1-Introduction-20091113

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					Oregon Transitional Care & Pressure Ulcers Project
   Tools for Preventing and Minimizing Pressure Ulcers
                   Across Care Settings




                          June 2009


                      Endorsed by the
        Advancing Excellence and Oregon IHI Network
                     Joint Committee

                        Acumentra Health
          Oregon Alliance of Senior and Health Services
               Oregon Association for Home Care*
        Oregon Association of Hospitals and Health Systems
                Oregon Health Care Association
               Oregon Patient Safety Commission
               Seniors and People with Disabilities




                         *Endorsement pending
Oregon Transitional Care & Pressure Ulcers Project




Introduction and purpose
In the summer of 2007, healthcare leaders in Oregon began a conversation about the gaps in care
transitions, especially around patients with pressure ulcers. Although preventable and treatable if
found early, pressure ulcers are associated with increased mortality, especially in the elderly, and
are one of the leading iatrogenic causes of death reported in the United States. According to
recent estimates, 1.3 million to 3 million adults have a pressure ulcer, with an estimated cost to
heal each ulcer of $500 to $40,000. The incidence of pressure ulcers varies greatly by clinical
setting: 0.4% to 38.0% for hospitals, 2.2% to 23.9% for long-term care, and 0% to 17% for home
health care.
In Oregon, Advancing Excellence in America’s Nursing Homes and the Oregon IHI Network—
large statewide coalitions that were independently working on pressure ulcer reduction—decided
to join forces. Because people at high risk for pressure ulcers often move back and forth
between care settings, the two groups agreed to frame the issue as one of optimizing transitional
care and formed a Joint Committee to conduct research and develop interventions.
This toolkit is the culmination of the Joint Committee’s work over an 18-month period. It offers
practical information about reducing the prevalence of pressure ulcers, with a focus on
optimizing the outcomes of transitional care. Best practices are outlined for multiple settings of
care, including hospitals, nursing homes, community-based care, and home health and hospice
care. In addition, a handoff dataset is included, with several template options. The best practices
and handoff dataset tools were pilot tested in two community settings to confirm applicability
and usefulness.
Eleven stakeholder organizations initially committed to this project:
 Acumentra Health
 CareOregon
 Hartford Center of Geriatric Nursing Excellence, OHSU
 Oregon Alliance of Senior and Health Services
 Oregon Association of Hospitals and Health Systems
 Oregon Chapter, AARP
 Oregon Health Care Association
 Oregon Medical Association
 Oregon Nurses Association
 Oregon Patient Safety Commission
 Seniors and People with Disabilities
These organizations formed a subgroup to manage the ongoing day-to-day work. This group
became known as the Joint Committee and consisted of the following organizations:
 Acumentra Health
 Oregon Alliance of Senior and Health Services
 Oregon Association for Home Care
 Oregon Association of Hospitals and Health Systems
 Oregon Health Care Association
 Oregon Patient Safety Commission
 Seniors and People with Disabilities


Advancing Excellence and Oregon IHI Network Joint Committee                                       3
                                                   Oregon Transitional Care & Pressure Ulcers Project


The Oregon Association for Home Care, although not part of either of the founding coalitions,
was asked to participate to offer a critical additional voice regarding transitional care issues.

