The $$$ and Sense of Pressure Ulcer Reduction: People, Products, and Perseverance September 30, 2010, 2:00 PM EDT Hospitals are chosen to contribute to the NDNQI monographs based on NDNQI data showing their clear improvement in outcomes. These four hospitals all showed significant improvement in reducing pressure ulcer rates and provided case studies for the 2007 and 2009 NDNQI monographs. Now the authors of these case studies will report on the tools, teams, and processes they have used to sustain improvement over the intervening years. Margaret Talley PhD, RN, CNS, CWCN AP District Wound Clinical Nurse Specialist Palomar Pomerado Health Hospital District Poway and Escondido, California Margaret.talley@pph.org Margaret Talley, a wound care clinical nurse specialist for Palomar Pomerado Health in Escondido, Calif., took an existing wound care program to the next level, dramatically reducing the percentage of patients with hospital acquired pressure ulcers. For her efforts, Dr Talley received the prestigious Cherokee Inspired Comfort Award in 2007. Dr. Talley completed her PhD dissertation in May of 2010 titled Pressure ulcer risk factors for patients with hospital versus community acquired pressure ulcers for which she received the 2010 California Clinical Nurse Specialist Research grant. Nancy Cann, MSN, RN Clinical Outcomes Specialist, Nursing Performance Improvement Baptist Medical Center Downtown Jacksonville, Florida Nancy.cann@bmcjax.com Nancy has been involved in the Quality and/or Performance Improvement field for the past 13 years. She currently serves as a Clinical Outcomes Specialist Nursing PI for Baptist Medical Center Downtown. She received her CPHQ this past year as well as her Green Belt certification. As chair of the Skin Integrity Taskforce and consultant for the Skin Care Champions, Nancy works closely with a multidisciplinary team in the prevention and reduction of hospital acquired pressure ulcers. Page 1
Janet Doyle Munoz BSN, RN, CWON Wound and Ostomy Nurse Morristown Memorial Hospital Morristown, New Jersey Janet.munoz@atlantichealth.org Janet Doyle Munoz received her diploma in nursing from St. Peter s Medical Center School of Nursing in 1977. In 2005, she earned her Bachelor s Degree in Nursing (B.S.N.) from the College of St. Elizabeth. Doyle Munoz was certified in wound and ostomy care by the WOCNCB in 2003 and has been an active member of the Wound, Ostomy and Continence (WOCN) Nursing Society, serving on the Ostomy National Practice Committee. She currently holds the position of board certified wound and ostomy nurse at Morristown Memorial Hospital in New Jersey. In addition to the WOCN, Janet is a member of the society for the Advancement of Wound Care, The Academy of Medical Surgical Nurses, and Sigma Theta Tau International. Janet Hanley, MBA, BSN, RN, NEA BC CNO/VP of Patient Care Services Sharp Grossmont Hospital LaMesa, California Janet.hanley@sharp.com Janet Hanley was the author of an article titled NDNQI Data Stimulated Practice Improvement Plans to Reduce Pressure Ulcers published by the ANA. She has been the facility coordinator for Pressure Ulcer prevention and quarterly prevalence studies since early 2000. As CNO and VP of Patient Care Services at Sharp Grossmont, she has led the hospital in continuous improvement and best practices for many years, and the organization has presented their Pressure Ulcer program and data at several National, Statewide and local conferences. Page 2
The $$$ and Sense of Pressure Ulcer Reduction: People, Products, and Perseverance 4 Objectives 1. Describe the role of collaborative relationships among nurses, patients/families, and other disciplines in preventing pressure ulcers 2. Describe successful strategies involving people and/or products that resulted in decreased costs for pressure ulcer care. 5 1
Moderator Margaret Talley PhD, RN, CNS, CWCN, District Wound Clinical Nurse Specialist, Palomar Pomerado Health Hospital District San Diego, CA 6 Palomar Pomerado Health San Diego Only Magnet Recognized Public Health System in California 2 Acute Care Hospitals 2 Skilled Nursing Facilities Home Health Agency 2 Hyperbaric Wound Care Centers Margaret Talley PhD, RN, CNS, CWCN 2
