Presentation on theme: "Pressure Ulcers: What we all need to know Sharon Baranoski,"— Presentation transcript:
1 Pressure Ulcer Reduction and Prevention Project Outcome Congress and Celebration Pressure Ulcers:What we all need to knowSharon Baranoski,MSN, RN, CWCN, APN, FAAN
2 Pressure Ulcer Reduction and Prevention Project Congratulations
3 ObjectivesRecognize the Agency for Healthcare, Research & Quality pilot initiativesDiscuss what Preventive Legal Care isReview the new International PU Guidelines from NPUAP & EPUAP
4 Pressure Ulcers: What we all need to know Significant ProblemAnnually 2.5 million patients treated in acute-care facilities for Pressure UlcersPU patients are 3 times more likely to be discharged from acute care to LTC
5 Pressure Ulcers: What we all need to know More likely to occur among those over 65 years of age--By Potential for 1 out of every 5 American, (72 million people) to be over 65.Despite guidelines on prevention & treatment PU are becoming increasingly common
6 Pressure Ulcers: What we all need to know Medicare records from 1993 to 2003 show: PU increased by 63% in hospitalized patientsMean average LOS of 13 days in acute care —higher than national average for a hospital LOSNet cost $ billion per annum
7 Pressure Ulcers: What we all need to know Medicare Goal: improve quality for beneficiaries while avoiding unnecessary costsResulted in review of Medicare payments and new coverage decisionsIn FY 2007 there were 257,412 Medicare beneficiaries with PU’s. Average DRG payment $37, 800 to $43,180Cost of treating 2.5 times the cost of preventingMedicare has lookef at opportunities to grow better quality healthcare for the 90 million elderly, diabled and low-income Americans who use their programs. Faced with financial situation that Medicare part A trust fund is projected to potentially be depleted by 2017, the challenge has been to improve quality for beneficiaries while avoiding unnecessary costs. This has resulted in review of Medicare payments and new coverage decisions. In FY 2007 alone, there were Med. Beneficiaries with pressure ulcers, for which the average DRG payment was 37 to 43 thousand dollars.
8 Pressure Ulcers: What we all need to know Incidence rates:0.4-38% hospitals% skilled nursing facilities0-17% in home health agenciesEvidence supports that PU occur relatively early in the admission processHospitals within the first weekLTC within the first 4 weeksNo data for home care
9 Pressure Ulcers: What we all need to know MortalitySeveral studies show a 60% mortality for older persons with PU within 1 year of hospital dischargeMost often PU don’t cause death but may be a predictor of mortality60,000 patients die each year from PU complications
10 Pressure Ulcers: What we all need to know Lawsuits—More than 17,000 lawsuits related to pressure ulcers annually2nd most common claim after wrongful death and greater than falls and emotional distress
11 PU Projects 2004--LTC regulations Tag F-314 Guidelines2004--LTC regulations Tag F-3142005--PU reportable in some states2007--Some states start PU CollaborativeFederal Register “PU can reasonably be prevented through application of evidence-based guidelines”2008—CMS QIO 9th Scope of work2008--POA indicator, HAC2009--NPUAP/EPUAP International PU Guidelines
12 Pressure Ulcer Prevention Prevention should be the goal of all healthcare providersPU prevention requires an interdisciplinary approach to care. Some parts of PU prevention are highly routined, but care must also be tailored to the specifics risk profile of each patient. No individual clinician alone can prevent pressure ulcers from developing. Rather PU prevention requires activities among many individuals, including the multiple disciples and mutiple teams involved in developing and implementing the care plan. To accomplish this organizantional change requires coordination, high quality care and operational change as well as individual expertise. Therefore prevention requires a system focused approach.PREVENTION
13 PU Prevention Are we ready for change? AHRQ pilot project Assessing Readiness—organizational changePressure Ulcer Prevention InitiativeMultiple, simultaneous modifications to work flowCommunicationDecision makingFailure to assess leads to unanticipated difficulties in implementationBringing about org. change of any type is difficult. It is even more difficult when it involves multiple, simultaneous modifications to work flow, communication and decision making. Do organizational members understand why change is needed?Failure to assess leads to unanticipated difficulties in implementation or even complete failure of the effort.Is there urgency to change?Is senior leadership supporting this initiativeWho will take ownership?What kinds of resources are needed?What if we are not ready?Do members understand why change is needed?Is there urgency to change?Is senior leadership supportive?Who will take ownership?What resources are needed?
14 PU Prevention Managing Change Implementation Team Members with critical knowledge of care processesConsider existing procedures and practicesRe-design depends on assessment of current practice and knowledgePlan for change based on the needs identified specific to your organizationBeing ready for change is a necessary but not sufficient prerequisite to changing your organization’s approach to PU prevention.
