Pressure Ulcers: The Goal is Zero

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Pressure Ulcers The Goal is Zero
Kathy Duncan, RN IHI Faculty

• Colorado 5 Million Lives
• Campaign Launch
• November 15, 2007

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Prevent Pressure Ulcers

• The Goal
• Reduce the incidence of hospital-acquired
  pressure ulcers by December 2008.
• Focus on getting to zero.

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What Do we know?

• Whitfield MD, Kaltenthaler EC, Akehurst RL,
  Walters SJ, Paisley S. How effective are
  prevention strategies in reducing the prevalence
  of pressure ulcers?J Wound Care. 20009261-266.
• The prevalence of pressure ulcers has remained
  constant at about 7 over the past 20 years, even
  though considerable time and money has been
  invested in various prevention strategies.

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What Do we know?

• Lyder CH. Pressure ulcer prevention and
  management. JAMA. 2003289223-226.
• 1.3 million to 3 million adults have a pressure
  ulcer
• Estimated cost of 500 to 40 000 to heal each
  ulcer.
• The incidence of pressure ulcers varies greatly
  by clinical setting. Incidence rates of 0.4 to
  38.0 for hospitals, 2.2 to 23.9 for long-term
  care, and 0 to 17 for home care have been
  reported.
• Pressure ulcers in elderly persons have also been
  associated with increased mortality rates.

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What Do we know?

• Courtney BA, Ruppman JB, Cooper HM. Save our
  skin Initiative cuts pressure ulcer incidence
  in half. Nursing Management. 200637(4)35-46.
• OSF Saint Francis Medical Center initiated the
  implementation of the Six Sigma methodology which
  led to the development of the Save Our Skin (SOS)
  project, an effort that boasted an ambitious goal
  of reducing the number of hospital-acquired
  pressure ulcers in adult patients by 50 within
  one fiscal year.

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What Do we know?

• Breslow RA, Hallfrisch J, Guy DC, Crauwly D,
  Goldberg AP. The importance of dietary protein in
  healing pressure ulcers. J Am Geriatr Soc.
  199341(4)357-362.
• A study designed to determine the effect of
  dietary protein on healing of pressure ulcers in
  malnourished patients. The authors conclude that
  high protein diets may improve the healing of
  pressure ulcers in malnourished nursing home
  patients.

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What Do we know?

• Ferrell BA, Osterweil D, Christenson P. A
  randomized trial of low-air-loss beds for
  treatment of pressure ulcers. JAMA.
  1993269(4)494-497.
• Low-air-loss beds provide substantial improvement
  compared with foam mattresses.

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What Do we know?

• Risk is predictable.
• Risk factors include age, immobility,
  incontinence, poor nutrition, sensory problems,
  circulation problems, dehydration, and poor
  nutrition.
• Skin integrity can deteriorate in hours.
• Frequent assessment prevents minor problems from
  becoming major ulcers.
• Wet skin is more vulnerable to skin disruption
  and ulceration.
• Dry skin is a risk factor as well.
• Continual pressure, especially over bony
  prominences, increases risk.
• Pressure-relieving surfaces may help.

Reddy M, Gill SS, Rochon PA. JAMA.
2006296974-984.
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Burden of Pressure Ulcers

• Prevalence in acute care 15
• Incidence in acute care 7
• 5-7 of all acute hospital admissions
• 2.5 million patients treated each year
• Nearly 60,000 die each year from complications
• 11 billion dollars per year

Sources How-to-guide JAMA systematic review by
Reddy 2006, referenced a national pressure ulcer
Advisory panel (2001) Pressure Ulcers in
America Prevalence, Incidence, and Implications
for the Future An Executive Summary Of the
National Pressure Ulcer Advisory Panel Monograph
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An Example of What Is Possible
Decrease of 71

Source Pryor DB, Tolchin SF, Hendrich A, Thomas
CS, Tersigni AR. The clinical transformation of
Ascension Health eliminating all preventable
injuries and deaths. Jt Comm J Qual Patient Saf.
2006 Jun32(6)299-308.
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Reducing Pressure Ulcers
For All Patients

