An overlooked area in pressure ulcer development has

EVIDENCE-BASED PRACTICE THE PRESSURE IS ON! AN INNOVATIVE APPROACH TO ADDRESS PRESSURE ULCERS IN THE ED SETTING Authors: Linda Bjorklund, BSN, RN, MHS, CPHQ, Alice Basch, MSN, RN, WOCN, Betsy Borregard, MS, RN, CNS, Beth Brown, RN, Jennifer Denno, BSN, RN, CEN, Emy Montgomery, BSN, RN, MPA/HSA, PLNC, Kathryn Pedicini, RN, and Jo Saporito, ASN, BHA, MHA, ACHE, Sacramento, Greenbrae, Crescent City, Santa Rosa, Auburn, and Vallejo, CA Section Editor: Nancy McGowan, RN, PhD An overlooked area in pressure ulcer development has been the emergency department, which is frequently the point of entry for patients who require hospitalization. The risks associated with pressure ulcer prevention are not considered a priority to be addressed in the emergency department. 1 However, patients often remain in the emergency department for hours. 1,2 Most mattress surfaces in the emergency department are designed for transport or short-term use. Patients who remain on these surfaces are at risk for the development of pressure ulcers. A pressure ulcer can develop in two hours if precautions are not implemented. 1 This situation presents an opportunity for early identification and intervention for Linda Bjorklund is Risk Management Consultant, Sutter Health, Sacramento, CA. Alice Basch is Wound/Ostomy Nurse Specialist, Marin General Hospital, Greenbrae, CA. Betsy Borregard is Director, Nursing Education & Clinical Effectiveness, Marin General Hospital, Greenbrae, CA. Beth Brown is Director of Emergency Services, Respiratory Therapy and Rural Health, Sutter Coast Hospital, Crescent City, CA. Jennifer Denno is Clinical Nurse Educator, Emergency Department, Sutter Medical Center, Sacramento, CA. Emy Montgomery is Manager Accreditation, Licensure and Risk Management, Sutter Medical Center, Santa Rosa, CA. Kathryn Pedicini is Nursing Manager, Emergency Services, Sutter Auburn Faith Hospital, Auburn, CA. Jo Saporito is Manager, Integrated Quality Services, Sutter Solano Medical Center, Vallejo, CA. All of the authors were employed by either Sutter Health or an affiliate of Sutter Health at the time this article was written. For correspondence, write: Linda Bjorklund, BSN, RN, MHS, CPHQ, Sutter Health, 2200 River Plaza Dr, Sacramento, CA 95833; E-mail: BjorklL@sutter health.org. J Emerg Nurs 2012;38:159-64. Available online 22 April 2011. 0099-1767/$36.00 Copyright 2012 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2010.12.013 patients at risk. 3,4 This article will provide the reader with examples of tools used at two Sutter Health facilities to identify skin issues and prevent pressure ulcers in the emergency department. Sutter Health is a not-for-profit organization with 23 affiliated hospitals plus physician care centers serving patients and their families in more than 100 Northern California cities and towns. Elements of Typical Pressure Ulcer Prevention Programs Hospitals face increasing legislative and financial burdens related to the development of pressure ulcers. Health care providers must explore methods for improving early detection, documentation, and interventions to truly mitigate the incidence of these wounds. Current published prevention programs focus primarily on the long-term or acute inpatient care facility. With good intentions but sometimes insufficient results, many institutions worldwide have implemented inpatient pressure ulcer reduction programs. 5-11 These institutions incorporated elements to achieve a significant decrease in hospital-acquired pressure ulcers (HAPUs). For example, the programs ensure that care providers assess patients for the presence of a pressure ulcer or the risk for developing one within the first 24 hours of admission to a hospital. They then reassess the patients on a regular basis (per hospital policy), depending on their initial status. The majority of hospitals in the United States use one of several accepted skin-risk assessment tools. The most commonly used tools are the Braden Scale and the Norton Scale. 12-15 After the initial skin-risk assessment, the nurse assigns a risk level and establishes a care plan based on the patient s co-morbidities. Most care plans include a choice of support systems for the bed or chair; a turn/repositioning schedule; elevation of the head of the bed/floating the heels; and routine skin care and evaluation by a dietitian. Despite these preventative efforts by acute care hospitals, the national HAPU rate has remained constant at approximately 7% for the years 2001, 2003, and 2004. 16 March 2012 VOLUME 38 ISSUE 2 WWW.JENONLINE.ORG 159

