Alaina Tellson, PhD, RN-BC, NE-BC

Alaina Tellson, PhD, RN-BC, NE-BC

Localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction tional Pressure Ulcer Advisory Panel (NPUAP)

HAPIs affect more than 1 million patient per year (LEAF Healthcare, 2014) Treatment cost: $1,200 to $70,000 depending on stage of ulcer (O Brien et al, 2013) US annual treatment cost: $11 billion (http://www.ahrq.gov)

CMS Stage III and IV Pressure: Identified as preventable by CMS Hospitals no longer receive additional reimbursement for Stage III and IV HAPI or present on admission which progress Research shows that strong collaborative approach can help reduce number of HAPUs

Identification Treatment options Prevention of progression Care team communication

Occiput Shoulder blades Spine Elbows Sacrum Coccyx Heels

Incidence measures number of patients developing new pressure ulcers during period of time. New pressure ulcers over defined period of time. Prevalence measures number of patients with pressure ulcers at certain point in time. Total pressure ulcers on one specific day.

Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 14% June 2012-July 2015 HAPU Prevalence 12% 10% 8% 6% Prevalence 4% 2% 0% -2% 2012 2013 2014 2015

Unique Patient Population Knowledge Deficit Lack of Collaboration Lengthy OR Time Braden Scale knowledge Resistance to change Multiple co-morbidities Disbelief that we had a problem Lack of nutrition consults Hemodynamic instability Improper staging of pressure ulcers Expedited admission process Poor perfusion/pvd Lack of knowledge on bed functions Role of PT & RN in wound care Cardiac Universal Bed Model Skin Champion Team/Wound Consult Interdisciplinary communication Shortage of bed modules No certified wound care RN Hemodynamic instability Mepilex sacral dressing PT for wound care/therapy Nutritional status Large Number of HAPU s at THHBP Lack of pillows & boots Lack of Informatics Intelligence Restrictions on repositioning Inadequate PAR levels Lack of resources on weekends Patient s fear of moving Lack of waffle cushion Confusion on supplies Cultural considerations Supplies Resources Patient Recovery Process

1 2 3 4 TEAM EDUCATION COMMUNICATION CULTURE

Multidisciplinary team was created: Physician Liaison Certified Wound Care RN Cardiac Universal Bed units Nurse managers Nursing Administration Education OR Emergency Department PACU PT/OT Nutrition Alone we can do so little, together we can do so much --Helen Keller

Add certified wound care nurse to guide the prevention efforts Increase staff education at nursing orientation to 2.5 hours Train Skin Champions Educate the Champions One day workshop Staff Quarterly Education Events Brownies for Braden Scores Ask the Expert Event Stage Fair Road Show Recipe for Disaster/Ingredients for Success Hospital Communication 4PUP Hotline: 469.814.4787 Email: 4PUP@baylorhealth.edu PUPdate Newsletter Physician Liaison & Wound Care RN rounds

Cardiac surgery patients: at higher risk for pressure ulcer development compared to noncardiac surgery patients HAPUs have long reaching affects on patients, caregivers and the hospital s bottom line.

Lengthy OR Times 44.1% of THHBP OR times > 3 hours Multiple co-morbidities Hemodynamic instability Poor central & peripheral arterial perfusion (CAD/PAD) 45 40 35 30 25 20 15 10 5 % Of Procedures 0 >180 Minutes>300 Minutes>400 Minutes>500 Minutes>600 Minutes

42% of all HAPIs occur in surgery patients Effects on patients: Increased length of stay (3-5 days longer) Increased cost to patient & health care system Predisposition to complications Osteomyelitis Sepsis Squamous cell CA

Heel & sacral HAPIs OR support surfaces i.e. thickness of OR foam mattress Mepilex sacral dressings Offloading & repositioning Skin assessments Preoperative Intraoperative Postoperative Communication between units

Stage 1: Identify the Problem Large Number of HAPIs Leadership support Seek resources Initiate Skin Champion Team Stage 2: Identify Education Needs Educate Skin Champions and staff Obtain ancillary support and collaboration Initiate clinical support-wound Care RN, PUP hotline and email Stage 3: Expand Interdepartmental Collaboration Involve Advance Practice Nurses, Nutrition, Nursing Informatics, PT/OT Expand nursing knowledge-ask the Expert Identify at-risk patients prior to procedures-cpm reports

Stage 4: Increase Efforts to Reach Goal Increase role of certified Wound Care RN Improve collaboration with supply chain management and ancillary departments Increase staff education events Stage 5: Expand Education Opportunities & Collaboration Obtain MAP 30-day trial Launch PUP-date Newsletter Initiate Progressive Mobility Working Group and Move to Improve Campaign

Move from a culture of proactive prevention to a culture of innovative interprofessional initiatives Continue rounding & multidisciplinary collaboration Expand education events & opportunities for staff Recruit new Skin Champions & involve outpatient departments Provide bedside support & consultation Include patient & family in prevention process

Braden PUPDate Apples for staging Don t be afraid to peek under the mepliex

Clinically proven tool used to assess patient's risk for developing pressure ulcers (PrU) Identifies six areas of risk and prompts nursing interventions to prevent PrU Composed of six sub-scales

Respect & understanding of patient s concerns regarding HAPU prevention Integrate care through multidisciplinary team approach Communicate & educate team members to improve outcomes Reposition patient frequently to increase patient comfort Empower patient & family to reposition safely to decrease fear & anxiety Educate family about repositioning & use of Turning Clock

Preoperative Identify at-risk patients Obtain complete medical history Perform thorough skin assessment Maximize nutritional status Prevent solutions/preps to pool against skin Mepilex sacral dressing: prevent friction & shear Protect skin from moisture

Intraoperative OR support surface Positioning devices: redistribute pressure Proper transfer techniques: reduce friction & shear Draw sheets Care with temperature regulation devices Place sheet between patient & warming device Elevate heels off bed Gel/foam pads

Postoperative Assess skin and report any changes Monitor heels, back, sacrum, buttocks, elbows Early ambulation/progressive mobility Low-air loss module Surgery < 3 hours OR Patient with peripheral vascular disease Protect skin from moisture Optimize nutrition

Multiple co-morbidities Lower preoperative Braden score Diabetes mellitus Anemia: lower hemoglobin & hematocrit Nutritional status: Serum albumin & prealbumin Quicker return to preoperative body temperature Intra-aortic balloon pump (IABP) Hemodynamic instability Restrictions on repositioning/immobility Patient s fear of moving Cultural considerations

Sharing our methods within our system: Nursing Quality Summit-2014 Bill Aston Quality Summit-2014 HAPU Council-Sharing of Our Best Practices-2013 to Present Team leader shadowed by another facility to learn Skin champion team part of NTX HAPU council Sharing our story outside our system: Poster Presentation-ANA National Conference March 2016 World-wide Pressure Ulcer Awareness Day BSWH Podium Presentation November 2015 Cardiac Innovations Podium Presentation- May 2014