15 PU Prevention Best Practice What “bundles” of best practices do we use How should a comprehensive skin assessment be done?How should a standardized PU risk assessment be conducted?What can be done at the unit level to enhance prevention practicesWhat additional resources are available?Once you’ve determined that you are ready for change the implementation and unit teams should demonstrate a clear understanding of where it is headed in terms of implementing best practices. What quality improvement effort are you trying to do. Consensus should be reached on the above.
16 PU Prevention Implementing Best Practice Implementing the new prevention practices at the front-line levelCustomized to your organization & integrated to ongoing work processesNot a special project, it is a new required practiceAs you progress, additional interim changes may be neededRoles, responsibilities, engaging staffNo matter how good the bundle of best practice you develop is, if it is not used by the staff it will not be successful.
17 PU Prevention Checklist for implementing best practice Roles & responsibilities of staff:specific roles have been assignedMembers of wound care teamMembers of the unit-based teamThe unit championOrganizing the prevention work:Paths of ongoing communication & reporting identifiedMechanisms to address accountability have been developedStrategies for building new practices into daily routine identified
18 PU Prevention Putting practices into operations: An implementation plan has been developedSupport from key stakeholders has been assuredA plan to pilot test new practices has been initiatedA strategy for engaging staff has been establishedEducation plans have been devised to help staff learn new practices
19 PU Prevention Measuring PU rates & practices “If you can’t measure it, you can’t improve it.”QI program—tracking performance--Care is improving, staying the same, or even getting worseMonitor outcome ( P & I rates); at least one or two care processes (skin assmts, risk assmts)Monitor the staff compliance with their roles“If you can’t measure it, you can’t improve it.” Therefore PU performance must be counted and tracked as one component of a quality improvement program.
20 PU Prevention Sustaining prevention practices Most difficult part of a change processKeeping new practices in placeHow successful have we been in supporting new practices?Reinforcing the desired prevention practicesThe one step more difficult than implementating the initial changes is ensuring that those changes become woven into the day to day fabric of operations so that they are sustanined beyond the life of the formal improvement process.Essential that changes become integrated into existing organizational structure and routines, and that management goals and reporting mechanism are in alignment with the new standards and practices.
21 PU PreventionNo matter how well you are doing you can always do better! Perfection in pressure ulcer preventive care is NEVER achieved. All you can do is take steps to reach the ideal of no avoidable pressure ulcers.
22 Preventive Legal CareFederal Register (May 2007) states that PU’s can be “reasonably be prevented through the application of evidence-based guidelines”.Reasonably preventable DOES NOT MEAN“always preventable”Legal Uncertainty about the impact of this new Federal Register statement in the medical liability context
23 Preventive Legal CareIt is more important now than ever for healthcare providers to fully understand, appreciate and adapt to the legal issues that arise from the care of patients with pressure ulcers.The interrelationship betweenmedical-decision-making,reimbursement and legalissues has never been greater
24 Preventive Legal Care Lawsuits Judgments Common in acute and LTC $312 million in one single case Unlike other medical complications, they NEVER go unnoticed Visuals that PU’s create add to the financial potential of even the most meritless claims
25 Preventive Legal Care Areas of Vulnerability Guidelines P & P are guidelines not rules or regulations“policy” used interchangeably with rules and regulations“Words” used in P & P’sMandatory & exact compliance in the minds of our patients and lay personsAssist with care recommendations, rather than specifically regulate careReview yearly—check clinical currency, legal & healthcare implicationsReview wording carefully :always, never, must, shall, or immediately should be rigorously avoided
26 Preventive Legal Care Compliance Dilemma Institutional practices need to be evaluated to ensure compliance with prescribing regulations.Prescriptive privileges:MD’s, Do’s, NP’s, PA’sMust sign ordersStanding Orders:Must comply with prescribing lawP & P Can’t overrule the lawie: Ordering a enzymatic debrider; a pharmaceuticalNeed an Order/signature
27 Preventive Legal Care Scope of Practice Nursing Ensure that all caregivers are practicing within their scope of practice with regard to PU assessment & documentationCMS billing policy: advanced practitioners and other CMS-defined providers can make medical diagnoses.Staff delegationLVN, LPN—assessment cannot be performed independently
28 Preventive Legal Care Clinical Documentation Legal Perspective “What was not documented, was not done” Plaintiff’s argumentsUnreasonably high standard for cliniciansDocumentation must be balanced with patient careComprehensive, consistent, concise, chronological, continuing and also reasonably complete.The chart should note every time the patient was turned, his wound cleaned, the patient instructed on wound care, and so on.The notion that every event can be accurately and fully documented removes the focus from the patient care and puts it on creating a perfect paperwork”.
