Presentation on theme: "Pressure Ulcer Prevention Revisited"— Presentation transcript:
1Pressure Ulcer Prevention Revisited Linda J. Cowan, PhD, ARNP, FNP-BC, CWSResearch Health ScientistNorth Florida / South Georgia Veterans Health SystemGainesville, FLClinical Associate Professor, University of Florida College of Nursing
2Financial Disclosures Research Funding Received:VA Office of Nursing ServicesVA QUERIBiomondeHealthPoint/Smith & NephewCelleration, Medline, Hollister
3Clinical ProblemPressure ulcer prevention (PUP) is used as a quality of care indicator and is a top priority for all health care facilities.Preventable pressure ulcers still occurPUs impact 1.6 million Americans each year, collectively costing $3.6 billion annually in the United States (US) (Baranowski, 2006).
4Objectives Describe important evidence from PUP research Identify at least 3 components of successful PUP programsList essential members of PUP teamsDescribe methods of PUP education that providers may be more inclined to complete
5Key Questions to Answer How is your facility doing?Who should be involved?Where do we start with PUP strategies?Do providers want more PUP education?How should this education be delivered?Does recent research or the scientific literature have anything to contribute to PUP efforts?What are some helpful tips to making a successful PUP program?
6How is Your Facility Doing? PUP Efforts:How is Your Facility Doing?
7Our Organization: Veterans Health Administration (VHA) America’s largest integrated health care systemOver 1,700 sites of careServes over 8.3 million Veterans each yearAspirational goal for pressure ulcer reduction set by VHA: “Getting to zero”Target preventing all avoidable pressure ulcers - particularly most severe (stage III & stage IV)Office of Inspector General (OIG) completed 42 site visits of VA facilities (July 2013 to April 2014) to evaluate implementation of VHA Handbook “Prevention of Pressure Ulcers” revised July 1, 2011
8OIG: Top 7 areas for VA improvement 1. Consistent documentation of PU location, stage, risk scale score, and date acquired. (Facilities need the most improvement in this area)2. Facility-defined requirements for patient & caregiver PU education (for those at risk or w/PU); staff documentation of how/when this was provided3. Required activities performed (and documented) for patients determined to be at risk for pressure ulcers and for patients with pressure ulcers4. Facility defined requirements for staff pressure ulcer education, and acute care staff received training on how to administer the pressure ulcer risk scale, conduct the complete skin assessment, & accurately document findings.5. Skin inspections & risk scales performed: transfer, change in condition, & D/C6. If the patient’s PU was not healed at discharge, a wound care follow-up plan was documented, and patient was provided appropriate dressing supplies.7. For patients at risk for and with PUs, interprofessional treatment plans were developed, interventions were recommended, and Electronic Health Record (EHR) documentation reflected that interventions were provided.
9PUP Efforts in VA Facilities OIG: two areas needing most attention:Education (24 findings)Documentation (28 findings)These two areas accounted for 35% of all negative site visit findings
10VA Wound Provider Survey 2014 National VA Survey:March 3rd to March 31st, 2014online, anonymous1,726 VA wound providers~24% response ratePurpose:gather current evidence about experiences, education, preferences, and opinions of wound care providers related to wound management and PUPCowan, L & Garvan, C. (2014). Online Survey of VA Wound Providers. Poster presentation at SERWOCN, August 27, 2014, Montgomery, AL.
11Characteristics of Respondents and their facilities N % Main role (n=303 respondents)RNWound ConsultantARNPMDPTDPMOther (OT, CWOCN, SW, PharmD, etc.)9877493116131932%25%16%10%5%4%6%Main clinical setting (n=302)Inpatient acute care (not intensive care)Inpatient acute care (intensive care)Outpatient careRehabilitation careLong term careSpinal cord injury careOther534110783554418%14%35%3%12%1%Cowan, L & Garvan, C. (2014). Online Survey of VA Wound Providers. Poster presentation at SERWOCN, August 27, 2014, Montgomery, AL.
12Board certification (n=303) Currently board certified (wound) Was (wound) board certified in the pastNever (wound) board certified(SCI Providers: 12 BC / 0 BC in past / 38 never BC) N1578138 %52%3%46%Nature of wound management training (n=303)NoneOnly informalSome formal7981982%32%65%Years’ experience in wound care field (n = 271)Mean = 14.2SD = 9.8Cowan, L & Garvan, C. (2014). Online Survey of VA Wound Providers. Poster presentation at SERWOCN, August 27, 2014, Montgomery, AL.