National Drivers Nurse Sensitive Outcome NDNQI Provider Driven Reimbursement Present on Admission: On July 31, 2008, in the Inpatient Prospective Payment System (IPPS) CMS included Hospital acquired Stage III & IV Pressure Ulcers as one of the 10 categories of conditions that were selected for non-payment py by Medicare. Public Reporting of HAPUs Nancy Cann MSN, RN, Clinical Outcomes Specialist Baptist tmedical lcenter Downtown Jacksonville, FL Panelists Janet Doyle-Munoz BSN, RN, CWON Wound and Ostomy Nurse Morristown Memorial Hospital Morristown, NJ Janet Hanley, MBA, BSN, RN, NEA-BC CNO/VP of Patient Care Services Sharp Grossmont Hospital San Diego, CA 9 3
Using an Evidence-Based Protocol to Reduce Nosocomial Pressure Ulcers BAPTIST MEDICAL CENTER Nancy Cann MSN, RN 10 407 bed hospital in Northeastern t Florida Flagship of 5 hospital system Magnet hospital 2007 Accredited Chest Pain Center Certified Primary Stroke Center Pressure Ulcer Prevention 4
Hospital Acquired Pressure Ulcers 2005 Focus on 3 adult critical care units Clinical Quality Goals Multifaceted approach Advanced Practice Partners (APP) NDNQI data ercent of Patients Surveyed with HAPU Pe 20 18 16 14 12 10 8 6 4 2 0 2nd Qtr 2005 3rd Qtr 2005 4th Qtr 2005 Percent of Patients Surveyed with Hospital Acquired Pressure Ulcers 2005-2010 1st Qtr 2006 2nd Qtr 2006 3rd Qtr 2006 4th Qtr 2006 1st Qtr 2007 Prior to Interventionention 2nd Qtr 2007 3rd Qtr 2007 4th Qtr 2007 1st Qtr 2008 2nd Qtr 2008 3rd Qtr 2008 4th Qtr 2008 1st Qtr 2009 2nd Qtr 2009 3rd Qtr 2009 4th Qtr 2009 1st Qtr 2010 Data Source: Quarterly Point Prevalence Study 5
Pressure Ulcer Prevention Protocol (PUPP) 2005 Quality Improvement Plan PUPP Revised to encompass all types of units Empowerment of bedside nurse 2 committees dedicated to Pressure Ulcer prevention: Skin Integrity Task Force Skin Care Champions 6
PUPP 2009 16 Screening Tool 7
Screening Tool (cont.) ercent of Patients Surveyed with HAPU Pe 20 18 16 14 12 10 8 6 4 2 0 2nd Qtr 2005 3rd Qtr 2005 4th Qtr 2005 Percent of Patients Surveyed with Hospital Acquired Pressure Ulcers 2005-2010 1st Qtr 2006 2nd Qtr 2006 3rd Qtr 2006 4th Qtr 2006 1st Qtr 2007 2nd Qtr 2007 3rd Qtr 2007 4th Qtr 2007 1st Qtr 2008 2nd Qtr 2008 3rd Qtr 2008 4th Qtr 2008 1st Qtr 2009 2nd Qtr 2009 3rd Qtr 2009 4th Qtr 2009 1st Qtr 2010 Data Source: Quarterly Point Prevalence Study 8
Performance Improvement and Pressure Ulcer Prevention MORRISTOWN MEMORIAL HOSPITAL Janet Doyle-Munoz BSN, RN, CWON 20 Performance Improvement and Pressure Ulcer Prevention 650 bed regional hospital in Northwestern t New Jersey Magnet hospital 2001, 2005, 2009 Level I Trauma Center Cardiac Surgery Center Level III regional Perinatal Center 21 9
Performance Improvement and Pressure Ulcer Prevention MMH NDNQI Hospital Acquired Pressure Ulcer (HAPU) 14% 12% 10% Interventions Implemented 8% 6% 4% 2% 0% 1st Qtr 2004 2nd Qtr 2004 3rd Qtr 2004 4th Qtr 2004 1st Qtr 2005 2nd Qtr 2005 3rd Qtr 2005 4th Qtr 2005 1st Qtr 2006 2nd Qtr 2006 3rd Qtr 2006 4th Qtr 2006 1st Qtr 2007 2nd Qtr 2007 3rd Qtr 2007 4th Qtr 2007 1st Qtr 2008 2nd Qtr 2008 3rd Qtr 2008 4th Qtr 2008 1st Qtr 2009 2nd Qtr 2009 3rd Qtr 2009 4th Qtr 2009 1st Qtr 2010 2nd Qtr 2010 % Patients with HAPU- All Stages 22 Performance Improvement and Pressure Ulcer Prevention 2004-2005 Moved dfrom yearly to quarterly NDNQI pressure ulcer prevalence WOC Nurse has to interpret the data. What does the data mean? How do we use the data to empower staff and, drive improvements? Ultimate Goal: decrease HAPU rate and make staff more aware and accountable for HAPU development. 23 10
