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Pressure Ulcer Prevention Revisited

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1 Pressure Ulcer Prevention Revisited
Linda J. Cowan, PhD, ARNP, FNP-BC, CWS Research Health Scientist North Florida / South Georgia Veterans Health System Gainesville, FL Clinical Associate Professor, University of Florida College of Nursing

2 Financial Disclosures
Research Funding Received: VA Office of Nursing Services VA QUERI Biomonde HealthPoint/Smith & Nephew Celleration, Medline, Hollister

3 Clinical Problem Pressure 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 occur PUs impact 1.6 million Americans each year, collectively costing $3.6 billion annually in the United States (US) (Baranowski, 2006).

4 Objectives Describe important evidence from PUP research
Identify at least 3 components of successful PUP programs List essential members of PUP teams Describe methods of PUP education that providers may be more inclined to complete

5 Key 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?

6 How is Your Facility Doing?
PUP Efforts: How is Your Facility Doing?

7 Our Organization: Veterans Health Administration (VHA)
America’s largest integrated health care system Over 1,700 sites of care Serves over 8.3 million Veterans each year Aspirational 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

8 OIG: 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 provided 3. Required activities performed (and documented) for patients determined to be at risk for pressure ulcers and for patients with pressure ulcers 4. 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/C 6. 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.

9 PUP 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

10 VA Wound Provider Survey 2014
National VA Survey: March 3rd to March 31st, 2014 online, anonymous 1,726 VA wound providers ~24% response rate Purpose: gather current evidence about experiences, education, preferences, and opinions of wound care providers related to wound management and PUP Cowan, L & Garvan, C. (2014). Online Survey of VA Wound Providers. Poster presentation at SERWOCN, August 27, 2014, Montgomery, AL.

11 Characteristics of Respondents and their facilities N %
Main role (n=303 respondents) RN Wound Consultant ARNP MD PT DPM Other (OT, CWOCN, SW, PharmD, etc.) 98 77 49 31 16 13 19 32% 25% 16% 10% 5% 4% 6% Main clinical setting (n=302) Inpatient acute care (not intensive care) Inpatient acute care (intensive care) Outpatient care Rehabilitation care Long term care Spinal cord injury care Other 53 41 107 8 35 54 4 18% 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.

12 Board certification (n=303) Currently board certified (wound)
Was (wound) board certified in the past Never (wound) board certified (SCI Providers: 12 BC / 0 BC in past / 38 never BC)  N 157 8 138  % 52% 3% 46% Nature of wound management training (n=303) None Only informal Some formal 7 98 198 2% 32% 65% Years’ experience in wound care field (n = 271) Mean = 14.2 SD = 9.8 Cowan, L & Garvan, C. (2014). Online Survey of VA Wound Providers. Poster presentation at SERWOCN, August 27, 2014, Montgomery, AL.

13 VA Wound Provider Survey 2014
Active inter-professional skin or PUP task force at your facility? (n=303) Yes No Not sure  N 229 31 28  % 80% 11% 8% SCI Setting 67% 2% 10% Cowan, L & Garvan, C. (2014). Online Survey of VA Wound Providers. Poster presentation at SERWOCN, August 27, 2014, Montgomery, AL.

14 PUP Efforts: Who should be involved?

15 TEAM: Together Everyone Aims for More Interprofessional Approaches to Pressure Ulcer Prevention (PUP) VeHU Presentation September 18, 2014 Charlene Demers, ARNP, CWOCN Aimée D. Garcia, MD, CWS, FACCWS

16 Team “ 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.

17 Teams for PUP Pressure ulcer assessment, prevention, and monitoring are an interprofessional (not solely WOC nurse) responsibility that includes: Systematic application of risk assessment Implementation of preventive and therapeutic measures Monitoring outcomes Education Documentation

18 Team members Physicians- Surgeon and Medicine (PAs)
Nursing (NP, RN, LPN, CNA) Physical Therapy (PT, PTA) Occupational Therapy Nutrition Pharmacy Prosthetics Social worker(s) / Case Managers Administration

19 Interprofessional Approach
Physicians Early surgical intervention to improve mobility Ordering of pressure redistribution surface after surgery Supervision of overall clinical care Collaborate in prevention plan Nursing Nursing assumes the primary role by identifying those at risk, initiating and coordinating the plan of care for prevention Risk assessment and prevention strategies Implementation of standing order sets Turning and repositioning / Offloading Identifying and entering necessary consults PT/OT, dietician, social worker, etc. ADD WHAT PHYSICIANS AND TEAM MEMBERS WOULD DO IN GENERAL, AND WHAT WAS SPECIFICALLY DONE IN THIS CASE.

20 Rehabilitative and/or SCI staff
recommend strategies to improve mobility and use of protective & pressure redistributing devices Physical Therapy improve mobility, function and activity levels Evaluate safety of ambulation Ordering appropriate durable medical equipment to improve patient’s functional status Occupational Therapy Seating evaluations

21 Pharmacists Social Workers Informatics
assist with analysis of medication profile, product availability, and parenteral nutrition formulation Social Workers assure prevention is priority across continuum of care evaluate and address special needs and discharge planning Informatics facilitate documentation and accurate communication among team

22 Logistics and Prosthetics
Quality Management assists with monitoring incidence and evaluating program outcomes Education Department assists with ongoing education for staff and patients and/or the patient’s designated family members, surrogates, or authorized decision makers Logistics and Prosthetics assist with availability of products and devices for prevention The responsibility for communication is the whole team. The team works with informatics to set up documentation.

23 Where do health care facilities start with PUP strategies?
PUP Efforts: Where do health care facilities start with PUP strategies?