13VA Wound Provider Survey 2014 Active inter-professional skin or PUPtask force at your facility? (n=303)YesNoNot sure N2293128 %80%11%8%SCI Setting67%2%10%Cowan, L & Garvan, C. (2014). Online Survey of VA Wound Providers. Poster presentation at SERWOCN, August 27, 2014, Montgomery, AL.
15TEAM: Together Everyone Aims for More Interprofessional Approaches to Pressure Ulcer Prevention (PUP)VeHU Presentation September 18, 2014Charlene Demers, ARNP, CWOCNAimée D. Garcia, MD, CWS, FACCWS
16Team“ A number of people with complementary skills who are committed to a common purpose, performance goals, and approach for which they are mutually accountable.”Katzenbach J & Smith D The Wisdom of Teams: Creating the High-performance Organization. Harvard Business School Press.
17Teams for PUPPressure ulcer assessment, prevention, and monitoring are an interprofessional (not solely WOC nurse) responsibility that includes:Systematic application of risk assessmentImplementation of preventive and therapeutic measuresMonitoring outcomesEducationDocumentation
18Team members Physicians- Surgeon and Medicine (PAs) Nursing (NP, RN, LPN, CNA)Physical Therapy (PT, PTA)Occupational TherapyNutritionPharmacyProstheticsSocial worker(s) / Case ManagersAdministration
19Interprofessional Approach PhysiciansEarly surgical intervention to improve mobilityOrdering of pressure redistribution surface after surgerySupervision of overall clinical careCollaborate in prevention planNursingNursing assumes the primary role by identifying those at risk, initiating and coordinating the plan of care for preventionRisk assessment and prevention strategiesImplementation of standing order setsTurning and repositioning / OffloadingIdentifying and entering necessary consultsPT/OT, dietician, social worker, etc.ADD WHAT PHYSICIANS AND TEAM MEMBERS WOULD DO IN GENERAL, AND WHAT WAS SPECIFICALLY DONE IN THIS CASE.
20Rehabilitative and/or SCI staff recommend strategies to improve mobility and use of protective & pressure redistributing devicesPhysical Therapyimprove mobility, function and activity levelsEvaluate safety of ambulationOrdering appropriate durable medical equipment to improve patient’s functional statusOccupational TherapySeating evaluations
21Pharmacists Social Workers Informatics assist with analysis of medication profile, product availability, and parenteral nutrition formulationSocial Workersassure prevention is priority across continuum of careevaluate and address special needs and discharge planningInformaticsfacilitate documentation and accurate communication among team
22Logistics and Prosthetics Quality Managementassists with monitoring incidence and evaluating program outcomesEducation Departmentassists with ongoing education for staff and patients and/or the patient’s designated family members, surrogates, or authorized decision makersLogistics and Prostheticsassist with availability of products and devices for preventionThe responsibility for communication is the whole team. The team works with informatics to set up documentation.
23Where do health care facilities start with PUP strategies? PUP Efforts:Where do health care facilities start with PUP strategies?
24Start with ABCDE… ABCDEs of PUP Initiatives (Lyder & Ayello, 2009). Administrative support backed by support at patient care level is vitalBundling care practices + having an identifiable themeCreating culture of change, commitment, and communicationDocumentation of pressure ulcer prevention practices must be visibleEducation is essential (I would also add: all initiatived should be Evidence-based)
25Administrative Support Top – Down approach (National, Regional, Facility)Create positive culture, support staff, provide accurate & consistent policies and tools (outcome tracking & reporting)Ways to approach AdministrationFocus on Improving Quality and Cost SavingsDemonstrate how efforts (investment of people, resources, time) will improve delivery of safe & effective patient care & patient outcomesNumbers talk: Know your potential ROI (Return on Investment)Conference, Workgroup, Lean Project, Systems RedesignPU prevention and management must be identified as priority with resources allocated to develop & sustain effective programSupport for interprofessional approachesSupport for certified wound specialists & their continuing education (CWOCN, CWCN, CWS, WCC, etc.)Support for equipment & devices such as OR table pads, specialty beds, mattresses & seat cushions, heel floatation devices, etc.
