1. Pressure Ulcer Reduction and Prevention Project Outcome Congress and Celebration
Pressure Ulcers:
What we all need to know
Sharon Baranoski,
MSN, RN, CWCN, APN, FAAN

2. Pressure Ulcer Reduction and Prevention Project
Congratulations

3. Objectives
Recognize the Agency for Healthcare, Research & Quality pilot initiatives
Discuss what Preventive Legal Care is
Review the new International PU Guidelines from NPUAP & EPUAP

4. Pressure Ulcers: What we all need to know
Significant Problem
Annually 2.5 million patients treated in acute-care facilities for Pressure Ulcers
PU 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 patients
Mean average LOS of 13 days in acute care —higher than national average for a hospital LOS
Net cost $ billion per annum

7. Pressure Ulcers: What we all need to know
Medicare Goal: improve quality for beneficiaries while avoiding unnecessary costs
Resulted in review of Medicare payments and new coverage decisions
In FY 2007 there were 257,412 Medicare beneficiaries with PU’s. Average DRG payment $37, 800 to $43,180
Cost of treating 2.5 times the cost of preventing
Medicare 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 facilities
0-17% in home health agencies
Evidence supports that PU occur relatively early in the admission process
Hospitals within the first week
LTC within the first 4 weeks
No data for home care

9. Pressure Ulcers: What we all need to know
Mortality
Several studies show a 60% mortality for older persons with PU within 1 year of hospital discharge
Most often PU don’t cause death but may be a predictor of mortality
60,000 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 annually
2nd most common claim after wrongful death and greater than falls and emotional distress

11. PU Projects 2004--LTC regulations Tag F-314
Guidelines
2004--LTC regulations Tag F-314
2005--PU reportable in some states
2007--Some states start PU Collaborative
Federal Register “PU can reasonably be prevented through application of evidence-based guidelines”
2008—CMS QIO 9th Scope of work
2008--POA indicator, HAC
2009--NPUAP/EPUAP International PU Guidelines

12. Pressure Ulcer Prevention
Prevention should be the goal of all healthcare providers
PU 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 change
Pressure Ulcer Prevention Initiative
Multiple, simultaneous modifications to work flow
Communication
Decision making
Failure to assess leads to unanticipated difficulties in implementation
Bringing 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 initiative
Who 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 processes
Consider existing procedures and practices
Re-design depends on assessment of current practice and knowledge
Plan for change based on the needs identified specific to your organization
Being 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 practices
What 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 level
Customized to your organization & integrated to ongoing work processes
Not a special project, it is a new required practice
As you progress, additional interim changes may be needed
Roles, responsibilities, engaging staff
No 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 assigned
Members of wound care team
Members of the unit-based team
The unit champion
Organizing the prevention work:
Paths of ongoing communication & reporting identified
Mechanisms to address accountability have been developed
Strategies for building new practices into daily routine identified

18. PU Prevention Putting practices into operations:
An implementation plan has been developed
Support from key stakeholders has been assured
A plan to pilot test new practices has been initiated
A strategy for engaging staff has been established
Education 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 worse
Monitor 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 process
Keeping new practices in place
How successful have we been in supporting new practices?
Reinforcing the desired prevention practices
The 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 Prevention
No 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 Care
Federal 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 Care
It 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 between
medical-decision-making,
reimbursement and legal
issues 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’s
Mandatory & exact compliance in the minds of our patients and lay persons
Assist with care recommendations, rather than specifically regulate care
Review yearly—check clinical currency, legal & healthcare implications
Review 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’s
Must sign orders
Standing Orders:
Must comply with prescribing law
P & P Can’t overrule the law
ie: Ordering a enzymatic debrider; a pharmaceutical
Need 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 & documentation
CMS billing policy: advanced practitioners and other CMS-defined providers can make medical diagnoses.
Staff delegation
LVN, LPN—assessment cannot be performed independently

28. Preventive Legal Care Clinical Documentation Legal Perspective
“What was not documented, was not done” Plaintiff’s arguments
Unreasonably high standard for clinicians
Documentation must be balanced with patient care
Comprehensive, 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 Assessment
Risk Assessment
Pressure Ulcer Assessment
Staging & Wound Description
Electronic Medical Record/Manual
Photography
Support Surface use
Long Term Care: CMS language: determination of compliance with Medicare law
Tag F-314
Evaluate resident’s clinical condition and risk factors
Define & implement interventions
Monitor & 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 them
Hospital Acquired Condition applies to acute care, remember “reasonably preventable”
Skin and Risk Assessment
Pressure Ulcer Assessment
Staging & Wound Description
Documentation in the EMR or Narrative chart
Interventions and impact
Photography—follow facility policy
Turn/Reposition/Support Surface use

31. Preventive Legal Care Home Care Home Care New OASIS C coming 2010
13 elements addressing Pressure ulcers
Important to document POA also with a full assessment
Focus: Appropriate wound care with improved outcomes; risk of developing wounds; care planning & prevention
Skin and Risk Assessment
Pressure Ulcer Assessment
Staging & Wound Description
Documentation in the EMR or Narrative chart
Interventions and impact
Photography—follow facility policy
Turn/Reposition/Support Surface use

32. Home Care Success will be measured by:
Reported outcomes-quality & adverse events
Supply cost containment
OASIS accuracy
Visit utilization
Appropriate wound care interventions based on evidence based protocols

33. Preventive Legal Care Education Education Professional Education—
Education based on skill level
In-house training
Annual reviews
Include CNAs role
Patient & Family Education
Lack of knowledge can fuel unrealistic expectation
Basics of skin & pressure ulcer care
Importance of turning & repositioning
Support surfaces
What interventions you are doing for prevention
Risk factors
Notify them when you see a problem occurring