Performance Improvement and Pressure Ulcer Prevention 2005 Partner with PI and risk management Evaluated current processes Identified breakdowns in the process Outcome was the development of a strategic plan for improvement Goal was a sustainable reduction in the HAPU rate. 24 Performance Improvement and Pressure Ulcer Prevention 2005-2010 Pressure Ulcer Prevention Committee o Composed of staff nurses, PI manager, risk manager, dietician, WOC nurses, physical therapist, infection control nurse o Reports directly to Shared Governance Quality Improvement Council Established yearly youtcome and process goals o Outcome Goal- decrease HAPU by % by date o Process goals strategies that help us achieve outcome goal o Focus o Establishment of priorities and timeline 25 11
Performance Improvement and Pressure Ulcer Prevention 2005-2006 Formalized educational requirements for data collectors Verified all HAPU by WOC nurse Standardized data collection form Analyzed unit data and compared to NDNQI national mean Focus on high risk units Empowers staff to make change on unit level 26 Performance Improvement and Pressure Ulcer Prevention 2006-2007 Root Cause Analysis for all HAPU Analyze common themes Identify high risk populations Obesity Hypovolemia Prolonged OR time Low diastolic B/P Immobility LOS 27 12
Performance Improvement and Pressure Ulcer Prevention 2006-2007 Purchase of Pressure redistribution surfaces: Medical surgical units Critical care areas Standardization: Documentation Intranet web-site Education 28 Performance Improvement and Pressure Ulcer Prevention 2006-2010 Developed of processes to track, report,and evaluate HAPU Quantos reports Unit-based RCA with action plans Unit-based reports Wound measurement Standardized yearly competencies Accountability! 29 13
30 The Use of a Camera in Clinical Documentation SHARP GROSSMONT HOSPITAL Janet Hanley MBA, BSN, RN, NEA-BC 31 14
Sharp Grossmont Hospital 536 bed hospital in San Diego Magnet Designation 2006 Malcolm Baldrige National Quality Award Recipient 2007 Policy and Procedure The Use of a Camera in Clinical Documentation Camera in Use Documentation Review 33 15
Digital picture of wound Typical digital camera 35 16
QUESTIONS 36 17
Pressure Ulcer (Braden Scale Risk Assessment and Skin Inspection) Flow Chart Patient Admitted to Nursing Unit Admission Nursing Assessment Completedincluding Braden Scale Risk Assessment and Skin Inspection Reassess Q 24H Reassess Q 8H Braden Scale Risk Assessment: At Risk? (18 or below) No Braden Scale 19 or Above Skin Inspection Abnormal Yes No Good color & Integrity Yes Implement Prevention Protocol Based on Risk Level Stage I Wound Identified Deep Tissue Injury Partial Thickness (Stage II) Wound Identified Full Thickness (Stage III or IV) Wound Identified Braden 18 or below without an existing wound Implement Prevention Protocol: Turn and reposition Q2H (bed); Q15-30 (chair) Decrease friction/ shearing Support surface to redistribute pressure (bed/chair) Offload heels Braden 18 or below with an existing wound Notify wound care 4191 or 5522 Turn and reposition Q2H (bed); Q15-30 (chair) Decrease friction/ shearing Support surface to redistribute pressure (bed/chair) Offload heels Manage urine and fecal incontinence Monitor nutrition/ hydration Decrease HOB to 30 Assess support surface functioning * Immediate intervention Assess, measure, document Low air loss/air fluidized ASAP Reposition. Omit lying on area Wedge or pillow to reposition Q 30 min. MD Notification for Wound Treatment Orders Manage urine and fecal incontinence Monitor nutrition/ hydration No positioning on threatened area or wound site Consider dietary consult Decrease HOB to 30 Request pre-albumin Reassess Skin Inspection Q 8H Reassess Braden Risk Q 24H Courtesy of Morristown Memorial Hospital
Pressure Ulcer Prevention Protocol (PUPP) Assessment/Documentation *Documentation of assessment and interventions is essential* Upon admission to Unit, every 12 hours, caregiver change or transfer from another area Confirmed by another RN. Braden Score calculated Documented on Database 2 & 24-hour flow sheet. *If pressure ulcer develops, initiate Integumentary IPOC Category Sensory Perception Moisture Braden Score 3 or less 3 or less Interventions See Mobility and Activity for interventions Prevent Device-related breakdown foam cushions on elastic straps over ears. Apply cushioned material on bridge of nose (BiPAP). Watch for placement of tubing, catheters and