Background
A brief overview of the process
The Joint Committee organized the work into four stages:
    1. Learn more about the current state of the art by interviewing wound care and quality
       improvement experts.
       The Joint Committee completed structured interviews with 68 individuals during
       July and August 2007. Respondents were asked to comment on a draft of Best
       Practices for screening, preventing, and assessing pressure ulcers and to describe
       any systems they might currently have in place to support those Best Practices.
       They were also asked to comment on a definition of transitional care and describe
       how gaps in current practices might contribute to adverse pressure ulcer
       outcomes. Finally, they were asked to comment on areas where pressure ulcer
       care in Oregon can be improved and who needs to be involved in the effort. This
       toolkit includes a copy of the structured interview and a brief summary of
       findings.
    2. Develop a consensus best practice on how to prevent or minimize pressure ulcers.
       The Joint Committee sought to create a pressure ulcer best practice on which all
       healthcare facilities and providers could agree. To accomplish this, the Joint
       Committee convened a 22-member multidisciplinary Advisory Panel, with
       experts from nursing homes, hospitals, community-based long-term care, and
       home health.
       Through a series of facilitated face-to-face meetings and follow-up conference calls, the
       Advisory Panel crafted a linked set of Oregon Best Practices based on the most current
       evidence for preventing, assessing, and monitoring pressure ulcers in each setting of the
       continuum of care.
    3. Develop a handoff dataset that would define the most important information to be
       shared as patients/residents move from one care setting to another.
       The Advisory Panel also created a handoff dataset that defines key data elements
       to be shared as people at risk for or with pressure ulcers move from one care
       setting to another.
       Additional information about the development process of the Advisory Panel and
       the handoff data set are included later in this introduction.
       The best practices and handoff dataset are included in the toolkit for providers.
    4. Pilot the best practices and handoff dataset in two Oregon communities.
          The goal was to bring together hospitals, nursing homes, community-based care
           providers, and others for a practical test of the “in-development” transitional care
           approach. The focus was on facilitating conversations and implementation strategies
           at the local level, using natural referral networks and existing communication


4                                     Advancing Excellence and Oregon IHI Network Joint Committee
Oregon Transitional Care & Pressure Ulcers Project


           channels. This was difficult and exciting work. The pilot groups sought to answer the
           following basic questions: Do facilities’ care processes align with the recommended
           Best Practices?
          Can facilities solve transitional care problems using a “safe table” model?
          Will Best Practices and improved transitional care practices lower the prevalence of
           pressure ulcers in a community?
The Advisory Panel
The Oregon Best Practices and handoff dataset were developed through the collaborative efforts
of an Advisory Panel recruited by the Joint Committee. The selection process entailed
 identifying experts via the structured interviews
 seeking experts from stakeholder groups within the Joint Committee
 balancing membership to represent all settings of care appropriately
 drawing recruits from across the entire state
 limiting participation to a “workable” number of 20–25 individuals
As a result, the Advisory Panel was a well-balanced group that included wound care experts,
care coordinators/discharge planners, dietitians, physical therapists, representative physicians,
health plan representatives, and the state survey and certification program. Collectively, the
Advisory Plan had experience in four settings of care in Oregon: hospitals, nursing homes, home
health agencies, and community-based long-term care facilities.
Oregon Best Practices
The Advisory Panel reviewed existing guidelines, current clinical evidence, and regulatory
language related to preventing and minimizing pressure ulcers. Using a consensus model, they
organized the Oregon Best Practices for each care setting into two categories: those for which
there is published research evidence to support the recommendation and those for which the
recommendation is based on expert opinion or clinical experience (see the left and right columns,
respectively, in each best practice document).
The purpose of the best practice documents is to
 provide consistent care processes based on clinical evidence and scope of practice
   considerations
 develop population-based measures for care processes to support QI efforts
 consider emerging issues and make recommendations based on expert consensus or clinical
   experience
By disseminating these Best Practices, we hope to achieve the following goals:
 Reduce the prevalence of pressure ulcers in Oregon communities.
      Reduce the incidence of pressure ulcers in Oregon hospitals, nursing homes, home
         health agencies, and licensed community-based care facilities through the consistent use
         of evidence-based practice to prevent and minimize pressure ulcers.
    Improve the coordination of care for Oregonians at risk for or with pressure ulcers when
     they transition from one care setting to another.
    Use population-based measures to guide quality improvement efforts to prevent or
     minimize pressure ulcers within hospitals, nursing homes, home health agencies, and
     licensed community-based long-term care facilities.



