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Preventing Pressure Ulcers

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1 Preventing Pressure Ulcers
Tuesday, May 6, 2014 These presenters have nothing to disclose IHI Expedition Preventing Pressure Ulcers Kathy Duncan, RN Annette Bartley, RN

2 Today’s Host Sarah Konstantino, Project Assistant, Institute for Healthcare Improvement (IHI), assists in programming activities for expeditions, as well as maintaining Passport memberships, mentor hospital relations and collaboratives. Sarah is currently in the Co-Operative Education Program at Northeastern University in Boston, MA, where she majors in Business Administration with a concentration in Management and Health Science. She enjoys cooking, traveling, and fitness.

3 Audio Broadcast You will see a box in the top left hand corner labeled “Audio broadcast.” If you are able to listen to the program using the speakers on your computer, you have connected successfully.

4 Phone Connection (Preferred)
To join by phone: Click the button on the right hand side of the screen. A pop-up box will appear with call in information. Please dial the phone number, the event number and your attendee ID to connect correctly .

5 Audio Broadcast vs. Phone Connection
If you are using the audio broadcast (through your computer) you will not be able to speak during the WebEx to ask question. All questions will need to come through the chat. If you are using the phone connection (through your telephone) you will be able to raise your hand, be unmuted, and ask questions during the session. Phone connection is preferred if you have access to a phone.

6 WebEx Quick Reference Welcome to today’s session!
Please use chat to “All Participants” for questions For technology issues only, please chat to “Host” WebEx Technical Support: Dial-in Info: Communicate / Join Teleconference (in menu) Raise your hand Select Chat recipient Enter Text

7 Please send your message to
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8 Expedition Director Kathy D. Duncan, RN, Faculty, Institute for Healthcare Improvement (IHI), oversees multiple areas of content and is the clinical lead for IHI’s National Learning Network. Ms. Duncan also directs content development and provides spread expertise for IHI’s Project JOINTS as well as additional content direction for the Hospital Portfolio, directs a number of virtual learning webinar series, and manages IHI’s work in rural settings. Previously, she co-led the 5 Million Lives Campaign National Field Team and was faculty for the Improving Outcomes for High Risk and Critically Ill Patients Innovation Community. In addition to her leadership on the field team during the Campaign, Ms. Duncan was the content lead for several interventions in IHI’s 100,000 Lives and 5 Million Lives Campaigns. She also serves as a member of the Scientific Advisory Board for the American Heart Association’s Get with the Guidelines Resuscitation, NQF’s Coordination of Care Advisory Panel and NDNQI’s Pressure Ulcer Advisory Committee. Prior to joining IHI, Ms. Duncan led initiatives to decrease ICU mortality and morbidity as the Director of Critical Care for a large community hospital.

9 Overall Program Aim The aim of the Expedition is to provide participants with strategies for preventing pressure ulcers that have been tried and tested in a variety of different contexts with great success. cory

10 Expedition Objectives
At the end of this Expedition, participants will be able to: Identify a range of simple tools and methods which will help you to prevent pressure ulcers Test strategies for identification of patients at risk for pressure ulcers Implement reliable processes for pressure ulcer risk assessment and pressure ulcer prevention Implement reliable processes for pressure ulcer prevention strategies​s

11 Schedule of Calls Session 1: Getting to Zero – Strategies for Success Date: Tuesday, April 22, 12:00 – 1:30 pm ET Session 2: Identification and Assessment of Patients at Risk Date: Tuesday, May 6, 12:00 – 1:00 pm ET Session 3: Developing Reliable Care Processes Date: Tuesday, May 27, 12:00 – 1:00 pm ET Session 4: Measurement for Improvement Date: Tuesday, June 10, 12:00 – 1:00 pm ET Session 5: Engaging Patients, Families, and the Community in Pressure Ulcer Prevention Date: Tuesday, June 24, 12:00 – 1:00 pm ET Session 6: Generating Ideas from Frontline Staff Date: Tuesday, July 8, 12:00 – 1:00 pm ET

12 Today’s Agenda Welcome and introduction
Discuss the action period assignment from call 1 Identification and assessment of patients at risk Guest presentations Action Period Assignment

13 Faculty Annette Bartley is a registered nurse with over 30 years of experience in healthcare. She has held leadership roles in frontline clinical care, management and at director level. In 2006 she was awarded a Health Foundation Quality Improvement Fellowship spent at the US Institute for Healthcare Improvement (IHI), during which time she also completed a Masters in Public Health at Harvard University. Annette is now an Independent Quality Improvement Consultant responsible for developing, supporting and leading a number of highly successful quality improvement and patient safety initiatives across the UK at regional, and national level. Her work extends internationally and she is viewed as an authority on the prevention of avoidable pressure ulcers using quality improvement methodology. Annette’s passion is inspiring and supporting frontline care teams to reliably deliver high quality, safe, person centered care.

