Cross-setting PU Care

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					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

   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

   History of PU care
   Differences between settings
   PU prevalence rates by setting

   Pointing fingers
   New CMS-driven reasons to pay attention
                        History of PU Care

   How’d 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
MDS 2.0
MDS 2.0 (Continued)
    What’s next in the NURSING HOME: MDS 3.0

   Revisions
        Eliminates reverse staging (doesn’t 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 > 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
MDS 3.0
MDS 3.0
MDS 3.0
              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?)
                   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 <12%.
        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
        New priority area for IHI in 5 million lives campaign
            What has proven effective in NHs?

   National approach—Advancing Excellence in America’s Nursing
    Homes Campaign
   Similar to IHI’s 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
                      What’s 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
Progress in Nursing Home Care QI Toward National Goal
   By AE Campaign Participation and Target Setting:
           Campaign Results after One Year
                         0.0%   20.0%   40.0%   60.0%   80.0%   100.0%

  Goal 1 Pressure Ulcers

                                                                         Participants Selecting Goal

        Goal 2 Restraints
                                                                         Participants Selecting Goal
                                                                         and Setting Target

 Goal 3 Pain in Long-Stay

 Goal 4 Pain in Short Stay
                            Pointing Fingers

   Presently
        Rounding at the nursing home:
           ―We heal our PU’s. When we send our patients without PUs to the
             hospital, they come back with them.‖
        In the ED:
           ―I can’t believe they’d send such a patient to the hospital! Don’t 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 ulcers—they’ve been at a systematic approach longer, and
         worked through many of the difficulties in managing them
              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?
 Head Elevation to Reduce Ventilator Associated
Pneumonia and Skin-ICU Bed Interface Pressures
                        Peterson M, Schwab W, McCutcheon K, Gravenstein N, Caruso L

                                    Affected Supine Area over 30 mmHg
                                 y = -0.0026x3 + 0.378x - 8.0662x + 452.82
                                                R = 0.9987
                 800                                                  *
   Area (cm2 )




                        0      10        20          30         40           50        60   70       80
                                                  Head Elevation (degrees)
                                                      Series1        Poly. (Series1)
 Side Turning Does Not Reliably Reduce
       Skin-Bed Interface Pressure
Peterson M, Schwab W, McCutcheon K, Gravenstein N, Caruso
              Examples of What We Think vs.
                     What We Know

   Present examples:
       Unloading high pressure areas doesn’t always work the way we think it
       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 <1.9)
          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
Initial plot: From Counting/Intervention Start
After a Few Years
                            Take away:

   Pressure ulcer incidence refers to those that develop while in the
   Pressure ulcer prevalence refers to the total # of pressure ulcers
    from all sources
   Prevalence=what we inherit from others + what occurs under our

   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
                              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
            Key Steps to Match Up

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

               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, & @ 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
…and see if your data improves
   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

                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 doesn’t place patient in jeopardy through the hand-of
           process, and that the same things are counted in the same way
                    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
   Mitigation (have rescue protocols and antidotes available, engage
Wound              Stage I -            Stage II - Pressure Ulcer           Stage III or IV Pressure Ulcer                Wounds with
                Pressure Ulcer                      or                           or Full Thickness Wound                   Necrosis
                                        Partial Thickness Wound

Definitions   Stage I - An area         Stage 2 - An area of partial        Stage 3 - Full        Stage 4 - Deep       Stage 4– The base of
              where the epidermis       thickness loss of skin layers       thickness skin loss   tissue destruction   the wound cannot be
              is intact and the         involving the epidermis and         extending through     extending through    visualized – i.e.
              erythema (reddened        possibly penetrating into but not   the dermis to         subcutaneous         obscured by necrosis or
              skin) does not resolve    through the dermis                  involve               tissue to fascia     yellow slough
              within 30 minutes of                                          subcutaneous          and may include
              pressure relief.                                              tissue                muscle, tendon,
                                                                                                  joints, or bone

Exudate          PREVENTION             Dry to Light        Moderate          Dry to Light        Heavy Exudate            Wounds with
                                         Exudate            Exudate            Exudate                                      Necrosis
Dressings     Prevention                Cleanse: NS       Cleanse: NS       Cleanse: NS           Cleanse: NS          Cleanse: NS
and           Guidelines                If Dry: apply     Fill If Needed:   If Dry: apply         Fill: Calcium        Necrotic Wounds:
              Pressure relief to area    Wound gel to     Calcium           Wound gel to          Alginate to absorb   To facilitate autolytic
Change        Turn or reposition         Hydrate          Alginate          hydrate               exudate or to fill   debridement – apply ¼
Frequency     q2hr in bed; q1hr in      Cover:            absorb                                  dead space           inch Wound-Gel on
              chair                     Telfa type or     exudate           Fill If Needed:       Cover: Gauze or      necrotic area covered
              Pillow under calf to      Hydrocolloid      Cover:            Calcium alginate to   hydrocolloid         by Hydrocolloid
              float heels, cushion      Dressing          Gauze or           absorb exudate       dressing             dressing OR
              needed if in WC/GC        Change: q3        hydrocolloid      Cover:                Change: q3 days      Enzymatic can be used
              Monitor skin q 8 hours    days or when      dressing          Hydrocolloid          or when exudate      OR
              Protective Barrier if     exudate           Change: q3        dressing              is                   If gel & exudate create
              skin denuded, Wet, &      reaches 1 inch    days or when      Change: q3 days       1 inch from edge     too much moisture use
              Weepy                     from the edge     exudate           or when exudate                            Calcium Alginate to
              Hydrocolloid Drsg if                        reaches 1 inch    is      1 inch from                        absorb or Hydrocolloid
              friction involved                           from the edge     edge                                       Drsg alone to continue
                                                                                                                       autolytic debridement
                                                                                                                       Change: q3 days or
                                                                                                                       when exudate
                                                                                                                       reaches 1 inch from
                                                                                                                       the edge
                     Tools Everywhere

   Staging
   Process Frameworks
   Root cause analysis
   Management interventions
   Tracking
                          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
   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; who’s 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 >2/8h; what to report to RN
         every shift
   Louisiana: Skin Care Fair
                              Experience Abounds
   Minnesota:
        Safe SKIN program and toolkit, conference calls, business case,             AGE
         implementation tips, electronic & other documentation examples,
         interactive turning schedules, pediatric resources, staff training          ALB

          ppts, policies                                                             ASA
        OR issues
        Scott Triggers
            Assess pre-op for ALL 3 Triggers
              – Age over 62
              – Albumin < 3.5
              – ASA Score 3 or greater

           Consider length of Surgery (>3 hrs), position, current skin integrity.
           Type of surgery: Cardiac, vascular, trauma, transplants, and
                        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
   South Carolina: Pressure Ulcer Task Force Charter (5 Million Lives
        Set target for 10% reduction in PU statewide for 2008, definitions,
         treatment protocol, universal skin assessment tools across settings
                         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
          pressureulcers_slides.ppt
       Advancing Excellence Campaign: process framework, implementation
        guide, NJ collaborative experiences, slides and materials
       NPUAP-

   Don’t 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
Wound healing is a complex
  multi-factorial process
                        Soft Tissue Infection



    Systemic                                     Environment
  Healing Ability

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