26Bundling PracticesAgency for Healthcare Research and Quality (AHRQ) evidence-based best practices (EBBP) for pressure ulcer prevention in “Toolkit for Improving Quality of Care” (2011)“Bundle” concept was developed by Institute for Healthcare Improvement (IHI)Concept of skin care “bundle”Groups together specific care practices to achieve desired outcomeThree critical components (evidence-based):Standardize pressure ulcer risk assessmentComprehensive skin assessmentCare planning and implementation to address areas of risk
27SKIN BundlesVA Skin Bundle (VASKIN): a concerted effort to disseminate EBBP into clinical setting(s)VA SKIN bundle exceeds three critical componentsby incorporating specific (evidence-based) interventions based on recommendations published by National Pressure Ulcer Advisory Panel and Wound Ostomy, Continence Nurses SocietyVA SKIN bundle is evidence-based frameworkbut will allow for innovation for special population(s)
28Great Example: VISN16 Success “VA Skin Bundle” concept approved by 21 subject matter experts from VISN 16 Skin Integrity WorkgroupAt VISN 16 Skin Integrity Summit II held September, 2012 in Ridgeland, MSAdditional edits/revisions provided by members of VHA National “HAPU” Prevention Initiative supported by Office of Nursing Services (ONS)Skin Bundle example in next slide presented nationally on Virtual Learning University (VeHU) in 2013Special recognition goes to Suzy Scott-Williams, RN, MSN, CWOCN & Mona Baharestani, PhD, APN, CWON, FACCWSOver 300 clinicians attended virtually
29V A S K I N Veteran’s Skin Bundle Assess Skin and Risk Status Risk Assessment on Admission (Braden, SCI, Surgery, medical device)Inspect skin (head to toe) during care activities (e.g. turning, bathing)Select Surfaces and Devices to Redistribute/Relieve PressureKeep Turning and RepositioningIncontinence ManagementNutrition and Hydration Assessment and InterventionVeteran’s Skin BundleAssess Skin and Risk Status1,2,3,4Risk Assessment on Admission (Braden, SCI, Surgery, medical device)Inspect skin during care activities (e.g. turning, bathing)Select Surfaces and Devices to Redistribute/Relieve Pressure1,2,3Keep Turning and Repositioning1,2,3Incontinence Management1,2,3Nutrition and Hydration Assessment and Intervention1,2,3,4The VA skin bundle was our effort to disseminate evidence based best practices into the clinical setting.The Agency for Healthcare Research and Quality (AHRQ)5 has identified evidence based best practices for pressure ulcer prevention in the “Toolkit for Improving Quality of Care” (2011). Among these best practices is the notion of creating a skin care bundle that takes specific care practices and groups together to achieve the desired outcome. The bundle concept was developed by the Institute for Healthcare Improvement (IHI). Three critical components were identified including:Comprehensive Skin assessmentStandardize pressure ulcer risk assessmentCare planning and implementation to address areas of riskThe VA Skin bundle takes these identifiable themes a step beyond by incorporating specific interventions based on recommendations published by the National Pressure Ulcer Advisory Panel2 and the Wound Ostomy, Continence Nurses Society3.- The va Skin bundle is an evidence based framework but will allow for innovation for special population.Suzy Scott-Williams, RN, MSN, CWOCN, 2013
30Using Quality Improvement Process Improvement / Quality Improvement and Continuous Quality Improvement methods to implement Bundles:Plan – Do – Check - ActLeanSix SigmaSystems RedesignVA TAMMCS
32Reduce HAPU stage III & IV by 30% from FY12 to FY13 Interprofessional Team, Nurse Managers, Staff NursesNursing ProcessVANOD data, Internal assessment Mini RCA on each incidenceVANOD = VA Nursing Outcomes DatabaseRCA = Root Cause AnalysisAction Plan, Education, compliance, equipment, devices resourcesCommunication plan, feedback, Executive leader involvement
33Comparison of other Skin Bundles VHA: VA SKINVA: Assess risk & skin, Select surfaces/devices, Keep turning/repositioning, Incontinence management, Nutrition & hydration (assess & address)AHRQ: AHRQ Pressure Ulcer BundleComprehensive skin assessment, standardized risk assessment, evidence-based care planning & implementation to address areas of risk, defining staff roles, educate staff, clinical pathwaySIGN & Ascension Health: SSKINSkin inspection, Surface selection, Keep turning/keep moving, NutritionCommon to all: Documentation, Education, Evidence