Advancing Excellence and Oregon IHI Network Joint Committee                                    5
                                                   Oregon Transitional Care & Pressure Ulcers Project


Handoff dataset
The Advisory Panel was charged with creating a pressure ulcer handoff dataset. The purpose of
this document is to expedite care planning for a person with a suspected deep tissue injury or a
pressure ulcer as he or she transitions from one setting to another (e.g., hospital to nursing home,
nursing home to hospital, home with home health care). Generated by the transferring provider,
it includes the elements of a person’s risk factors for pressure ulcers or care plan for existing
pressure ulcers that are critical for the receiving provider to notice and respond to within a short
time after the transition. The handoff dataset is not intended to be a complete care plan, but is a
communication trigger for the facilities that are transferring and receiving the person.
The list of elements in the handoff dataset is based on recommendations of the Advisory Panel,
which paid close attention to differences among care settings regarding scope of practice, data
definitions, and use of common language. The dataset was evaluated by community pressure
ulcer teams in Albany/Lebanon and The Dalles, Oregon. The teams looked at how many of the
data elements are currently collected in their existing wound care tracking systems, how the data
elements can be organized (e.g., paper form, electronic medical record printout), and how to
ensure that the data get to the right person at the next setting of care. The handoff dataset was
modified based upon the feedback from these two test sites and the Advisory Panel.
Pilot community experience
The best practices and handoff dataset were piloted in two Oregon communities: The Dalles and
Lebanon. Participants in the community pilots were “cluster workgroups” consisting of the area
hospital and the care facilities in the surrounding area, which included nursing facilities, assisted
living facilities, and rehab facilities.
A key success factor in the work of the pilot communities was the use of an outside facilitator or
project manager to coordinate the participants and keep the project moving forward. Early in the
pilot, she met with prospective participants to explain and market the project as well as to gain an
understanding of the community culture. Understanding past history and working relationships
was important to successful facilitation in these small communities.
The facilitator also organized the cluster workgroup meetings, accommodating the ongoing
responsibilities and commitments of the individual team members.

The Dalles pilot community participants
   Columbia Basin Care Facility—nursing facility
   Evergreen The Dalles Health and Rehabilitation Center—nursing facility
   Mid-Columbia Medical Center—49-bed type B hospital in Wasco County, Oregon
   Mill Creek Point Assisted Living Community—assisted living facility
   Oregon Veterans’ Home—nursing facility

Comments from The Dalles participants
“Oregon Veterans’ Home has learned that the common goal of quality care kept us all committed
to the project. It has been a positive experience working with the other facilities. We learned that
changes can happen from this level, instead of it being a regulation that is mandated.” Assistant
Director of Nursing, Oregon Veterans’ Home
“I learned the beauty of a group coming together, working together and creating something to
improve our Resident/Patient care—which is why we do what we do. It was exciting to make a

6                                      Advancing Excellence and Oregon IHI Network Joint Committee
Oregon Transitional Care & Pressure Ulcers Project


difference that will hopefully change an area that really needed addressing. I haven’t had the
chance to implement the process, but was involved on the receiving end and it was invaluable to
get the detailed data of a wound for reference. In my particular job, I tend to be isolated—so it
was amazing to get involved with my peers and be so creative. Thanks.” Health Services
Director, Mill Creek Point Assisted Living Community

Lebanon pilot community participants
   Samaritan Lebanon Community Hospital—25-bed type B hospital in Linn County, Oregon
   Good Samaritan Regional Medical Center—134-bed hospital in Benton County, Oregon
   Regency Albany Rehabilitation Center—nursing home
   Avamere Rehabilitation of Lebanon—nursing home
   Avamere Rehabilitation (Twin Oaks) of Sweet Home—nursing home
   Mennonite Village—nursing home
   Willamette Manor—assisted living facility

