Crosssetting Pressure Ulcer Care - PowerPoint PPT Presentation

Title: Crosssetting Pressure Ulcer Care


1
Cross-setting Pressure Ulcer Care

• Stefan Gravenstein, MD, MPH
• Professor of Medicine
• Alpert Medical School of Brown University
• Clinical Director, Quality Partners of Rhode
  Island

2
Objectives

• Understand the issues in PU Care
• Historical and setting contexts
• Understand reasons to collaborate
• Measures
• Learn about models of collaboration
• What has happened nationally
• What has happened in RI
• Apply lessons learned to present initiative
• Discuss intervention plan
• Measures
• Interventions

3
Background

• History of PU care
• Differences between settings
• PU prevalence rates by setting
• Pointing fingers
• New CMS-driven reasons to pay attention

4
History of PU Care

• Howd we get to turning every two hours?
• Is ICU care better than ward care?
• If you put weight and pressure sensors on ICU
  patients and turn them more often, does turning
  more often (reducing pressure reading) reduce
  risk more?
• How do we stage? And reverse stage?
• What about NHs?
• Initiatives for reduced PUs
• More than process steps
• More than nutrition
• More than consistent assignment (but the next Big
  Thing)
• Measures

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MDS 2.0
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MDS 2.0 (Continued)
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Whats next in the NURSING HOME MDS 3.0

• Revisions
• Eliminates reverse staging (doesnt reflect
  pathophysiology)
• Measures changes in size (captures improvement
  and deepest anatomical change per NPUAP and
  WOCN)
• Separated venous stasis ulcers ( not staged) and
  diabetic ulcers
• Documents PUs on admission (incidence
  prevalence) by stage gt 1
• Allows for category of unstageable (NPUAP,
  WOCN)
• Matches best practices (no need for double
  charting by best homes)
• New PUSH items (tissue type for most advanced
  stage, largest PU)
• healed, worsened
• Deep tissue injury added to un-stageable group
• No documentation of exudate

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MDS 3.0
9

MDS 3.0
10

MDS 3.0
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Differences Between Settings

• Measures
• In NH, Minimum Data Set (MDS) reports PU
  prevalence (admission intervals) at facility
  level state reports state/national mean
  comparison. MDS Update (coming) fixes many of
  current MDS shortcomings
• In hospital, assessment is made near admission,
  but is not uniformly applied between
  institutions, making it difficult to compare
  prevalence is standard, but does not facilitate
  PDSA-driven improvement
• Care delivery
• NH has arrival, with documented MDS at intervals
  ritualized components of skin care relatively
  consistent approach between wards
• Hospitals has arrival assessment, but multiple
  provider, caregiver, materials, educational
  (departments, staff, location) interfaces
  complexity of environment and interfaces poses a
  special challenge
• Accountability issues (who owns the PU?)

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PU Prevalence By Setting

• Since 8th SOW, PU prevalence has been declining
  in NURSING HOMEs by 0.5 each year, translating
  into a decline of 20,000 pressure ulcers in just
  the last three years, now at a rate of lt12.
• Nursing home incidence is 2.2-24 Home health
  0-17
• HOSPITAL prevalence is between 7-14.
• Hospital incidence somewhere between .4 and 38
  point prevalence study in March, 1998 indicated a
  prevalence of 14 nationally
• No reliable data available on true present
  incidence or prevalence in hospitals
• New priority area for IHI in 5 million lives
  campaign

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What has proven effective in NHs?

• National approachAdvancing Excellence in
  Americas Nursing Homes Campaign
• Similar to IHIs 5 million lives campaign focus
  on getting to zero
• We already know what to do clinically
• Established
• Nutrition protein / AA adequacy
• Pressure turning, sleep surfaces
• Perfusion cardiac, atherosclerotic, pressure
• Oxygenation perfusion, ventilation, oxygen
  supplementation
• Sheer forces transfers, head of bed elevation
• Sleep surface foam vs. low-air loss vs. more
  advanced surfaces

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Whats the Latest? (1/3)Systems Thinking

• Agree to work on this as a common goal
• Know your number (establish incidence
  prevalence surveillance)
• Set a target
• Raise the bar
• Do a root cause analysis in high incidence areas
• Understand work flow
• Understand high incidence areas (ICU, for
  example)
• Responsibility and Accountability
• Consider patient perspective
• begin from initial encounter, i.e., ED
• Finish from final encounter, i.e., in transport
  vehicle leaving hospital
• Policies, procedures, and link to outcomes

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GOAL
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Pointing Fingers

• Presently
• Rounding at the nursing home
• We heal our PUs. When we send our patients
  without PUs to the hospital, they come back with
  them.
• In the ED
• I cant believe theyd send such a patient to
  the hospital! Dont they know how to practice
  medicine at the nursing home?
• In the hospital
• Can you believe all the pressure ulcers the
  nursing homes have that they send to us?
• The reality
• Nursing homes probably do a better job at
  preventing and treating pressure ulcerstheyve
  been at a systematic approach longer, and worked
  through many of the difficulties in managing them

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What Happens in the Hospital?

