Skin Champions Improving Practice: A Model for Implementing EBP MaryBeth Makic, RN, PhD(c), CCRN Kathleen Oman, RN, PhD, CNS University of Colorado Hospital ANA & NDNQI Annual Conference Transforming Nursing Data into Quality Outcomes January 2007 Learning Objectives Describe how champions of change can facilitate evidence-based practice Identify effective strategies used to improve patient outcomes related skin integrity 1
UCH EBP Innovation: Champions of Change Model Change champions are practitioners from the local group who continually promote the new idea. (Titler & Everett, 2001) CNS/Educator or clinical experts mentor staff nurses to be ambassadors of change Change begins by examining the evidence and current practice When staff nurses examine evidence, they become engaged, believe the evidence is is credible, see positive impacts on patient care outcomes and clinical relevance. Champions of Change Model Staff nurses facilitate change by demonstrating innovator qualities Become knowledgeable about practice change Willing to disseminate information/change to peers Participate in education of peers/eb practice change Empowered and gain autonomy with other disciplines Become passionate and persistent about EBP Model knowledge of current evidence and engage peers in EBP change Provide feedback to peers/eb team 2
UCH Champions of Change Model Membership Change agent/chair CNS/Educator and/or clinical expert Research Nurse Scientist Champions Bedside staff (RNs, PTs, pharmacists, MDs, RRT, CNAs) Any healthcare professional who is interested in acting as an ambassador for change Champion Team Structure Monthly meetings Consistent date, time, place set Meetings are working meetings Paid administrative time Focus of meetings Increase champion knowledge of EBP topic Review of current EBP change, outcomes data Review current documentation forms/policies and products Discuss what the staff are saying address bumps in the road Discuss dissemination of EBP (ongoing) Journal club 3
Innovative EBP Communication Successful communication of EBP changes are critical to effective implementation Use multiple avenues to disseminate information Intranet and Web-based forums, pre-printed orders, pre-printed MARs, bathroom flyers, documentation forms, computer cues, policy, outcomes boards, meeting minutes Ensure champions can walk the talk Empower champions through mentorship and ownership of practice changes Resources need to be available/accessible and make sense to the bedside nurse Champions bring EBP back to the bedside Role of Champion of Change actualized Resource to staff When not working, re-disseminate information face to face value for informing peers of EBP changes and practice priorities Champion role reinforces peer s desire to learn more about a specific practice Consistent theme with flyers to trigger staff that THIS flyer is about EBP topic 4
Skin Champions of Change First champion of change group at UCH Started in 1999; evolved from increased pressure ulcer prevalence Multidisciplinary team membership Skin Champions of Change Conducted research (2001-2002) on RN knowledge of pressure ulcer prevention strategies Changed documentation to reflect AHRQ and WOCN guidelines for PU prevention Wound care symposium with Dr. Braden (2000) Adapted Braden scale for pressure ulcer risk assessment into all clinical forms (2000) Create and revise tools to help RNs diagnosis, prevent and treat pressure ulcers and wounds Evaluate and select all skin/wound care products for UCH Participate in NDNQI quarterly data collection Participate in PU validation study (July 2005) Conduct annual journal club (group and unit-based) 5