Comments from Lebanon participants
“The information from the nursing home care plan would be so helpful to our nurses!” Nurse
Manager, Samaritan Lebanon Community Hospital.
“I am so excited about the application of this process to other areas.” Director of Nursing
Services, Avamere Rehab
Using the toolkit
The Joint Committee has organized the toolkit with sections arranged for specific users:
 Advisory Panel (initial research)
 Providers (hospitals, nursing homes, community-based care, home health and hospice care)
 Communities wishing to pursue a transitional care initiative
We believe the toolkit will be useful to individual organizations that are beginning quality
improvement efforts, to communities hoping to improve transitional care and handoff efficiency,
and to states and regions looking to build cooperative efforts. To keep current with science, our
Advisory Panel has agreed to reconvene every two years to evaluate the toolkit content.
To date, our efforts represent the energy and talents of
 11 convening organizations
 9 Joint Committee members
 68 wound care and quality improvement experts
 22 Advisory Panel members
 2 community teams
 Multiple hours of discussion and collaboration
Although Oregon doesn’t have all the answers, we are making great progress with
communication, collaboration, and alignment of goals. We recognize this project as a work in
progress; however, the format can certainly be applied to other statewide issues, such as pain
management, readmissions, and medication reconciliation.
We hope our journey can inform your journey. Good luck with your efforts!




Advancing Excellence and Oregon IHI Network Joint Committee                                      7
                                                 Oregon Transitional Care & Pressure Ulcers Project




Advisory Panel Members
The Joint Committee thanks the Advisory Panel members for their hard work and dedication to
this project. Their expertise and commitment were invaluable. Advisory Panel members were not
compensated by the Joint Committee for their participation. They participated because they are
committed to improving pressure ulcer care in Oregon.

Name                                 Organization
Janelle Asai, RD, LD                 Asai Consulting, LLC

Linda Barclay, RN                    Atrio Health Plans

Karen Bernius, PT

Mary Borts, RN                       DHS, Seniors and People with Disabilities,
                                     Client Care Monitoring Unit

Becky Callicrate, RN                 DHS, Seniors and People with Disabilities,
                                     Office of Licensing and Quality of Care

Debbie Christensen, BS, RN, CWOCN    Sacred Heart Medical Center, Wound and Ostomy Center

William Duncan, MD                   Legacy Wound Clinic

Cathy Eager, RN, BC, WOCN, CWS       Wound Care Protocols

Christina Ernst, CWCN, RN            Salem Hospital Home Care

Patti Garibaldi, RN, BA, RAC-CT      Marquis Companies/Consensus Healthcare

Lanny Hammett, MS, ANP, CWCN         Kaiser Permanente Long-Term Care

Theresa Harvath, PhD, RN, CNS        OHSU School of Nursing

Melissa Levesque, RN, BSN, IBCLC     Pioneer Memorial Hospital, Prineville

Janyce Lundstedt, MS, RN, CNS        Regional Nursing Administration, Providence Health & Services

Marijo Medcraft, RN                  U.S. Department of Veterans Affairs

Lesley Neville, RN                   DHS, Community-based Long-Term Care

Kerry O’Brien, ARNP                  Legacy Wound Clinic

Terry Ross, RN, MS, CWCN             OHSU School of Nursing, Klamath Falls

Darcie Ryan, RN, MS                  Consulting Resources

Ritu Sahni, MD                       DHS, Emergency Medical Services & Trauma Systems

Kim Williams, RN                     Clear Choice Health Plans




8                                   Advancing Excellence and Oregon IHI Network Joint Committee
Oregon Transitional Care & Pressure Ulcers Project




Best Practice References
The Advisory Panel reviewed the following literature in the process of compiling its
recommendations.
Articles
Keast DH, Parslow N, Houghton PE, Norton L, Fraser C. Best practice recommendations for the
prevention and treatment of pressure ulcers: update 2006. Wound Care Canada [serial online].
2006; 4(1):31–43. Available at: http://www.cawc.net/open/wcc/4-1/vol4no1-BP-PU.pdf.
Accessed April 20, 2009.

Lyder C, van Rijswijk L. Pressure ulcer prevention and care: preventing and managing pressure
ulcers in long-term care: an overview of the revised federal regulation. In: Pressure Ulcer
Prevention and Care: Incorporating New Federal Guidelines for Assessment, Documentation,
Treatment, and Prevention Supplement. Ostomy Wound Management. April 2005:2–6. Available
at: http://www.o-wm.com/files/docs/owmsupp_0405.pdf. Accessed April 20, 2009.