• Conduct a pressure ulcer admission assessment for
  all patients
• Reassess risk for all patients daily
• Inspect skin daily
• Manage moisture keep the patient dry and
  moisturize skin
• Optimize nutrition and hydration
• Minimize pressure

For High Risk Patients

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Conduct a Pressure Ulcer Admission Risk
Assessment Reassess Daily

• Use visual cues in admission documentation for
  completion of skin and risk assessment.
• Standardize risk assessment tool/checklist across
  the institution.
• Incorporate action steps linked to risk.
• Use multiple methods to visually identify
  patients at risk.
• Place stickers on chart, use visual cues on door
  and bed.
• Post compliance rates to motivate staff.
• Improve processes to ensure risk assessment is
  conducted within four hours of admission and
  reassess daily.
• Assess surgical patients.

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Inspect Skin Daily

• Daily skin inspection is required for high-risk
  patients.
• Skin integrity can deteriorate in a matter of
  hours.
• Always look at sacrum, back, buttocks, heels, and
  elbows every time the patient is assessed.

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Manage Moisture

• Cleanse skin at time of soiling and at routine
  intervals.
• Watch for excessive moisture due to perspiration
  and wounds.
• Use gentle cleansing agent.
• Use moisturizers for dry, fragile skin.
• Provide under-pads that wick moisture away from
  skin.
• Keep kit of needed supplies at bedside for
  at-risk incontinent patients.

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Optimize Nutrition/Hydration

• Respect patients dietary preferences.
• Involve dietician, use supplements as needed.
• Monitor hydration.
• Offer water (when appropriate) whenever patient
  is turned.

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Minimize Pressure

• Turn/reposition patient at least every two hours.
• Use alerts and cues to remind staff to turn
  patient.
• Protect skin when turning patient (use lift
  devices or drawsheets, heel and elbow
  protectors, sleeves and stockings do not
  drag).
• Use pillows and cushions strategically.
• Use static and/or dynamic pressure-relieving
  support surfaces.
• Static surfaces include well-designed mattresses,
  mattress overlays filled with water, air, gel,
  foam, or a combination of these.
• Dynamic surfaces include devices that vary
  pressure beneath the patient, reducing duration
  of pressure at any given skin site.

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Reduce Methicillin-Resistant Staphylococcus
aureus (MRSA) Infection
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Reduce MRSA Infection

• The Goal
• Reduce methicillin-resistant Staphylococcus
  aureus (MRSA) infection by December 2008.

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A Vision for the Future? MRSA in Denmark
100
Rosdahl VT, et al. Infect Control Hosp Epidemiol.
19911283-88.
90
80
70
60
50
MRSA Bloodstream Infections
40
30
20
10
0
1960 1965 1970
1975 1980 1985
1990 1995

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Or This? MRSA in the UK

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This Can Be Done!
University of Virginia Hospital

Thompson RL, Cabezudo I, Wenzel RP. Epidemiology
of nosocomial infections caused by
methicillin-resistant Staphylococcus aureus. Ann
Intern Med. 198297(3)309-317.
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VAPHS 4-West Hospital-Acquired MRSA Infection
Rate(per 1,000 days of care)

Source Eliminating Hospital-Acquired
Infections presentation slides from Jon Lloyd,
MD, FACS, from VHAs Best Practice Symposium,
September 18, 2006
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What Does the Evidence Tell Us?