EVIDENCE-BASED PRACTICE/Bjorklund et al According to a more recent prevalence study, facilityacquired rates were 6% in 2008 and 5% in 2009. 17 The number of admissions related to pressure ulcers acquired either prior to or during hospitalization has increased by nearly 80% between 1993 and 2006, according to data from the Agency for Healthcare Research and Quality (www.ahrq.gov). A literature search for pressure ulcer prevention programs in the emergency department resulted in three articles: van Rijswijk and Lyder, 3 Baumgarten et al, 18 and Denby and Rowlands. 4 van Rijswijk and Lyder 3 recommend further exploration to determine if pressure ulcers develop in the emergency department and whether a formal risk assessment is needed. They suggest that providers perform a quick assessment at the time of presentation to the emergency department to determine if a pressure ulcer exists. Baumgarten 18 determined that there was a 6.2% incidence of HAPUs within the first three days of hospitalization of elderly patients admitted through the emergency department. Baumgarten further states, New models of care may be required to ensure that preventive interventions are provided very early in the elderly person s hospital stay. 18 Denby and Rowlands 4 designed a correlation study to determine the feasibility of a Pressure Ulcer Prevention Protocol in the emergency department. Spahn 1 spoke on the need to begin interventions for at-risk patients earlier in the admission process. Point of admission is typically considered to be the time when the physician writes the order for admission. 1,3 This point of admission can be hours prior to the time a patient is assigned a room number and actually transferred from the emergency department. Sutter Health s Approach In 2003, a group of Sutter Health nurses and leadership committed to the system-wide decrease of HAPUs. The health care network convened a group of multidisciplinary professionals comprised of front-line nurses, wound specialty nurses, nursing managers, physicians, physical therapists, nutritionists, and many other professionals who continue to collaborate in this program. Nurses led the implementation and education of Pressure Ulcer Program (PUP) policies and procedures, including taking charge of the quarterly nosocomial prevalence studies, surface selections and upgrades, ongoing evaluations, and relentless communications to system staff and leadership. The primary focus has been on preventing HAPUs. At the inception of PUP, the system-wide prevalence rate FIGURE 1 Simple Triage Tool. ALOC, Altered level of consciousness. of pressure ulcers topped almost 12%. As a result of the interventions implemented by this dedicated team of clinicians and leadership, the system-wide HAPU prevalence rate decreased approximately 77% to 2.7% overall for the year ending 2008 and further decreased to 2.0% for the year ending 2009 and 1.7% as of the end of the second quarter of 2010. With the same steadfast principles in mind, in 2008 the ED PUP Team was formed to focus on the concern that traditional care conditions increase a patient s riskof HAPUs. The ED PUP Team, again led by nurses, developed a plan for assessment and early intervention for patients entering into a hospital through the emergency department. A Model for ED Pressure Ulcer Prevention ED staff participating on the team found the existing inpatient skin assessment tools too cumbersome and not applicable to patients in a busy emergency department. van Rijswijk and Lyder 2 recommend that EDs should use the activity subscale of the Braden or Norton scale to screen patients for pressure ulcer risk. The ED PUP Team was unable to validate usefulness of the currently accepted risk-assessment tools (Braden and Norton) for pressure ulcer prevention in the ED setting. Additionally, the ED PUP Team decided to look at the mobility Braden subscale for use in developing the team s triage tool. Following the recommendation by van Rijswijk and Lyder, 2 the ED PUP Team selected elements specific and pertinent to the ED setting in the development of the Simple Triage Tool and the ED Skin/Risk-Assessment Tool (Figures 1 and 2). Risk levels were set for pressure ulcer development as none, low, or high with a brief intervention plan recommended for each level. A wound assessment would be performed by an ED nurse and a photograph of any wound would be attached to the ED Skin/Risk Assessment Tool. Finally, the ED physician would be notified and a referral would 160 JOURNAL OF EMERGENCY NURSING VOLUME 38 ISSUE 2 March 2012