• Imperial thinking
• Have the answers
• Inconsistent approach
• Different things, resources, standards in
  different areas
• Different knowledge among providers (nutrition,
  disease, wound care, for example)
• Different accountability, authority,
  responsibility, priority
• More hand-offs between services
• Are the gurney mattresses as good as low air loss
  mattresses?
• How long does a patient sit on a gurney between
  ED and ward, between ward and specialty test, and
  what position?

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Head Elevation to Reduce Ventilator Associated
Pneumonia and Skin-ICU Bed Interface Pressures
Peterson M, Schwab W, McCutcheon K, Gravenstein
N, Caruso L
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Side Turning Does Not Reliably Reduce Skin-Bed
Interface Pressure Peterson M, Schwab W,
McCutcheon K, Gravenstein N, Caruso
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Examples of What We Think vs.What We Know

• Present examples
• Unloading high pressure areas doesnt always work
  the way we think it does
• The turn q2h guideline is arbitrary, not
  evidence-based (even though it is a standard of
  practice)
• Many other examples
• Protein supplementation relatively ineffective
  per se for those who are severely malnourished
  (e.g., albumin lt1.9)
• Arginine and glutamate become essential amino
  acids
• High energy drinks can accelerate wound
  deterioration if osmotic diarrhea is consequence
  (skin maceration, zinc depletion)
• Staffing patterns matter

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Initial plot From Counting/Intervention Start
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After a Few Years
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Take away

• Pressure ulcer incidence refers to those that
  develop while in the facility
• Pressure ulcer prevalence refers to the total
  of pressure ulcers from all sources
• Prevalencewhat we inherit from others what
  occurs under our care
• There is ability to affect incidence much more so
  than prevalence
• Incidence CAN be lowered to 2 or less
• Lowering prevalence is a SHARED responsibility

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Set up a Pilot

• Identify current processes and practices, and
  compare to evidence
• Set up a pilot (informed by a Root Cause
  Analysis)
• Start on a ward with high-risk patients and a
  clinical champion
• Segment Achieve high reliability with patients
  who share risk factors, such as high-risk
  clinical conditions/predisposing factors.
• Examples
• Medication adverse consequences
• Causing lethargy, confusion, loss of appetite,
  incontinence, fluid deficits, dry skin, etc.
• Restraints
• Preventive skin care
• Management of comorbidities
• Heart failure, thyroid disease, delirium, etc.
• Distinguish incidence in both those at high risk
  and low risk for PU

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Key Steps to Match Up

• Management
• Good basis for treatment selection
• Basic equipment and supplies
• Review approaches to selecting interventions
• Monitoring
• Processes to monitor progress
• Processes to monitor performance
• Processes to monitor practice

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Collect and then Use Your Data

• Care plan all patients, not just high risk
  (collect your data) skin assess regularly
  (daily?) reassess risk weekly, adm, _at_ d/c
• If PU incidence is high in those at low-risk for
  getting them, then there are likely care issues
• If not, but incidence higher than expected in
  high-risk individuals, there probably still are
  care issues (limits of current risk prediction
  tools)
• Figure out how to share your data with your
  competitors, to see how you are performing on a
  relative basis (use your QIO or some other
  neutral broker to blind identities)
• Use authoritative evidence-based interventions
  (what are the policies and procedures currently
  used based on?),
• Use a systematic process and experts to assist in
  selecting interventions
• and see if your data improves

29
Management

• Implement pertinent generic and cause-specific
  interventions, e.g.,
• Generic Give more training
• Cause-specific Address root causes of failures
  to carry out assignments related to preventive
  skin care, such as
• Priorities in care not clarified for staff
• Inadequate equipment or supplies
• Inadequate monitoring of performance
• Remember 4 Main Processes
• Problem recognition/assessments
• Cause identification/diagnosis
• Management/treatment
• Monitoring
• And, 3 Implementation steps
• Care process step
• Nursing implementation
• Recognizing success