29 Preventive Legal Care Documentation Avoidable/Unavoidable Skin AssessmentRisk AssessmentPressure Ulcer AssessmentStaging & Wound DescriptionElectronic Medical Record/ManualPhotographySupport Surface useLong Term Care: CMS language: determination of compliance with Medicare lawTag F-314Evaluate resident’s clinical condition and risk factorsDefine & implement interventionsMonitor & evaluate impact of interventions
30 Preventive Legal Care Acute care Acute care CMS list four conditions that are never events, PU’s is not one of themHospital Acquired Condition applies to acute care, remember “reasonably preventable”Skin and Risk AssessmentPressure Ulcer AssessmentStaging & Wound DescriptionDocumentation in the EMR or Narrative chartInterventions and impactPhotography—follow facility policyTurn/Reposition/Support Surface use
31 Preventive Legal Care Home Care Home Care New OASIS C coming 2010 13 elements addressing Pressure ulcersImportant to document POA also with a full assessmentFocus: Appropriate wound care with improved outcomes; risk of developing wounds; care planning & preventionSkin and Risk AssessmentPressure Ulcer AssessmentStaging & Wound DescriptionDocumentation in the EMR or Narrative chartInterventions and impactPhotography—follow facility policyTurn/Reposition/Support Surface use
32 Home Care Success will be measured by: Reported outcomes-quality & adverse eventsSupply cost containmentOASIS accuracyVisit utilizationAppropriate wound care interventions based on evidence based protocols
33 Preventive Legal Care Education Education Professional Education— Education based on skill levelIn-house trainingAnnual reviewsInclude CNAs rolePatient & Family EducationLack of knowledge can fuel unrealistic expectationBasics of skin & pressure ulcer careImportance of turning & repositioningSupport surfacesWhat interventions you are doing for preventionRisk factorsNotify them when you see a problem occurring
34 Preventive Legal Care Expectations Communications Patient & Family expectationsPU riskPU developmentPrevention measuresPhysician should explain PU’s and document risk factorsDocument education on PU with patient and family members
35 EPUAP & NPUAP International Pressure Ulcer Guidelines PU’sLit. reviewBedsLit. reviewNutritionResearchInternational P. U. Guidelines, EPUAP/NPUAP Draft 2009
36 Pressure Ulcers Guidelines Purpose of the GuidelinesPrevention: Aim of these recommendations is to prevent the development of PU’s. The recommendations apply to all patient and vulnerable people of all age groups in all healthcare settingsTreatment: Aim is to recommend evidence-based care for patients with existing PU’s. The recommendations apply to all patient and vulnerable people of all age groups in all healthcare settingsInternational P. U. Guidelines, EPUAP/NPUAP Draft 2009
37 International P. U. Guidelines, EPUAP/NPUAP Draft 2009 Stage/CategorySTAGE IStage Intact skin with non-blanchable erythema of a localized area usually over a bony prominence. Discoloration of the skin, warmth, edema, hardness or pain may also be present. Darkly pigmented skin may not have visible blanching.Further description—no changeDefinitions: slight changesInternational P. U. Guidelines, EPUAP/NPUAP Draft 2009
38 International P. U. Guidelines, EPUAP/NPUAP Draft 2009 Stage/Category IISTAGE II Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguineous filled blister. Further description –no changeInternational P. U. Guidelines, EPUAP/NPUAP Draft 2009
39 International P. U. Guidelines, EPUAP/NPUAP Draft 2009 Stage/CategoryStage IIINO CHANGEStage IVNO CHANGEInternational P. U. Guidelines, EPUAP/NPUAP Draft 2009
40 International P. U. Guidelines, EPUAP/NPUAP Draft 2009 Stage/CategoryUnstageable or UNCLASSIFIEDAdded will be either a Stage III or IVNO CHANGEsDTI/ DEEP TISSUE INJURY—NO CHANGEInternational P. U. Guidelines, EPUAP/NPUAP Draft 2009
41 International P. U. Guidelines, EPUAP/NPUAP Draft 2009 Risk AssessmentRisk assessment all settings’Educate health care professional on how to achieve accurate & reliable risk assessmentStructured approach---use a scaleIncludes a skin assessmentConduct on admission and repeat as determined by patient acuityPrevention planInternational P. U. Guidelines, EPUAP/NPUAP Draft 2009
42 International P. U. Guidelines, EPUAP/NPUAP Draft 2009 NutritionBoth poor nutritional intake and poor nutritional status have been shown to correlate with the development of PU’s as well as protracted healing of wounds.Malnutrition –status of nutrition in which a deficiency or excess, or imbalance of energy, protein and other nutrients causes measurable adverse effects on tissue, body structure, body function and clinical outcome. In the guideline, malnutrition refers to a status of under-nutrition or undernourishment.Dehydration—common and under-recognized problemThe Exact causal relationship between PU’s and nutrition still remains unclearInternational P. U. Guidelines, EPUAP/NPUAP Draft 2009