Bjorklund et al/evidence-based PRACTICE FIGURE 2 ED Skin/Risk Assessment Tool. March 2012 VOLUME 38 ISSUE 2 WWW.JENONLINE.ORG 161

EVIDENCE-BASED PRACTICE/Bjorklund et al be made to the wound team for admitted patients. The team developed two tools: a Simple Triage Tool and an ED Skin/Risk-Assessment Tool. Tool Development SIMPLE TRIAGE TOOL The Simple Triage Tool, which began as the Initial Skin Integrity Assessment tool, asked if the patient had any indication for skin/wound/ulcer problem. In addition to asking if the patient was non-ambulatory, had restricted/limited mobility, or had altered level of consciousness, the tool asked that skin breakdown or discoloration be identified. The ED staff reported they were unable to perform a complete body skin assessment in the triage environment. In an effort to facilitate a quick method of identifying patients at risk, the tool transitioned into the Simple Triage Tool. The Simple Triage Tool focuses on the mobility subscale by only asking if the patient is non-ambulatory or has restricted/limited mobility or altered level of consciousness. The triage nurse is able to answer with a simple yes/no response. If yes, use of the ED Skin/Risk Assessment Tool is initiated. ED SKIN/RISK ASSESSMENT TOOL The ED Skin/Risk Assessment Tool experienced several modifications during the pilot process. Staff requested further clarification of each section, and a frequently asked questions sheet was developed to assist the staff in utilizing the tool. The ED Skin/Risk Assessment Tool scoring section is based on the Braden subscale. The total score aids in determining the risk level. The results (total score) aid in determining the skin risk level (low/high) for the patient in the emergency department. The risk sections of low or high provide a plan of care to mitigate the risk of developing a pressure ulcer while in the emergency department and decrease the furtherance of skin issue severity. During the tool design process, three additional items were addressed: Wound staging. Because staging remains a challenge for many staff, the team determined that ED staff would use wound description instead of staging. Wound care specialists and/or specially trained staff members who had demonstrated competency as defined by each facility would provide wound staging. As a result, nurses and physicians would describe the wounds rather than risk inaccurately staging them. Wound photography. A wound photography policy and procedure was developed and provided to our hospitals for implementation. Some affiliate emergency departments chose to purchase cameras and color printers to attach photos to the inpatient chart. Follow-up. Another challenge involved the follow-up procedure for identified wounds. The team encouraged facilities to determine appropriate use of the tools during the admission process and implement their use in transferring patients to the inpatient unit. Implementation Two affiliate facilities piloted the Simple Triage Tool and the ED Skin/Risk-Assessment Tool in their emergency departments. In collaboration with the facilities, the ED PUP Team modified the tools based on staff feedback. Following review by the PUP Clinical Advisory Team, the ED PUP Team made the tools available for implementation. To assist in education of ED staff, the ED PUP Team created an ED friendly Power- Point presentation that reviewed pressure ulcer development, pressure ulcer stages, regulatory concerns, and specific issues targeted to the emergency department. In addition, some affiliates educated their ED physicians one on one. MONITORING PROCESS The ED PUP Team implemented a monitoring process before all hospitals began using the tools. The ED PUP Team developed an audit process for the participating emergency departments (Figure 3). This process began with an ED chart audit. Additionally, an audit was conducted to demonstrate each facility s progressinimplementing the tools. AUDIT RESULTS Results of the audit demonstrated the helpfulness of the Simple Triage Tool and ED Skin/Risk-Assessment Tool. It revealed that ED staff and physicians appropriately completed the forms. For example, admitting physicians were able to incorporate accurate and consistent wound descriptions from these tools to meet the current regulatory requirements for physician documentation of community-acquired pressure ulcers at point of admission. They referred some patients for follow-up with primary care physicians, wound centers, or other resources based on findings. Under standard regulatory review, state investigators reported improved documentation and validation of required nursing care when the emergency departments used the tools. 