Van Rijswijk L, Lyder C. Pressure ulcer prevention and care: implementing the revised guidance
to surveyors for long-term care facilities. In: Pressure Ulcer Prevention and Care: Incorporating
New Federal Guidelines for Assessment, Documentation, Treatment, and Prevention
Supplement. Ostomy Wound Management. April 2005:7–19. Available at: http://www.o-
wm.com/files/docs/owmsupp_0405.pdf. Accessed April 20, 2009.

Gardner SE, Frantz RA, Troia C, et al. A tool to assess clinical signs and symptoms of localized
infection in chronic wounds: development and reliability. Ostomy Wound Management. 2001;
47(1):40–47.

Guidelines
Institute for Clinical Systems Improvement. Health Care Protocol: Skin Safety Protocol: Risk
Assessment and Prevention of Pressure Ulcers. 2nd ed. March 2007. Available at:
http://www.icsi.org/pressure_ulcer__skin_safety_protocol__risk_and_assessment_of/pressure_ul
cer__skin_safety_protocol__risk_assessment_and_prevention_of__protocol_.html. Accessed
April 20, 2009.

Institute for Clinical Systems Improvement. Health Care Protocol: Pressure Ulcer Treatment.
1st ed. January 2008. Available at:
http://www.icsi.org/pressure_ulcer_treatment_protocol__review_and_comment_/pressure_ulcer_
treatment__protocol__.html. Accessed April 20, 2009.

Wound, Ostomy, and Continence Nurses Society (WOCN). Guideline for Prevention and
Management of Pressure Ulcers. Glenview, Ill.: WOCN; 2003. Available at:
http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=3860&nbr=3071. Accessed
April 20, 2009.

Agency for Health Care Policy and Research. Pressure Ulcers in Adults: Prediction and
Prevention. Clinical Practice Guideline Number 3 (AHCPR 92-0047). Agency for Health Care



Advancing Excellence and Oregon IHI Network Joint Committee                                    9
                                                Oregon Transitional Care & Pressure Ulcers Project


Policy and Research, May 1992. Available at:
http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.4409. Accessed April 20, 2009.

Regulations
Centers for Medicare & Medicaid Services, State Operations Manual, Appendix PP – Guidance
to Surveyors for Long Term Care Facilities (Rev. 26, 08-17-07) §483.25(c) Pressure Sores.
Available at: http://www.cms.hhs.gov/manuals/downloads/som107ap_pp_guidelines_ltcf.pdf.
Accessed April 20, 2009.

Other sources
Institute for Healthcare Improvement, 5 Million Lives Campaign. Getting Started Kit: Prevent
Pressure Ulcers. How-To Guide. v03. Boston: IHI; 2008. Available at:
http://www.ihi.org/nr/rdonlyres/5ababb51-93b3-4d88-ae19-
be88b7d96858/0/pressureulcerhowtoguide.doc (free registration required). Accessed April 20,
2009.

Advancing Excellence in America’s Nursing Homes. Implementation Guide: Goal 1: Reducing
High Risk Pressure Ulcers. Quality Partners document 8SOW-RI-NHQIOSC-072307-1.
Available at: http://www.nhqualitycampaign.org/files/im/1_PressureUlcer_TAW_Guide.pdf.
Accessed April 20, 2009.

Minnesota Hospital Association. Road Map to a Comprehensive Skin Safety Program.
Minnesota Hospital Association. 2007. Available at:
http://www.mnhospitals.org/inc/data/tools/SafeSkin-Toolkit/roadmap.pdf. Accessed April 20,
2009. (Additional tools available at http://www.mnhospitals.org/index/tools-
app/tool.353?view=detail.)

New Jersey Hospital Association Quality Institute. Pressure Ulcer Prevention Change Package.
n.d.




10                                  Advancing Excellence and Oregon IHI Network Joint Committee

				
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