14 Faculty Bevette Griffin, RN, CWON
Graduated from Saint Francis School of Nursing in Peoria, IL in 1973 Worked from 1973 to 1989 as Staff RN/ Charge RN at OSF Saint Francis Medical Center Working since 1989 as Ostomy/ Wound Care Nurse at OSF Saint Francis Medical Center Certified Ostomy/ Wound Care Nurse through Wound Ostomy Continence Certification Board since 1999

15 Action Period Assignment
W asked you to test the use of the Safety Calendar. Review your pilot unit’s current performance. Ask five members of staff what the unit’s process for preventing pressure ulcer is and check whether their responses match. In addition, check if they are consistent with your local policy/protocol. Check the charts of five patients and review the percentage compliance with risk assessment. We would welcome a couple of volunteers to share their learning from their pre-work Please raise your hands?

16 Identification and Assessment of Patients at Risk

17 Appropriate preventative
Developing a System’s Based Approach Risk Identification What will success look like? Risk Assessment Communication of Risk status Partnership with patient Appropriate preventative strategy implemented Do you have a clearly articulated care processes? Are they visible to all- if you are not able to ‘see’ them, then how can they be improved? How do you know how reliable your processes are? Evaluation of outcome

18 Who is at Risk?

19 High Risk Groups The presence of pressure ulcers has been associated with an increased risk of secondary infection and a two to four fold increase of risk of death in older people in intensive care units (Bo M, Massaia M et al, 2003). Pressure ulcers can occur in any patient but are more likely in certain high risk groups such as: The elderly, obese, malnourished and those with certain underlying conditions. Pressure ulcers can occur in any patient but are more likely in high risk groups

20 Anyone can get a pressure sore whether they are aged 10 or aged 80
Anyone can get a pressure sore whether they are aged 10 or aged 80. But the people who are most at risk are: People who have trouble moving and cannot change position themselves People who cannot feel pain over part or all of their body People who are incontinent People who are seriously ill, or have had surgery People who have a poor diet and don’t drink enough water People who are very young or very old People who have damaged their spinal cord and can neither move nor feel their bottom and legs Older people who are ill or have suffered an injury like a broken hip

21 Patient Stories Sarah aged 9 got a pressure sore on her heal after having an operation on her broken leg. Josie aged 28 had a pressure sore after giving birth to her first child and having an epidural. James, aged 35 suffered a pressure sore on the back of his leg after changing to a new wheelchair. Stan, age 73 got a pressure sore on his bottom after a bad chest infection kept him housebound for 2 months.

22 Risk Factors Limited Mobility Impaired Mental Status
Exposure to moisture Urinary incontinence Bowel incontinence Wound exudate Excessive Perspiration +++ Poor Nutritional Status Obesity Recent weight loss Feeding assistance needed Skin condition Pressure ulcer history

23 Risk of Pressure Ulcer by Number of Risk Factors
Number of risk factors present Mor, V et al Canadian J of Quality of Care

24 Risk Identification (Individual)
Consider risk factors that are present -Shortness of breath, weight loss, inability to eat, orthopedic surgery (hip, knee) diabetes Consider if patient cannot move voluntarily -Bedridden, chair ridden, coma, restrained, desaturation with movement, traction, pain Consider the history/ pattern of ulcer development -High risk? Or acquired, trapped in one place for extended time?

25 Risk Identification (unit/facility)
Patient Population Specialty Surgery, Gastrointestinal, ICU, Pediatric) Age Pain Urinary Catheters Nasogastric Tubes Oxygen cannula Oxygen masks Resources Staffing Equipment

26 Risk Assessment (NPUAP 2014)
Consider all bed-bound and chair-bound persons, or those whose ability to reposition is impaired, to be at risk for pressure ulcers. Use a valid, reliable and age appropriate method of risk assessment that ensures systematic evaluation of individual risk factors. Assess all at-risk patients/residents at the time of admission to health care facilities, at regular intervals thereafter and with a change in condition. A schedule is helpful and should be based on individual acuity and the patient care setting. Acute care: assess on admission, reassess at least every 24 hours or sooner if the patient’s condition changes Long-term care: assess on admission, weekly for four weeks, then quarterly and whenever the resident’s condition changes Home care: assess on admission and at every nurse visit. Identify all individual risk factors (decreased mental status, exposure to moisture, incontinence, device related pressure, friction, shear, immobility, inactivity, nutritional deficits) to guide specific preventive treatments. Modify care according to the individual factors. Document risk assessment subscale scores and total scores and implement a risk-based prevention plan.