162 JOURNAL OF EMERGENCY NURSING VOLUME 38 ISSUE 2 March 2012

Bjorklund et al/evidence-based PRACTICE FIGURE 3 Audit for ED Pressure Ulcer Program tools. BARRIERS The pilot revealed some barriers to implementation, which included the following: Staff and physician resistance to change Perceived increased workload Staffing shortages Implementation barriers at the facility level Staff resistance focused on concerns for additional paperwork for ED nurses and physicians. The primary focus for emergency departments is patient flow and stabilizing critical patients. However, regulatory requirements necessitate assessment, documentation, and interventions for what may seem to be non-critical needs. ED staff expressed their concerns regarding the added responsibility for increased focus on pressure ulcer prevention and the time required for such assessments. Physicians concerns included added responsibility for pressure ulcer identification including staging and interventions while the patient was in the emergency department. Several facilities also require mandatory administrative procedures to introduce new policies and tools, delaying rapid-cycle implementation. Some of these barriers also involved tool redesign to comply with the institution s established format. Piloting a new tool required approval from a variety of managers and committees including, but not limited to, the Medical Records Committee, Forms Committee, nursing leadership teams, and medical staff committees. In addition, a few facilities did not identify prevention of pressure ulcers as a priority for their emergency department. Results to Date ED staff have expressed positive feedback. They like the tools and have found them valuable and not as time consuming as feared. ED nurses also commented that the tool allows for continuity of care beyond the emergency department. The tool could easily identify potential problem areas, especially for high-risk patients, and it presented an opportunity to open the lines of communication to encourage patients to be pro-active about their health. Prior to implementation within all of its affiliates, the ED PUP Team will further examine the role of the tool for identifying patients at risk for skin breakdown, early pressure ulcer identification, and intervention. The team also identified the need for further education among ED staff including nurses, technicians, and physicians. As the program gains momentum system-wide, so does its guiding foundation. The Sutter Health ED leadership group found the PUP in the ED initiative so vital that they included it in their annual goals for 2009. They also transitioned the goal into 2010. Conclusion The use of the tools has raised the awareness of the ED staff regarding the importance of pressure ulcer prevention. These tools facilitate further intervention of early communication with the ED physician and wound care nurse. These tools became the driving force of awareness toward developing a proactive pressure ulcer program. Here are two scenarios: Case 1: State surveyors made multiple visits to a Sutter Health affiliate to investigate reported possible HAPUs. The surveyors viewed the medical record for documentation of any skin issues. For each occurrence, the ED staff documented on the tools (Simple Triage tool and ED Skin/Risk Assessment Tool) the existing skin condition at the time of admission. On all occasions, the state surveyors complimented the hospital on the effectiveness of these tools in identifying skin conditions present on admission. Case 2: An elderly woman was brought to the emergency department from home. The staff documented on the ED Skin/Risk Assessment Tool evidence of a stage 1 pressure ulcer. Upon discharge home, the ED staff forwarded the completed tool to the primary care physician. The primary care physician called the emergency department to thank them for the report because he was unaware of the situation and would be moving forward to treat her skin ulcer accordingly. March 2012 VOLUME 38 ISSUE 2 WWW.JENONLINE.ORG 163