34. Preventive Legal Care Expectations Communications
Patient & Family expectations
PU risk
PU development
Prevention measures
Physician should explain PU’s and document risk factors
Document education on PU with patient and family members

35. EPUAP & NPUAP International Pressure Ulcer Guidelines
PU’s
Lit. review
Beds
Lit. review
Nutrition
Research
International P. U. Guidelines, EPUAP/NPUAP Draft 2009

36. Pressure Ulcers Guidelines
Purpose of the Guidelines
Prevention: 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 settings
Treatment: 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 settings
International P. U. Guidelines, EPUAP/NPUAP Draft 2009

37. International P. U. Guidelines, EPUAP/NPUAP Draft 2009
Stage/Category
STAGE I
Stage 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 change
Definitions: slight changes
International P. U. Guidelines, EPUAP/NPUAP Draft 2009

38. International P. U. Guidelines, EPUAP/NPUAP Draft 2009
Stage/Category II
STAGE 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 change
International P. U. Guidelines, EPUAP/NPUAP Draft 2009

39. International P. U. Guidelines, EPUAP/NPUAP Draft 2009
Stage/Category
Stage III
NO CHANGE
Stage IV
NO CHANGE
International P. U. Guidelines, EPUAP/NPUAP Draft 2009

40. International P. U. Guidelines, EPUAP/NPUAP Draft 2009
Stage/Category
Unstageable or UNCLASSIFIED
Added will be either a Stage III or IV
NO CHANGE
sDTI/ DEEP TISSUE INJURY—NO CHANGE
International P. U. Guidelines, EPUAP/NPUAP Draft 2009

41. International P. U. Guidelines, EPUAP/NPUAP Draft 2009
Risk Assessment
Risk assessment all settings’
Educate health care professional on how to achieve accurate & reliable risk assessment
Structured approach---use a scale
Includes a skin assessment
Conduct on admission and repeat as determined by patient acuity
Prevention plan
International P. U. Guidelines, EPUAP/NPUAP Draft 2009

42. International P. U. Guidelines, EPUAP/NPUAP Draft 2009
Nutrition
Both 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 problem
The Exact causal relationship between PU’s and nutrition still remains unclear
International P. U. Guidelines, EPUAP/NPUAP Draft 2009

43. International P. U. Guidelines, EPUAP/NPUAP Draft 2009
Nutrition
Recommendations: ESPEN and ASPEN
Nutritional screen in every individual at risk of PU’s
Use a valid, reliable and practical screening tool
Nutritional screening policy in place
Nutritional risk and PU risk, refer to a dietician or other; consider enteral nutrition
Nutritional support-assess, monitor, evaluate, and reassess
Minimum of 35 kcal per kg body weight per day, with 1.5 g/kg/day protein and 1 ml per kcal /day of fluid intake
Palliative care: Prognostic profile and wishes of the individual
European 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 Prevention
All at risk individual
Repositioning must take into consideration the condition of the patient and the support surface in use
Repositioning frequency—influenced by the pt’s condition and support surface in use
DeFloor (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 floor
Defloor RCT with strength of evidence a A
International P. U. Guidelines, EPUAP/NPUAP Draft 2009

45. Repositioning for the Prevention of Pressure Ulcers
Avoid sloughed position
Limit the time sitting in a chair & use pressure relief
Select position that is acceptable to the individual and minimizes pressure and shear exerted on skin and soft tissue
Documentation should include, frequency,
position adopted and evaluation of outcome of repositioning regime
Education & Training of all caregivers
International P. U. Guidelines, EPUAP/NPUAP Draft 2009

46. International P. U. Guidelines, EPUAP/NPUAP Draft 2009
Support Surfaces
Prevention in individuals at risk should be provided on a continuous basis during the time that they are at risk
Do not base the selection of a SS solely on the perceived level of risk or category/stage of pressure ulcer
Choose a support surface compatible with the care setting
Examine the appropriateness and functionality on every encounter. Verify that the SS is within its functional life span
Use 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 prevents
International P. U. Guidelines, EPUAP/NPUAP Draft 2009

47. International P. U. Guidelines, EPUAP/NPUAP Draft 2009
Support Surfaces
Continue to turn & reposition
Use a pillow under the calf to elevate the heels
Heel protecting devices should elevate the heel completely so to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon
Seating surface need more repositioning than when in a lying position
No synthetic sheepskin, donuts or cut-out ring type devices
International P. U. Guidelines, EPUAP/NPUAP Draft 2009

48. International P. U. Guidelines, EPUAP/NPUAP Draft 2009
Operating Room
Refine risk assessment of individuals undergoing surgery by examining other factors which increase risk of PU development including:
Surgery greater than 4 hours
Increased hypotensive episodes intra-operatively
Low core temperature during surgery
Reduced mobility on Day 1 Post-op
Use a pressure redistributing mattress on the operating table for all individuals identified as being at risk
Position to avoid pressure during surgery and on heels, elevate
Use a pressure redistributing mattress pre and post op
Change 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 Management
New section on Pain Management:
Prevent, Reduce, manage
Assess 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 Comprehensive
More Detail
More Evidence Based
ACCOUNTABLE
International P. U. Guidelines, EPUAP/NPUAP Draft 2009

51. Pressure Ulcers occur in all settings, work together
Keys to Success
Pressure Ulcers occur in all settings, work together
Think out of the box. What can your institution/practice do to create a Center of Pressure Ulcer Prevention