasley@covhlth.com 43 22