27 Risk Assessment Tools It is not what you use… it’s the way that you use it
Braden Risk Scale was developed in 1987 by Barbara Braden and Nancy Bergstrom. Tested for reliability and validity with results published in Nursing Research in 1987. A larger multi-site study was conducted to determine the reliability and validity of the tool in a variety of settings. Results were published in Nursing Research in 1998. A follow-up report in Nursing Research in 2002 demonstrated that the tool could be used in Black and White subjects with similar validity. The Braden Scale offers the best balance between sensitivity and specificity and highest prediction capacity

28 Risk Assessment Assess pressure ulcer risk on admission for ALL patients within 2 hours (as soon as possible!) Re-assess skin at least daily (depending on individual risk) or when patients needs changes. Initiate and maintain correct and suitable preventative measures.

29 Need to Reduce Complexity
Gut Instinct- Is the patient at risk? YES or NO? Pre-Pressure Ulcer Risk Assessment (PPURA) - NHS Scotland

30 Engage Patients and Family
Involve patients and families in pressure ulcer prevention at the earliest opportunities Develop a contract of care What can we do together to help prevent pressure ulcers Patient Information leaflets

31 Predictable Risk Utilize patient ‘At risk’ cards to quickly identify those at increased risk

32 Making the Connection Risk assessment Communicate Preventative action
Measure impact

33 Communication Verbal Written Visual

34 PDSA Changes Patient risk cards Patient and family contracts
Visual cues Safety briefing/huddles Movement /activity sessions 100 days free campaign….

35 Questions? Raise your hand Use the Chat

36 Guest Presentations


38 OSF Saint Francis Medical Center And Children’s Hospital of Illinois
Peoria, IL 600+ Bed Level 1 Trauma Center Bevette Griffin, RN, CWON Graduated from Saint Francis School of Nursing in Peoria, IL in 1973 Worked from 1973 to 1989 as Staff RN/ Charge RN at OSF Saint Francis Medical Center Working since 1989 as Ostomy/ Wound Care Nurse at OSF Saint Francis Medical Center Certified Ostomy/ Wound Care Nurse through Wound Ostomy Continence Certification Board since 1999

39 HISTORY Decreasing HAPU’s was one of the first 6-Sigma projects adopted by OSF Saint Francis Medical Center in 2002. Pressure ulcer incidence was 9.4% when the project started. Initial goal was to decrease the incidence of HAPU’s by 50%. 3 root causes were identified: accountability, knowledge deficit and communication

40 IMPROVEMENTS Accountability: Ultimate ownership to the staff RN, NCM as the process owner, chart audits with action plans and collaborative turning effort Knowledge Deficits: Revised the skin breakdown prevention protocol, educated staff housewide, SOS team established Communication Deficits: SOS champion became the “ skin expert” on their units, SOS signs posted outside the door, overhead music and pages for turn reminders, pt and family education booklets

41 2002-present Gradual decrease in HAPU’s to below 2% quarterly since June 2011,reported to NDNQI. Constant challenges: Making skin a priority and creating a culture of prevention

All HAPU’s are assessed by the WOCN nurses for accuracy ( with the staging and IF they are really from pressure) All HAPU’s are reviewed on the unit level , by the unit council and an action plan is made. Then reviewed by the Evidence Based Practice council and the question is asked: Was the HAPU avoidable or unavoidable?

43 RECENT ADDITIONS 2 RN’s will assess every pt upon admission and transfer Unit “huddles” list patients with low Braden scores Report sheets have Braden score on them Trial on sacral dressings to decrease shear EICU-another pair of eyes for assessment Bedpan pages Continue “no-lift” culture and promoting early activity

44 PRESENT CHALLENGES Device related HAPU’s ( NG tubes, FMV, catheters)
Correct staging and documentation of pressure ulcers on admission by Physicians and nursing staff Transitioning the use of the sacral dressing to all the ICU’s Keeping the SOS initiative live and well

45 QUESTIONS? Please feel free to contact me at :

46 Action Period Assignment
Undertake at least one small test of change (PDSA) taking one or more of the ideas /changes you have heard presented on to-days call Test it in your area on a small scale Identify what you learnt and how you will build upon this learning Identify a local strategy for promoting pressure ulcer prevention awareness across the multi-disciplinary team and with patients and families

47 Expedition Communications
Listserv for session communications: To add colleagues, us at Pose questions, share resources, discuss barriers or successes

48 Next Session Annette Bartley, RN Kathy Duncan, RN
Karen Cole: Claxton-Hepburn Medical Center Stephanie Calcasola: Baystate Medical Center

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