Skin Champions of Change Pressure Ulcer Prevention Algorithm Skin Champions of Change: Pressure Ulcer Prevention Protocol Therapeutic surfaces serve as adjuncts to care and are NOT replacements for frequent repositioning. 1-4 Nursing Standard of Care of Prevention of Pressure Ulcers and Skin Breakdown (all patients) Turn patient every 2 hours and PRN 1-4 HOB < 30 o if patient does not have pulmonary risks; HOB > 45 o if patient has risk for pulmonary complications (increase turning frequency) Moisturize skin daily and PRN 1-4 Control moisture; determine and treat cause of moisture; apply moisture barrier creams as needed 1,2 Nutritional Consult if albumin < 3.4 g/dl and/or pre-albumin <20 mg/dl 1,2 Maximize use of turning sheets and slide boards to move patient. 1,2 CWOCN RN Consult (Amie Kirkwood RN CWOCN) if Stage III, IV or unstageable pressure ulcer present Braden Score 15-18 Interventions: Implement turning schedule (Q2 hours and PRN) Moisturize skin daily and PRN Out of bed and reposition patient if not independent Control moisture Assess nutritional status Minimize friction and sheer Discontinue KCI therapeutic surface Braden Score 13-14 Interventions: Consider Advanta bed AND ensure prevention mode is activated (especially ICU beds) Implement turning schedule (Q2 hours and PRN) Moisturize skin daily and PRN Out of bed and reposition patient if not independent Control moisture Assess nutritional status Minimize friction and sheer Discontinue KCI therapeutic surface Braden Score 10-12 Interventions: Advanta bed; ensure prevention mode activated Implement turning schedule (Q1-2 hours and PRN) Moisturize skin daily and PRN Out of bed and reposition patient if not independent Control moisture Nutrition consult Minimize friction and sheer Discontinue KCI therapeutic surface Bariatric patients (300lbs): Braden Score 13 use a UCH Bariatric Bed; Braden Score <13 KCI Bariatric bed; Braden <9 KCI BariAir References: 1. Ratliff, C.R., et al. (2003). Guideline for prevention and management of pressure ulcers. Wound Ostomy and Continence Nurses Society. Lake Avenue, Glenview IL. 2. U.S. Department of Health and Human Services. (1992). Pressure ulcers in adults: prediction and prevention. AHCPR. Rockville, MD. 3. Alleyo, E.A. et al. (2004). By the numbers: Braden score interventions. Advances in Skin & Wound Care 17(3): 150. 4. Olshansky, K. (2004). Pressure ulcer prevention: a total disconnect. Advances in Skin & Wound Care. 17(5): 259 5. Wall, S. et al. (2005). Development of an evidence-eased specialty support surface decision tool. Ostomy Wound Management 51 (2): 80 Braden Score <9 Interventions: Order low airloss bed (KCI First step overlay-verification by CNS/educator/WOCN RN needed) Implement turning schedule (Q1-2 hours and PRN) Moisturize skin daily and PRN Out of bed and reposition patient if not independent Control moisture Nutrition consult Minimize friction and sheer 6
Skin Champions of Change 2001 hospital wide PU prevalence rate 12.7%; currently 6.8% Products changed to reflect evidence Skin care line Wound care line Pressure relief products/beds PU prevention protocol rental bed usage (cost savings $194,000) Web-based resources Wound VAC, ostomy supplies, wound care products 2006 2 nd Qtr NDNQI Data 14 12 10 8 6 4 PU prevalence Benchmark 2 0 Med/Surg Critical Care Stepdown Rehab 7
UCH Skin and Wound Care Website Sample of Product Guidelines Indications for dressing: Partial thickness or Stage II wound with minimal moderate drainage Category of dressing: HYDROCOLLOID Wound Dressing Guidelines: 3 day dressing change and PRN; Occlusive dressing that promotes autolytic debridement and moist healing Impermeable to outside bacteria and waterproof Heat activated adhesive-must hold in place one minute for best adherence Contraindications: infected wounds Interactive dressing that can produce odorous wound gel exudate; irrigate wound and re-assess for signs and symptoms of infection Product Name/Number (how to order) Exuderm wnd Exuderm LP #51207Exudern Sacrum#51206Exuderm Satin4X4 #512046x6 #51205 8
Improving practice one RN by one RN Champions of change allow group projects for changing practice across the organization Implementing EBP can happen with one RN Other tools to evaluated/implement EBP Journal club Unit based outcomes Clinical questions Clinical articles of interest/conferences Clinical Excellence Innovative Strategies Mentoring Staff Adoption Translating Research Into Practice Evidence-Based Practice 9
marybeth.makic@uch.edu kathy.oman@uch.edu 10