cables. Perineal foam cleanser - Avoid soap and water. Disposable washcloths Do not use cloth washcloths. Avoid scrubbing. Barrier cream apply to skin every 4 hours & PRN Dri-Flo incontinent pads. NO reusable cloth pads. Avoid use of diapers except when ambulating patient. Diarrhea/C. difficile obtain order for fecal management system. Urinary consider condom cath for male patients. DO NOT place towels between legs. Identify fungal infections and obtain order for medications. Consult Wound Care for: Braden score 13 or less Cardiac surgery patients indicate in Special Instructions s/p heart surgery; Braden less than 13. Problems with surgical incisions Other skin problems pressure ulcers, skin tears, perineal dermatitis, tape burns, chemical burns, candida, etc. Use Screening Tool for Specialty Bed/Mattress to identify need for pressure redistribution surface REMOVE from specialty surface if ALL of the following are true (assess daily): Pt. not tall, heavy/wide or on rotation therapy Skin intact with no moisture issues Ambulatory several times/day with minimal assist Activity Mobility Nutrition Friction & Shear 3 or less 3 or less 2 or less 2 or less Passive range of motion unless contraindicated. PT/OT consult OOB to chair/ambulation when hemodynamically stable Pressure-redistribution cushion for ALL patients OOB in chair. (Order from SPD) Shift weight patients need to shift weight while sitting in chair every 15 minutes. If unable, then assist to stand every hour. Turn every 2 hours or more frequently using Maxislides & turning wedge. Avoid placing patient directly on trochanter. If skin breakdown on sacrum, DO NOT position on back If hemodynamic instability, place small pillows under hips and shoulders to relieve pressure. Pillows between knees when turned Turning Clock in room Heels off bed. (Heel Lift) May use pillow (temporarily) by placing lengthwise. Assess need for nutrition consult Evaluate for supplemental nutrition Adequate hydration; Accurate intake and output Daily weights Maxislides for repositioning Protect sacrum, elbows and heels (padding, Heel Lift) Elevate knees before raising HOB HOB no higher than 30 degrees unless contraindicated Skin protectant apply every 4 hours & PRN
Screening Tool for Specialty Bed/Mattress *All orders for specialty beds/mattresses must be approved by APP, ANM, NM or Wound Care* If patient has one of the following, an order should be placed for one of the beds listed below: Nonblanchable redness Reposition pt. and recheck in 30 minutes. (If no change and pt. at high risk for shearing) Pressure ulcer present (Stage 2 or higher, DTI) If 3 or more of the following criteria are present, an order should be placed for one of the beds listed below: Mechanical ventilation more than 24 hrs (*No possibility of extubation within the next 24 hrs.) IABP Infusions of vasopressors Neuromuscular blockade Paraplegia or quadriplegia 3 or more co-morbidities - (Hx CVA, DM, ecchymosis, renal insufficiency/failure, heart failure, respiratory disease, PVD) Hospitalized with bedrest for more than 24 hours prior to surgery Age greater than 60 (Critical Care areas) or greater than 70 (Non-critical care areas) More than 4 hours on OR table History of pressure ulcers Emergency Department Screen Non-ambulatory patients with greater than 4 hour stay awaiting inpatient bed. Selection Criteria for Beds/Mattresses: Envision mattress (less than 400 lbs) - Sleep surface 35.5 in. (W) 84 in. (L) If patient is TALL: (6 3 or taller; skin issue or not) VersaCare 500 (400 475 lbs) - Sleep surface 35.5 in. (W) 86 in. (L) TriFlex (greater than 475 lbs.) Sleep surface 48 in. (W) 86 in. (L) If patient is HEAVY/WIDE: (skin issue or not) VersaCare 500 (400 475 lbs) Sleep surface 35.5 in. (W) 86 in. (L) Total Care Bariatric w/air (400 475 lbs) Sleep surface 40 in. (W) 84 in. (L) TriFlex (greater than 475 lbs.) Sleep surface 48 in. (W) 86 in. (L) If patient requires ROTATION THERAPY (ICU ONLY): Wt limit 475 lbs. Total Care Connect Sleep surface 36 in. (W) 84 in. (L) Total Care Bariatric w/air Sleep surface 40 in. (W) 84 in. (L)