• Target Modes of MRSA Transmission
• Person-person via hands of health care providers
• Personal equipment (e.g., stethoscopes, PDAs) and
  clothing
• Environmental contamination
• Airborne transmission
• Carriers on the hospital staff
• Rare common-source outbreaks

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Prevent Infection and Colonization

• Colonized patients
• Reservoir for transmission
• Nearly 1/3 develop infection, often after
  discharge
• Long-lasting and can transmit MRSA to patients in
  other health care settings (e.g., nursing homes)
  and family members
• High rates of MRSA colonization complicate
  empiric antibiotic therapy (e.g., vancomycin)

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Human and Financial Impact

• Over 126,000 hospitalized persons infected
  annually
• 3.95 MRSA infections per 1,000 hospital
  discharges
• Over 5,000 patients die as a result of these
  infections
• Over 2.5 billion excess health care costs
  attributable to MRSA infections
• On average, each patient with MRSA infection has
• 9.1 days excess length of stay (LOS)
• Over 20,000 excess cost per case
• (range 7,000 32,000)
• 4 excess in-hospital mortality

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Expert Input

• Association for Professionals in Infection
  Control and Epidemiology (APIC)
• Centers for Disease Control and Prevention (CDC)
• Society for Healthcare Epidemiology of America
  (SHEA)
• Experts published in literature
• Other Campaign partners

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Five Key Interventions

• Hand hygiene
• Decontamination of the environment and equipment
• Active surveillance cultures (ASCs)
• Contact precautions for infected and colonized
  patients
• Compliance with Central Venous Catheter and
  Ventilator Bundles

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Hand Hygiene

• Single most important intervention
• before and after patient contact
• Compliance rates of 40-50 no longer are
  acceptable
• Hold staff accountable
• Encourage patients and families to remind
  caregivers
• Alcohol hand rubs make hand hygiene easier
• Rapidly kill bacteria (except Clostridium
  difficile spores)
• Surprisingly gentle on hands
• Not a substitute for soap and water when hands
  are grossly soiled

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TIPS Hand Hygiene

• Count the steps!
• Check placement.
• Provide the supplies.
• Provide real-time feedback.
• Send and post department-level data.

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Decontamination of Environment and Equipment

• Use dedicated equipment for colonized/infected
  patients.
• Clean patient care and personal equipment when
  leaving the bedside.
• Put environmental services personnel on the team
• Clean and disinfect the environment carefully.
• Focus on high-touch areas.

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TIPS Decontamination

• Use a checklist for cleaning.
• Educate staff.
• Verify competence.
• Schedule cleaning times for rooms of patients in
  isolation or on contact precautions.
• Use immediate feedback mechanisms to assess
  cleaning and reinforce proper technique.

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Active Surveillance

• Use cultures (ASCs) to detect colonized patients.
• Necessity of ASCs per se in controlling MRSA is
  controversial.
• Knowledge is power. Clinical cultures miss
  many colonized patients.
• Successful programs combine ASCs with reliable
  implementation of other interventions.
• Flag colonized patients when discharged.

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TIPS Active Surveillance

• Begin with admission cultures only.
• Measure compliance add the second culture when
  high (gt 90).
• Provide real-time notification of positive
  admission culture.
• Schedule consistent day of week for second
  culture.
• Include culture in routine discharge order sets.
• Measure transmission.
• Number or rate of patients who convert from
  negative to positive
• Flag colonized patients when discharged.

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Contact Precautions

• Use for infected and colonized patients per
  CDC/HICPAC guidelines
• Gloves, gowns, and hand hygiene
• Single rooms preferred
• Reinforces need for reliable barrier practices
• Facilitates cleaning during stay and
  post-discharge
• If necessary, cohort patients with MRSA

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TIPS Contact Precautions

• Train staff on importance
• Ensure adequate supplies
• Check and replenish supplies regularly
• Consider scheduled times for checking supplies
• Educate patients and families/visitors
• Encourage them to question personnel
• Use visual cue especially if single rooms or
  cohorting not possible
• Ensure patients on precautions have same standard
  of care as others
• frequency of entering the room
• monitoring vital signs
• Plan notify for patient leaving room

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Device Bundles

• Critically ill patients at high risk
• May be colonized or acquire in hospital
• Bundles
• Central Line prevent BSLI
• Ventilator prevent VAP
• Minimize device days!

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Additional Resources

• Ihi.org
• Campaign Materials
• Getting Started Kit
• Annotated Bibliography
• Tools
• National Calls
• Mentor Network Hospitals
• Discussion Groups
• kathydduncan_at_comcast.net