Pressure Injury Quality Imprvement Strategies M A R G A R E T W I L B E R, R N, B S N S H A R O N M O O R E ANP- B C, W O C N B R I A N L E H M A N O C T O B E R 1 7, 2 0 1 7
Pressure Injury Quality Imprvement Strategies Cathlic Health LIFE pened Nvember 1, 2009 Occurrence reprting-falls Falls Perfrmance Imprvement Team 2010 fall rate 19.51% 2016 fall rate 12.34%
Pressure Injury With increasing enrllment there were increased reprted pressure injuries Factrs driving LIFE t address this trend: 1. Changes t Level II reprting in 2013, 2014 & 2015 Level II Pressure Injuries LIFE Level II reprts
2012 & 2014 CMS Survey Findings 2. CMS audits resulted in findings fr SDY04-Participant Assessment, which als drve the standardizatin f surveillance and assessment CMS fund that the Hme Health Assessments were cmpleted by the clinic nurse. CMS required the Hme Health RN Assessment in the hme after enrllment including a skin check The crrective actin plan included ne assessment t be cmpleted by the cmmunity RN in the hme and the secnd assessment t be cmpleted by the Center RN This is in additin t the RN assessment cmpleted at enrllment
Wund Perfrmance Imprvement Team In 2014 a Wund Perfrmance Imprvement Team was created GOALS: Critically analyze the wund prcess and wund utcmes Review and analyze the rate f SNF vs. Cmmunity pressure injuries fr 2012 and 2013 t develp a reductin rate fr 2014 Nurse Practitiner t becme wund certified Develp a prcess t identify participants at risk upn admissin, when there is a decrease in mbility and upn discharge frm a hspital r SNF Develp interventins t address risk
Wund Perfrmance Imprvement Team Early Effrts Weekly Wund meeting Revise Skin Assessment & Pressure Injury Preventin Plicy & Prcedure 2013 audit determined that the Braden Tl did nt predict risk, fr thse participants that develped a pressure injury
Wund Perfrmance Imprvement Team Systems and Prcess The team: Develped a standardized nursing wund prgress nte Develped standards f wund measurement Develped a cnsent frm fr wund phtgraphy Revised the P & P: All participants have a full RN assessment t include cmpletin f the Braden Scale and PIPT at enrllment, 6 & 12 mnths r with a significant change in cnditin Fllw up hme visits include a full skin examinatin, educatin, ensuring a treatment plan is in place including apprpriate DME Once the participant has reached a 6 mnth reassessment withut a reccurrence, the plan can be re-evaluated in cncurrence with the PCP staff These assessments enable the IDT t priritize apprpriately and aggressively care plan pressure injury risk and pressure injury relieving interventins
Wund Perfrmance Imprvement Team Reintrduce Braden Risk assessment-validated risk assessment tl Braden tl reintrduced with educatin and guidance frm the LIFE WOCN NP Develped frequency f assessments based upn Braden scre: A scre f 16 r greater-fllw up visit every 6 mnths Scre f 15 r 14-every 3 mnths Scre f 13 r less and/r histry f previus pressure injury-every mnth
The Team develped a Pressure Injury Preventin Tl fr risk assessment and recmmendatins fr pressure relief. Pressure Injury Preventin Tl
Plicy and Prcedure Algrithm
Wund Certificatin Sharn Mre ANP-BC became wund certified, prviding educatin and leadership Educated staff RN s n pressure injury risk, staging, treatments, interventins, and educatin fr the participants/caregivers Educated and recgnized the HHA s as the frnt line preventin staff Crdinated DME vendrs t in-service staff n pressure relieving devices t include mattresses, wheel chair cushins, Brda chairs Urinary/bwel incntinence prducts, misture wicking mattress pads Educated surgens, wund specialists and infectius disease prviders n the PACE mdel f care NP, RN s and scial wrk ften attend appintments
Cntinuum f Care Prcess Imprvements LIFE RN cmpletes a weekly visit t the SNF t assess the participant s pressure injury and t cmplete a case cmmunicatin Pressure Injury Preventin Tl Utilized fr SNF nursing case cmmunicatins Faxed t the hspital fr all LIFE admissins LIFE supplies DME t the SNF
Cntinuum f Care Challenges SNF challenges: Culture f resistance frm the SNF staff Nursing staff unavailable t participate in case cmmunicatins Agency staff Unavailability f the medical recrd LIFE has: Gained access t the Cathlic Health SNF EMR Develped sme trust LIFE RN s have develped sme gd wrking relatinships in the SNF The SNF s have becme educated abut the LIFE prgram ver the years
Prcess Imprvements Staging and dcumentatin incnsistencies-life & SNF LIFE WOCN NP cnfirms the staging fr any reprted Stage III, IV r unstageable pressure injury-level II Upn discharge frm the hspital, SAR r a respite stay lnger than 3 days, the participant is brught directly t the clinic fr assessment and a cmplete skin check is perfrmed Allws clinical staff t address any skin issues that may nt have been knwn during the hspital, subacute r respite stay
Database Develpment Weekly Wund Meeting-Excel spreadsheet utilized t track the prgress f all pen wunds Access database was develped in 2014 Track all wunds acrss the cntinuum f care By 2015 LIFE was utgrwing Access Additinal reprting culdn t be supprted
Database Develpment 2015 LIFE began discussins with Emergencetek Grup Pints fr discussin included: Capital Expenditure and Cst Apprval Hsting Slutins Licenses fr Third Party Cmpnents Security Access Rights t Sftware IT Liaisn t facilitate access t vendr fr develpment
Database Develpment Much wrk was undertaken t create the new database: Creating standard wund types Creating standard anatmical structures & directin Creating standard treatments Creating standard interventins All wunds were mapped frm the Access database int the new database LIFE QA staff manually reviewed, verified and edited any insufficient mapping f 2015 and 2016 wunds int the database
Outcmes 2016 Quarter 4-the weekly wund reprt was peratinal This enabled the ability t determine pressure injury rates fr 2015 and 2016!!! Data driven prcesses
Pressure Injuries 6% LIFE Yearly Acquired Pressure Injury Rate (Includes all lcatins) 5% 4% 3% 2% 1% 0% 2015 2016 Cmmunity SNF Hspital Ttal Results: In 2015 pressure injury acquisitin rate amng cmmunity participants was 2.89%; in 2016, 2.12%. In the SNFs the 2015 rate was 5.34%; cmpared t 3.21% in 2016. The 2015 hspital rate was 0%; 2.22% in 2016. There was n significant difference (P>.05) amng care site cmparisns but the ttal reductin frm 3.41% in 2015 t 2.45% in 2016 was statistically significant (P <.05). The prevalence f pressure injury present at enrllment increased frm 0.17% in 2015 t 0.38% in 2016 was statistically significant (P<.05).
Weekly Wund Reprt
Metrics Reprt
Pressure Injury Graphs July 2016-July 2017
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Next Steps Determine if 2017 Wund Perfrmance Imprvement Team Gals have been met: Decrease the rate f newly develped pressure injuries by 25%. Prevent Stage II pressure injuries frm prgressing t Stage III, IV r Unstageable. Review and cnsider implementing Pressure Ulcer Scale fr Healing (PUSH) tl Develp Care Plan prblem that encmpasses all skin interventins The Braden Scre and Tissue Type have been added t the database fr future reprting and implementatin f the PUSH tl.