34Authors:Roger Resar, MD: Senior Fellow, IHI; Assistant Professor of Medicine, Mayo Clinic School of MedicineFrances A. Griffin, RRT, MPA: Faculty, IHICarol Haraden, PhD: Vice President, IHIThomas W. Nolan, PhD: Senior Fellow, IHI
36Build Your Own “Bundle” Acute Care Skin BundleRisk AssessmentSkin InspectionKeep Moving / RepositioningPrevent Shearing ForcesFloat / Elevate HeelsIncontinent Care: Moisture ManagementPressure Redistribution: Support SurfacesPatient / Caregiver / Staff EducationBuild Your Own “Bundle”Additional evidence based bundles can be developed to incorporate specifics of special patient populations such as community living centers , operating room, spinal cord injury, or patients at risk due to circulation. This specific bundles can be posted on the HAPU SharePoint site. I have included some examples from various clinical experts and facilities' within VAAcute CareIntensive Care/Progressive CarePerioperative/Operating RoomMental HealthSpinal Cord Injury (SCI)Community Living Centers (CLC)Hospice/Palliative CareAmbulatory CareHome CarePrimary CareOther
37Perioperative Skin Bundle (Scott-Williams, 2012) Skin Assessment : Pre-op, post-op, recovery, transfer (educate professionals)Scott-Triggers: Tool developed by Suzy Scott-Williams to identify surgical patients needing specific interventions to prevent perioperative PU (>2 = risk)Braden Scale: Common risk assessment tools may not be valid in O.R. setting(score <20 = risk)Transfer Devices: Appropriate transfer devices protects staff from injury and reduces risk of friction and shear injury to patientTable Pads: Pressure reducing/redistributing pads for O.R. tables (recommended for any surgical procedure over __ hours)Positioning Equipment: Stirrups, arm boards, heel devices, ulnar padding (based on evidence); heels should always be off-loaded in supine position.Padding: Use padding and padding practices that are evidence-basedHand-off Communication: Use effective and consistent communication tools/practices
38SCI Specific Skin Bundle Kathleen Dunn and Susan ThomasonRisk – Assessment – Interventions – Annual Evaluation – Patient EducationPressure Ulcer Risk Factors (Significant in evidence-based literature)Complete SCIHistory of at least 1 previous ulcerPressure Ulcer (PU) RecurrenceNumber of years since injuryInjury duration >30 years…Per VHA Handbook (2011) “Prevention of Pressure Ulcers”Document risk upon admission, discharge, transfer, or change in condition using Braden, or a pressure ulcer risk scale that has been validated in people with SCI …Per VHA Handbook (2011) “Spinal Cord Injury/Disorders (SCI/D) System of Care”All Veterans with impaired sensation or mobility must have an annual comprehensive assessment of risk factors, a review of prevention strategies, a thorough inspection of skin/body wall, and recommendations for pressure ulcer prevention shared with the Veteran (i.e., a pressure ulcer prevention plan)…
39Bundling care practices is only one part: Don’t Forget the whole ABCDE Approach Administrative support backed by support at the patient care level is vitalBundling care practiceshave an identifiable “theme”Creating a culture of change, commitment, and communicationDocumentation of pressure ulcer prevention practices must be visibleEducation is essential
40Creating a Culture… Change Commitment Communication Never easy but necessary for improvementEmbrace the concept of a JUST cultureAvoiding blaming people for failureCritically examine processes which result in failureCommitmentPatient Safety FirstCommunicationMost process failures result from lack of communicationDocumentation
41Documentation of PUP Practices Must be visible – readily available and easily found (patient’s medical records & unit tracking)Must be accurate – date, time, patient assessment, skin & wound assessment, patient needs (including education), plan to meet these needs, exactly what was done, and follow upMust be consistent“Tending of data on HAPU rates, severity, and documentation compliance must be integrated into the culture of the unit” (Susie Scott-Williams, 2012)
42Education is Essential AdministrationClinical staffAll settingsinpatient, outpatient, ICU, LTC, Rehab, home, etc.Ancillary staffhousekeeping, engineering, volunteers, etc.PatientCaregivers / family membersCommunity
43All Initiatives should be Evidence-Based Sources of Evidence:External EvidenceRobust researchStrength of evidenceQuality – Quantity – Validity - ReliabilityInternal EvidencePI/QI methodsApplicable to your situation?