EVIDENCE-BASED PRACTICE/Bjorklund et al Next Steps While the team continues efforts to monitor pressure ulcer prevention in the emergency department, the organization believes that the program and tools have identified community-acquired pressure ulcers on admission and created a proactive plan of care in the participating hospitals when properly adopted and implemented. The PUP leadership group has recommended continued use of the Simple Triage Tool and ED Skin/Risk-Assessment Tool with education as needed for the organization s facilities. The team will investigate further if the tools can be incorporated into the inpatient admission practices of the emergency departments as well as in discharge to home or other facilities. The ED PUP Team will monitor the data to further determine reliability of the tools and if these tools are consistently successful in identifying patients at risk for developing a pressure ulcer as well as preventing them. Acknowledgements We thank Nancy Kretz, Teresa Campbell, Elnora Valle, Kami Lloyd, Kia Koch, the ED Pressure Ulcer Program Team, and the Sutter Coast Hospital and Sutter Medical Center of Santa Rosa Emergency Departments for piloting the tools. REFERENCES 1. Spahn J. Pressure ulcer dilemma in the emergency department environment. http://www.ehob.com/pdf/seamless/ulcers-er.pdf. Accessed August 27, 2010. 2. Lucas R, Farley H, Twanmoh J, Urumov A, Evans B, Olsen N. Measuring the opportunity loss of time spent boarding admitted patients in the emergency department: a multihospital analysis. J Healthcare Manage. 2009;54(2):117-24. 3. van Rijswijk L, Lyder C. Pressure ulcers: were they there on admission? Am J Nurs. 2008;108(11):27-8. 4. Denby A, Rowlands A. Stop them at the door: should a pressure ulcer prevention protocol be implemented in the emergency department? J Wound Ostomy Continence Nurs. 2010;37(1):35-8. 5. Ayello E, Braden B. How and why to do pressure ulcer risk assessment. Adv Skin Wound Care. 2002;15(3):125-31. 6. Baldelli P, Paciella M. Creation and implementation of a pressure ulcer prevention bundle improves patient outcomes. Am J Med Qual. 2008;23 (2):136-42. 7. Bonham P. Pressure ulcers. A review of successful strategies for risk assessment and staging. Adv Nurs. 2007;9(23):25-8. 8. Magnan M, Maklebust J. The nursing process and pressure ulcer prevention: making the connection. Adv Skin Wound Care. 2009;22 (2):83-92. 9. National Pressure Ulcer Advisory Panel. Pressure ulcer stages revised by NPUAP. http://www.npuap.org/resources.htm. Published February 2007. Accessed August 27, 2010. 10. Reddy M, Gill S, Rochon P. Preventing pressure ulcers: a systematic review. JAMA. 2006;296(8):974-84. 11. Stoelting J, McKenna L, Taggart E, Mottar R, Recchia Jeffers B, Wendler MC. Prevention of nosocomial pressure ulcers: a process improvement project. J Wound Ostomy Continence Nurs. 2007;34(4):382-8. 12. Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden Scale for predicting pressure ulcer sore risk. Nurs Res. 1987;36(4):205-10. 13. Braden BJ, Bergstrom N. Clinical utility of the Braden Scale for predicting pressure sore risk. Decubitus. 1989;2(3):44-46, 50. 14. Comfort E. Reducing pressure ulcer incidence through Braden Scale risk assessment and support surface use. Adv Skin Wound Care. 2008;21 (7):330-4. 15. Jalali R, Rezaie M. Predicting pressure ulcer risk: comparing the predictive validity of 4 scales. Adv Skin Wound Care. 2005;18(2):92-7. 16. Whittington K, Briones R. National prevalence and incidence study: 6- year sequential acute care data. Adv Skin Wound Care. 2004;7(9):490-4. 17. VanGilder C, Amlung S, Harrison P, Meyer S. Results of the 2008 2009 International Pressure Ulcer Prevalence Survey and a 3-year, acute care, unit-specific analysis. Ostomy Wound Manage. 2009;55(11):39-45. 18. Baumgarten M, Margolis D, Localio R, et al. Pressure ulcers among elderly patients early in the hospital stay. J Gerontol A Biol Sci Med Sci. 2006;61(7):750-3. Submissions to this column are encouraged and may be sent to Nancy McGowan, RN, PhD Mcgowann@uthscsa.edu 164 JOURNAL OF EMERGENCY NURSING VOLUME 38 ISSUE 2 March 2012