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Intermountain-led CMS Hospital Engagement Network Preventing Pressure Ulcers October 22, 2013 Affinity Call Marlyn Conti - Intermountain, Patient Safety.

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Presentation on theme: "Intermountain-led CMS Hospital Engagement Network Preventing Pressure Ulcers October 22, 2013 Affinity Call Marlyn Conti - Intermountain, Patient Safety."— Presentation transcript:

1 Intermountain-led CMS Hospital Engagement Network Preventing Pressure Ulcers October 22, 2013 Affinity Call Marlyn Conti - Intermountain, Patient Safety Coordinator Gina Honermann-Garinger—Baylor Scott & White Health, Center for Clinical Innovation

2 Outline for Discussion HEN Pressure ulcer data What have you implemented this past year? What are your challenges? What’s next for your facility/system?

3

4 Intermountain HEN submitting Hospitals

5 Braden Risk Assessment Intermountain HEN Rate going up. Braden & Skin Assessment required within 24 Hours of admit

6 Ulcers below national best practice benchmark and trending down

7 Is this coding artifact? Are we charting better?

8 Intermountain HEN PrU =>3

9 HEN Pressure Ulcer Measures Metric specification resource manual content/uploads/2012/03/HEN_measure_Feb5.pdf content/uploads/2012/03/HEN_measure_Feb5.pdf Submission schedule: – November 20, 2013: for data through September 2013

10 Intermountain PrU Prevalence Trends All stages per quarterly prevalence survey, 22 hospitals

11 Intermountain Hospitals

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13 Call drill down to the patient and do cause analysis

14 Intermountain Hospitals Pressure Ulcer Prevention Tools Care plan for kardex Bed & surface algorithm Skin care product posters Patient fact sheets Working Harder

15 Baylor All Saints Hospital Acquired Pressure Ulcers PUT new data here please January 2013February 2013March

16 Baylor All Saints Pressure Ulcers > Stage Q1 & June Comparison Run Chart January 2012February 2013March

17 Baylor All Saints AHRQ PSI # Q1 & June Comparison Run Chart January 2013February 2013March

18 Participant Poll What to do for: Getting Started Working Harder Ahead of the Curve Pressure Injuries Identify areas needing most attention & appoint a leadership supported “lead” to drive improvement & education SWAT (or champion) teams that includes unit nurse/ Adopt decision algorithms for RNs to select appropriate surfaces make decisions independently of surface decisions. Establish monthly prevalence studies or incidence rates from electronic medical records then feed that data back to the SWAT teams. System What have you implemented What are your challenges What’s next Intermountain Pressure ulcer bundles Hard coding interventions in computer charting based on Braden scores ‘Getting to Zero’ Complacency Known complication Competing priorities Bundle compliance tracking Baylor Policy & procedures to back-up protocol Bedside reporting Present on admission reporting is improving EHR support for risk assessment Documentation of present on admission Participants Trial of iPad app for picture documentation in EHR

19 Pressure Ulcer Elimination “Bundle” = SKIN (Ascension Health) 19 Tissue injury can be more than skin deep…SKIN Manage N utrition and Hydration Manage I ncontinence K eep Patients Moving S election of Appropriate Support Surfaces

20 Getting Started Access Available Tool Kits Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care ch/ltc/pressureulcertoolkit/ ch/ltc/pressureulcertoolkit/ National Pressure Ulcer Advisory Panel AHRQ PSNet ov/ ov/ AHRQ Web M&M AHRQ Health Care Innovations Exchange hrq.gov/ hrq.gov/ Getting Started

21 Next Affinity Call Pending What questions or topics would you like addressed? Send questions to Access HEN webinars and resources at


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