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CMS and Who Pays for What

• Incidence vs. prevalence
• CMS pays for prevalent pressure ulcers
• CMS has removed payment for incident pressure
  ulcers
• Because of shifting to MDS 3.0
• CMS will have data on PU incidence that is not
  NURSING HOME acquired within the next years
• Hospitals will need to partner with sending
  providers to assure everyone is counting the same
  things in the same way
• Hospitals can partner with receiving providers so
  that the patient hand-off doesnt place patient
  in jeopardy through the hand-of process, and that
  the same things are counted in the same way

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Summary of What to Do

• Agree on PU reduction priority (align leadership
  and departments, set a goal for hospital-wide PU
  reduction)
• Share info Learn from each other and other
  settings (e.g., NHs)
• Use multidisciplinary teams (nursing, transport,
  quality, ED, materials)
• Measure (select measures, and add as indicated)
• Incidence and prevalence weekly then monthly
  basis (know your number, set your target)
• Improve methods, measures, reporting to detect
  harm and errors
• Use pilot rapid-cycle PDSA (small tests of
  change, weekly meetings)
• Prevention Standardize protocols and checklists
  across units and hospitals
• Mitigation (have rescue protocols and antidotes
  available, engage families)

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Tools Everywhere

• Staging
• Process Frameworks
• Root cause analysis
• Management interventions
• Tracking

34
Experience Abounds

• Arizona Collaboration across the continuum of
  Care
• Summit on care guidelines and coordination
  across settings, and on how collaboration
  improves quality and compliance, reduces risk
  explains methods and strategies for effective
  collaboration with other settings
• Iowa Baseline assessment
• RN Confidence in completing Braden accurately
  how long does it take to get a PU in a high risk
  person how often should the RN assess skin
  condition what can the RN do once skin
  discoloration suggests pressure injury whos
  responsible
• NA what is most common reason for PU how often
  check for signs of redness correct procedure for
  checking an air mattress every shift what
  products for stool incontinence of gt2/8h what to
  report to RN every shift
• Louisiana Skin Care Fair
• http//www.lhcr.org/html/providers/NHResources.ht
  m

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Experience Abounds

• Minnesota http//www.mnhospitals.org/index/tools-
  app/tool.353?viewdetail
• Safe SKIN program and toolkit, conference calls,
  business case, implementation tips, electronic
  other documentation examples, interactive turning
  schedules, pediatric resources, staff training
• ppts, policies
• OR issues
• Scott Triggers
• Assess pre-op for ALL 3 Triggers
• Age over 62
• Albumin lt 3.5
• ASA Score 3 or greater
• Consider length of Surgery (gt3 hrs), position,
  current skin integrity.
• Type of surgery Cardiac, vascular, trauma,
  transplants, and bariatric
• HIGH RISK SURGICAL PATIENT

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Experience Abounds

• Nevada Pressure Ulcer Task Force
• Nevada Transitions Group includes
• Hospitals, Home Health Agencies, Nursing homes,
  Managed care, Community stakeholders
• Prioritized 3 key areas of focus developing
  statewide standardized transfer form starting
  NJ-like collaborative in August
• New Jersey Pressure Ulcer Prevention Change
  Package
• See handout Patient level, Care team level,
  Leadership and system level
• South Carolina Pressure Ulcer Task Force Charter
  (5 Million Lives Campaign
• Set target for 10 reduction in PU statewide for
  2008, definitions, treatment protocol, universal
  skin assessment tools across settings

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Experience Abounds

• Washington Pressure Ulcer Steering Committee
• 4-6 subcommittees, talking points for
  recruitment, sample of subcommittee report, case
  review guidance
• National guidelines from most trade associations
  samples
• AMDA-complete CPG and forms toolkit
• www.amda.com/tools/cpg/pressureulcer.cfm
• www.amda.com/cmedirect/pressureulcers/
  pressureulcers_slides.ppt
• Advancing Excellence Campaign process framework,
  implementation guide, NJ collaborative
  experiences, slides and materials
• http//www.nhqualitycampaign.org/star_index.aspx?c
  ontrolsnhtechAssist
• NPUAP- http//www.npuap.org/resources.htm

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Conclusion

• Dont reinvent the wheel
• Use your local experts and QIO
• Work with provider partners and competitors
• Use the literature on-line, from nursing homes,
  expert consensus groups and task forces (pick one
  all can work on)
• Agree on the right measures
• This is too important not to be doing
• Especially for patients
• But also for all the other reasons

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Wound healing is a complex multi-factorial
process
Soft Tissue Infection
Pressure
SystemicIllness
Oxygen
Osteomyelitis
Perfusion
Wound Environment
Systemic Healing Ability
Nutrition
Compliance
Edema