44Having Evidence Based Protocols Taken from AAWC presentation “Developing a Comprehensive Content Validated Pressure Ulcer Guideline” (2012) on - Susan Girolami & Laura Bolton (Co-Chairs).
46AAWC Wound Care Specialty Council Significant Findings of Mean Content Validity for PU Prevention Guidelines (Sandwich)DocumentationInterdisciplinary ApproachRisk AssessmentNutritional AssessmentHydration & Nutrition plan of careMedical/surgical historyPsychosocial/quality of lifeEnvironmental factors (fall risk)Rehabilitation & restorative programsPosition to manage pressure, shear, frictionOff-loading beds, chairs, OR equipmentPhysical ExamSkin inspection & MaintenanceEducation
47PUP Efforts:Do providers want more PUP education? If so, How should this education be delivered?
482014 VA Wound Provider’s Survey 140Almost 50% said NO
49VERY confident caring for this wound type Which types of wound are you most confident caring for?VERY confident caring for this wound type% respondents See this wound type weeklyMinor injuries (abrasions, skin tears)81%66%Pressure ulcers72%73%Moisture related dermatitis and incontinence associated dermatitis65%53%Acute wounds62%55%Chronic wounds61%79%Surgical wounds60%51%Venous leg ulcers52%Traumatic wounds44%21%Diabetic foot ulcers41%Arterial ulcers/Peripheral Arterial Disease (PAD)38%43%
50Top 10 Topics of Interest for Clinical Education VA Wound Provider’s Survey1Current research findings regarding chronic wounds and wound care2Identifying and treating unusual wounds3New products available for dressings and topical treatments4Biological wound therapies (e.g., stem cell, personalized wound treatments, skin substitutes, wound matrices)5Infection and reducing bioburden/biofilm6Overview of advanced wound therapies (negative pressure, hyperbaric oxygen therapy, electrical stimulation, ultrasound, etc.)7How to achieve a multi-disciplinary approach to wound management8Legal issues with chronic, non-healing wounds or pressure ulcers9Pressure ulcer prevention, treatment or management10Vascular issues: Treatment (surgical and non-surgical interventions for venous and/or arterial insufficiency)Cowan, L & Garvan, C. (2014). Online Survey of VA Wound Providers. Poster presentation at SERWOCN, August 27, 2014, Montgomery, AL.
51Educational Preferences: Setting Preference of when and where you would like to receive wound management training, CEUs, CMEs, updates or in-services (n=299):Anything I can do during work hours - having “protected time” to complete it = 86% (n=257)Anything I can do at home or on my own time = 14% (n=42)
52Preferred method for receiving training, updates, CEUs, CME, or in-services (n=303) # of respondentsFace-to-face trainings or workshops245Attending professional conferences225Simulation learning in-person152Interactive computer modules with case scenarios133Self-study online73Self-study written materials65Online gaming modules where you can play a game while you are learning51
53PUP Efforts:What Does recent Research Evidence (scientific literature) contribute to PUP efforts?
54Clinical Pearls about Evaluating Research Evidence Know where to look in articlesAbstract: Research question same as yours?Methods: Appropriate type of study? Large enough sample? Sampling techniques? Robust methods? Valid tools and outcome measures?Results: Believable and can be applied to your situation?