43 International P. U. Guidelines, EPUAP/NPUAP Draft 2009 NutritionRecommendations: ESPEN and ASPENNutritional screen in every individual at risk of PU’sUse a valid, reliable and practical screening toolNutritional screening policy in placeNutritional risk and PU risk, refer to a dietician or other; consider enteral nutritionNutritional support-assess, monitor, evaluate, and reassessMinimum of 35 kcal per kg body weight per day, with 1.5 g/kg/day protein and 1 ml per kcal /day of fluid intakePalliative care: Prognostic profile and wishes of the individualEuropean society for clinical nutrition and metabolism and the American Society for Parenteral and enteral Nutrition.International P. U. Guidelines, EPUAP/NPUAP Draft 2009
44 Repositioning for the Prevention of Pressure Ulcers Component of PreventionAll at risk individualRepositioning must take into consideration the condition of the patient and the support surface in useRepositioning frequency—influenced by the pt’s condition and support surface in useDeFloor (2005) study: turning every 4 hours on a visco-elastic foam mattresses resulted in statically less pressure ulcers compared to turning 2 or 3 hours on a standard hospital mattress.Use a foot stool or foot rest when pt in chair and feet do not reach the floorDefloor RCT with strength of evidence a AInternational P. U. Guidelines, EPUAP/NPUAP Draft 2009
45 Repositioning for the Prevention of Pressure Ulcers Avoid sloughed positionLimit the time sitting in a chair & use pressure reliefSelect position that is acceptable to the individual and minimizes pressure and shear exerted on skin and soft tissueDocumentation should include, frequency,position adopted and evaluation of outcome of repositioning regimeEducation & Training of all caregiversInternational P. U. Guidelines, EPUAP/NPUAP Draft 2009
46 International P. U. Guidelines, EPUAP/NPUAP Draft 2009 Support SurfacesPrevention in individuals at risk should be provided on a continuous basis during the time that they are at riskDo not base the selection of a SS solely on the perceived level of risk or category/stage of pressure ulcerChoose a support surface compatible with the care settingExamine the appropriateness and functionality on every encounter. Verify that the SS is within its functional life spanUse high specification of foam mattresses rather than standard hospital foam mattress.Use an active SS (overlay or mattress) for pts at higher risk when frequent turning is not possible or condition preventsInternational P. U. Guidelines, EPUAP/NPUAP Draft 2009
47 International P. U. Guidelines, EPUAP/NPUAP Draft 2009 Support SurfacesContinue to turn & repositionUse a pillow under the calf to elevate the heelsHeel protecting devices should elevate the heel completely so to distribute the weight of the leg along the calf without putting pressure on the Achilles tendonSeating surface need more repositioning than when in a lying positionNo synthetic sheepskin, donuts or cut-out ring type devicesInternational P. U. Guidelines, EPUAP/NPUAP Draft 2009
48 International P. U. Guidelines, EPUAP/NPUAP Draft 2009 Operating RoomRefine risk assessment of individuals undergoing surgery by examining other factors which increase risk of PU development including:Surgery greater than 4 hoursIncreased hypotensive episodes intra-operativelyLow core temperature during surgeryReduced mobility on Day 1 Post-opUse a pressure redistributing mattress on the operating table for all individuals identified as being at riskPosition to avoid pressure during surgery and on heels, elevateUse a pressure redistributing mattress pre and post opChange the pts position pre & post operatively differently then when in surgery (if possible)International P. U. Guidelines, EPUAP/NPUAP Draft 2009
49 International P. U. Guidelines, EPUAP/NPUAP Draft 2009 Pain ManagementNew section on Pain Management:Prevent, Reduce, manageAssess all individuals for pain related to a pressure ulcer or its treatment. Assess for pressure-ulcer-related pain in adults using a validated scale.International P. U. Guidelines, EPUAP/NPUAP Draft 2009
50 So in the End, the new Guidelines are More ComprehensiveMore DetailMore Evidence BasedACCOUNTABLEInternational P. U. Guidelines, EPUAP/NPUAP Draft 2009
51 Pressure Ulcers occur in all settings, work together Keys to SuccessPressure Ulcers occur in all settings, work togetherThink out of the box. What can your institution/practice do to create a Center of Pressure Ulcer Prevention