Pressure Ulcers The Goal is Zero

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					             Kathy Duncan, RN
                IHI Faculty

    Pressure Ulcers:
    The Goal is Zero

Colorado 5 Million Lives
  Campaign Launch
    November 15, 2007
      Prevent Pressure Ulcers

The Goal:
Reduce the incidence of hospital-
 acquired pressure ulcers by December
Focus on “getting to zero.”
                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. 2000;9:261-
• 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.
                  What Do we know?
• Lyder CH. Pressure ulcer prevention and management.
  JAMA. 2003;289:223-226.
• 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.
                  What Do we know?

• Courtney BA, Ruppman JB, Cooper HM. Save
  our skin: Initiative cuts pressure ulcer incidence
  in half. Nursing Management. 2006;37(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.
                  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.
• 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.
               What Do we know?

• Ferrell BA, Osterweil D, Christenson P. A
  randomized trial of low-air-loss beds for
  treatment of pressure ulcers. JAMA.
• Low-air-loss beds provide substantial
  improvement compared with foam
                      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
    ─ 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. 2006;296:974-984.
                                       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
       • $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
                                   An Example of What Is

                                                                                   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 Jun;32(6):299-308.
         Reducing Pressure Ulcers
           For All Patients:
1. Conduct a pressure ulcer admission
   assessment for all patients
2. Reassess risk for all patients daily
         For High Risk Patients:
3. Inspect skin daily
4. Manage moisture – keep the patient dry
   and moisturize skin
5. Optimize nutrition and hydration
6. Minimize pressure
           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
   ─ 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
• Assess surgical patients.
           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
               Manage Moisture
• Cleanse skin at time of soiling and at routine
  ─ Watch for excessive moisture due to perspiration and
  ─ 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.
       Optimize Nutrition/Hydration

• Respect patient’s dietary preferences.
• Involve dietician, use supplements as
• Monitor hydration.
  ─Offer water (when appropriate) whenever
   patient is turned.
                   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
   ─ Static surfaces include well-designed mattresses, mattress
     overlays filled with water, air, gel, foam, or a combination of
   ─ Dynamic surfaces include devices that vary pressure beneath
     the patient, reducing duration of pressure at any given skin site.
Reduce Methicillin-Resistant
  Staphylococcus aureus
     (MRSA) Infection
            Reduce MRSA Infection

The Goal:
Reduce methicillin-resistant
 Staphylococcus aureus (MRSA)
 infection by December 2008.
                         A Vision for the Future?
                           MRSA in Denmark
          Rosdahl VT, et al. Infect Control Hosp Epidemiol. 1991;12:83-88.
                                        MRSA Bloodstream Infections
       1960    1965     1970     1975      1980    1985      1990    1995
  Or This?
MRSA in the UK
                                       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. 1982;97(3):309-317.
                    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 VHA’s Best Practice Symposium, September 18, 2006
         What Does the Evidence Tell Us?
• Target Modes of MRSA Transmission
   ─Person-person via hands of health care
   ─Personal equipment (e.g., stethoscopes, PDAs)
    and clothing
   ─Environmental contamination
   ─Airborne transmission
   ─Carriers on the hospital staff
     Rare common-source outbreaks
         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)
             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
                 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
          Five Key Interventions

1. Hand hygiene
2. Decontamination of the environment
   and equipment
3. Active surveillance cultures (ASCs)
4. Contact precautions for infected and
   colonized patients
5. Compliance with Central Venous
   Catheter and Ventilator Bundles
                       Hand Hygiene
• Single most important intervention
     before and after patient contact
• Compliance rates of 40-50% no longer are
  ─ 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
               TIPS: Hand Hygiene
•   Count the steps!
•   Check placement.
•   Provide the supplies.
•   Provide real-time feedback.
•   Send and post department-level data.
               Decontamination of
           Environment and Equipment

• Use dedicated equipment for colonized/infected
• Clean patient care and personal equipment
  when leaving the bedside. –
• Put environmental services personnel on the
• Clean and disinfect the environment carefully.
  ─ Focus on “high-touch” areas.
              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.
                Active Surveillance
• Use cultures (ASCs) to detect colonized
  ─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.
             TIPS: Active Surveillance
• Begin with admission cultures only.
  ─ Measure compliance; add the second culture when
    high (> 90%).
• Provide real-time notification of positive
  admission culture.
• Schedule consistent day of week for second
• 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.
              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-
• If necessary, cohort patients with MRSA
               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
                   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!
             Additional Resources
  ─Campaign Materials
     Getting Started Kit
     Annotated Bibliography
  ─National Calls
  ─Mentor Network Hospitals
  ─Discussion Groups