55Looking for Evidence Evidence Syntheses versus Evidence Summaries Meta-Analyses and Systematic ReviewsDecision Support Tools onlineBest Practices versus Evidence-Based GuidelinesEvidence-Based GuidelinesPrimary StudiesEvidence-based text-books, professional organizations, expert opinionPI/QI
56Association for Advancement of Wound Care Guideline Department Evidence Tables:Association for Advancement of Wound Care Guideline DepartmentPressure Ulcer Care InitiativeReferences Updated August 16, 2011.PU Evidence Table 8.1 derived from 13 PU Guidelines (56 pages):AAWC PU Guidelines:
58PUP Research Evidence Fogerty et al. 2008 Used 2003 National Inpatient Sample (NIS) dataset of 7,977,728 inpatient discharges.Included 37 states (representing 90.3% of US population)944 hospitalsTotal sample with PU was 94,758; without PU was 6,610,787Identified top 45 risk factors in acute care which included 25 medical diagnosesat top of list: Age >75, race, paralysis, infection/sepsis, and nutritional deficiency (see next slide for top 11 diagnoses)majority of risk factors identified were not accounted for by Braden ScaleFogerty M, Abumrad N, Nanney L, Arbogast P, Poulose B, Barbul A. (2008). Risk factors for pressure ulcers in acute care hospitals. Wound Repair and Regeneration, 16:
59Fogerty et al. Risk factors Age > 75 years OR 12.63**(as AA age, risk goes higher than Cauc as they age)Gangrene diagnosis OR (95% CI 10.43, 11.48)Paralysis OR 10.3 (95%CI 9.69, 10.69)Septicemia OR 9.78 (95%CI 9.33, 10.26)Osteomyelitis OR 9.38 (95% CI 8.81, 9.99)Malnutrition OR 9.18 (95% CI 8.81, 9.99)Pneumonitis/Pneumonia OR 8.7 (95% CI 8.33, 9.09)UTI OR 7.17 (95% CI 6.96, 7.38)Bacterial infection OR 5.71 (95% CI 5.49, 5.93)Senility OR 4.84 (95% CI 4.62, 5.07)Mycoses OR 4.47 (95% CI 4.41, 4.86)
60PUP Research Evidence Cowan et al. 2012 – Veteran Sample Sample of 213 Veterans. Compared Braden Risk Score to other Medical factors; found 2 Braden sub-scores more predictive of PU than total scores; 4 medical factors (pneumonia, surgery, candidiasis, malnutrition) more predictive than Braden total scoresNiederhauser et al – Systematic Review of 12 studiesComprehensive PUP programs can be effective but sites need to rigorously evaluate their programs and publish their resultsSullivan & Schoelles 2013 – Systematic Review of 26 implementation studiesKey components, “simplification & standardization of PUP interventions & documentation; interdisciplinary teams, leadership, designated skin champions, ongoing staff education, sustained audit & feedback”Soban et al – Systematic Review of nurse-focused QI interventionsSR of 39 studies: Interventions combined with educational and/or QI strategies are effective at reducing PU incidence: assembling a team, performance monitoring and FEEDBACK are very importantFalise et al PHHP Honor’s Thesis (in press)Looked at nutrition; ADL impairment; relationship between BMI and PU using MDS 3.0 dataset: ADL impairment more predictive than BMI, but very low BMI (undernourished) strongly associated with PU
61Pieper & Kirsner 2013Pieper, B. & Kirsner, R. (2013). Pressure Ulcers: Even the Grading of Facilities Fails. Ann Internal Med. 159(8):Estimate 7.5 million persons annually w/PU (worldwide)Problems with PU data and research evidence:Coders interpretations of documentation in medical recordTerminology about PU is confusing: PU, pressure sore, decubiti, decubitus, decub, bedsore, etc.Correct identification of PU pics by expert clinicians was only 57%, with lowest scores for identification of stages III and IV, suspected deep-tissue injury, and unstageable ulcersLevine and colleagues report mean total PU knowledge score of 69% for physicians, PU knowledge score of nurses was 79%.Lowest scores were in knowledge of risk factors.
62Risk AssessmentPancorbo-Hidalgo, P (2006). Risk assessment scales for pressure ulcer prevention: a systematic review (Meta Analysis), Journal of Advanced Nursing 54(1), 94–110. (Cited by 278 journals)14 databases, , 49179 33 studies met criteriaTable 5 Accumulated analysis of indicators of validity*Weighted average.Scalen studiesNtotalPatientsSensitivity(%)*SpecificityPPV(%)*NPV(%)*EfficacyBraden (1987) US20644357.167.522.991.066.7Norton (1962) UK5200846.861.818.487.060.2Waterlow (1985) UK6224682.427.416.089.034.4Clinical Judgment330250.660.132.975.958.0
63Pancorbo-Hidalgo Conclusions Lack of evidence that use of risk assessment scales decreases pressure ulcer incidenceBraden Scale has best validity and reliability indicators, and has been used in a large number of studies in a wide variety of settings (though application across settings should be validated)Braden and Norton Scales predict pressure ulcer development risk better than nurses’ clinical judgementWaterlow Scale has good sensitivity but low specificityTake home message:Something is better than nothing
64Other Difficulties with PUP Documentation and Research Evidence Cowan et al – Veteran SampleKey diagnoses not added to diagnosis list or active problem list; inconsistent Braden scores from one day to next (and sometimes one nurse to the next during same 24 hours); key risk factors and PUP interventions not documented; inaccurate Braden scores and PU identification (staging)Niederhauser et al – Systematic ReviewOnly 15% older adults at risk for PU had supportive device doc by day 3Study of 2,425 MCR pts in acute care: only 23% of immobile patients were documented “at risk” of PUMedical record review of 834 VA LTC pts: overall adherence to 6 critical best PUP practices (such as standardized risk assessment and regular repositioning) was 50%Kent, Cowan & Garvan 2014 (unpublished) – Veteran samplePoor agreement between RD assessment of nutritional risk and RN documentation of nutritional risk (Braden Scale nutrition sub-score); RD nutritional assessment of severe nutritional compromise strongly associated with PU (low nutritional sub-score of Braden was not)
65Discerning PUP “Best Practices” Evidence should be readily available for documented “best practices”Best Practices for Prevention of Medical Device-Related Pressure Ulcers (NPUAP poster):(evidence cited on poster?)
66Summary: Helpful tips to making a successful PUP program PUP Efforts:Summary: Helpful tips to making a successful PUP program
67Implementing Successful PUP Initiative AHRQ Toolkit says to address six questions:Are we ready for this change?How will we manage change?What are the best practices in pressure ulcer prevention that we want to use?How should those practices be organized in our hospital?How do we measure our pressure ulcer rates and practices?How do we sustain the redesigned prevention practices?
68Remember ABCDE Administrative support Bundling care practices Creating culture of change, commitment, and communicationDocumentationEducation and Evidence-Based
69ReferencesBaranoski S. (2006). Raising awareness of pressure ulcer prevention and treatment. Adv Skin & Wound Care. 19,Lyder CH, Ayello EA (2009). Annual checkup: the CMS pressure ulcer present-on-admission indicator. Adv Skin & Wound Care. 22 (10),Office of Inspector General (OIG) CAP Report evaluating implementation of VHA Handbook “Prevention of Pressure Ulcers” in VHA facilitiesCowan, L & Garvan, C. (2014). Online Survey of VA Wound Providers. Poster presentation at SERWOCN, August 27, 2014, Montgomery, AL.Garcia, A & Demers, C (VeHU Presentation September 18, 2014). TEAM: Together Everyone Aims for More: Interprofessional Approaches to Pressure Ulcer Prevention (PUP)Agency for Healthcare Research and Quality (AHRQ) evidence-based best practices (EBBP) for pressure ulcer prevention in “Toolkit for Improving Quality of Care” (2011)Katzenbach J & Smith D The Wisdom of Teams: Creating the High-performance Organization. Harvard Business School Press.
70Fogerty, M. , Abumrad, N. , Nanney, L. , Arbogast, P. , Poulose, B Fogerty, M., Abumrad, N., Nanney, L., Arbogast, P., Poulose, B., & Barbul, A. (2008). Risk factors for pressure ulcers in acute care hospitals. Wound Repair and Regeneration, 16,Cowan, L., Stechmiller, J., Rowe, M., & Kairalla, J. (2012). Enhancing Braden pressure ulcer risk assessment in acutely ill adult Veterans. Wound Repair and Regeneration, 20,Soban, L., Hempel, S., Munjas, B., Miles, J. & Rubenstein, L. (2011). Preventing pressure ulcers in hospitals: A systematic review of nurse-focused quality improvement interventions. Joint Commission Journal on Quality and Patient Safety, 37 (6),Berlowitz et al. (2011). Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. Retrieved from AHRQ website at:Sullivan, N. & Schoelles, K. (2013). Preventing in-facility pressure ulcers as a patient safety strategy. Annals of Internal Medicine, 158(5), 410—W186.Cowan, L. & Garvan, C. (2014). Online Survey of VA Wound Providers. Poster Presentation at NF/SG VHS Research Day, May 16, 2014.
71Niederhauser et al. 2012 – Systematic Review of 12 studies Sullivan & Schoelles 2013Falise et al PHHP Honor’s Thesis (in press)