24 Start with ABCDE… ABCDEs of PUP Initiatives (Lyder & Ayello, 2009).
Administrative support backed by support at patient care level is vital Bundling care practices + having an identifiable theme Creating culture of change, commitment, and communication Documentation of pressure ulcer prevention practices must be visible Education is essential (I would also add: all initiatived should be Evidence-based)

25 Administrative Support
Top – Down approach (National, Regional, Facility) Create positive culture, support staff, provide accurate & consistent policies and tools (outcome tracking & reporting) Ways to approach Administration Focus on Improving Quality and Cost Savings Demonstrate how efforts (investment of people, resources, time) will improve delivery of safe & effective patient care & patient outcomes Numbers talk: Know your potential ROI (Return on Investment) Conference, Workgroup, Lean Project, Systems Redesign PU prevention and management must be identified as priority with resources allocated to develop & sustain effective program Support for interprofessional approaches Support 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.

26 Bundling Practices Agency 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 outcome Three critical components (evidence-based): Standardize pressure ulcer risk assessment Comprehensive skin assessment Care planning and implementation to address areas of risk

27 SKIN Bundles VA Skin Bundle (VASKIN): a concerted effort to disseminate EBBP into clinical setting(s) VA SKIN bundle exceeds three critical components by incorporating specific (evidence-based) interventions based on recommendations published by National Pressure Ulcer Advisory Panel and Wound Ostomy, Continence Nurses Society VA SKIN bundle is evidence-based framework but will allow for innovation for special population(s)

28 Great Example: VISN16 Success
“VA Skin Bundle” concept approved by 21 subject matter experts from VISN 16 Skin Integrity Workgroup At VISN 16 Skin Integrity Summit II held September, 2012 in Ridgeland, MS Additional 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 2013 Special recognition goes to Suzy Scott-Williams, RN, MSN, CWOCN & Mona Baharestani, PhD, APN, CWON, FACCWS Over 300 clinicians attended virtually

29 V 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 Pressure Keep Turning and Repositioning Incontinence Management Nutrition and Hydration Assessment and Intervention Veteran’s Skin Bundle Assess Skin and Risk Status1,2,3,4 Risk Assessment on Admission (Braden, SCI, Surgery, medical device) Inspect skin during care activities (e.g. turning, bathing) Select Surfaces and Devices to Redistribute/Relieve Pressure1,2,3 Keep Turning and Repositioning1,2,3 Incontinence Management1,2,3 Nutrition and Hydration Assessment and Intervention1,2,3,4 The 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 assessment Standardize pressure ulcer risk assessment Care planning and implementation to address areas of risk The 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

30 Using Quality Improvement
Process Improvement / Quality Improvement and Continuous Quality Improvement methods to implement Bundles: Plan – Do – Check - Act Lean Six Sigma Systems Redesign VA TAMMCS

31 VA-TAMMCS Framework VISN16 Workgroup

32 Reduce HAPU stage III & IV by 30% from FY12 to FY13
Interprofessional Team, Nurse Managers, Staff Nurses Nursing Process VANOD data, Internal assessment Mini RCA on each incidence VANOD = VA Nursing Outcomes Database RCA = Root Cause Analysis Action Plan, Education, compliance, equipment, devices resources Communication plan, feedback, Executive leader involvement

33 Comparison of other Skin Bundles
VHA: VA SKIN VA: Assess risk & skin, Select surfaces/devices, Keep turning/repositioning, Incontinence management, Nutrition & hydration (assess & address) AHRQ: AHRQ Pressure Ulcer Bundle Comprehensive skin assessment, standardized risk assessment, evidence-based care planning & implementation to address areas of risk, defining staff roles, educate staff, clinical pathway SIGN & Ascension Health: SSKIN Skin inspection, Surface selection, Keep turning/keep moving, Nutrition Common to all: Documentation, Education, Evidence

34 Authors: Roger Resar, MD: Senior Fellow, IHI; Assistant Professor of Medicine, Mayo Clinic School of Medicine Frances A. Griffin, RRT, MPA: Faculty, IHI Carol Haraden, PhD: Vice President, IHI Thomas W. Nolan, PhD: Senior Fellow, IHI

35 Berlowitz et al.(2011) AHRQ

36 Build Your Own “Bundle”
Acute Care Skin Bundle Risk Assessment Skin Inspection Keep Moving / Repositioning Prevent Shearing Forces Float / Elevate Heels Incontinent Care: Moisture Management Pressure Redistribution: Support Surfaces Patient / Caregiver / Staff Education Build 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 VA Acute Care Intensive Care/Progressive Care Perioperative/Operating Room Mental Health Spinal Cord Injury (SCI) Community Living Centers (CLC) Hospice/Palliative Care Ambulatory Care Home Care Primary Care Other

37 Perioperative 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 patient Table 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-based Hand-off Communication: Use effective and consistent communication tools/practices

38 SCI Specific Skin Bundle
Kathleen Dunn and Susan Thomason Risk – Assessment – Interventions – Annual Evaluation – Patient Education Pressure Ulcer Risk Factors (Significant in evidence-based literature) Complete SCI History of at least 1 previous ulcer Pressure Ulcer (PU) Recurrence Number of years since injury Injury 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)…

39 Bundling care practices is only one part: Don’t Forget the whole ABCDE Approach
Administrative support backed by support at the patient care level is vital Bundling care practices have an identifiable “theme” Creating a culture of change, commitment, and communication Documentation of pressure ulcer prevention practices must be visible Education is essential

40 Creating a Culture… Change Commitment Communication
Never easy but necessary for improvement Embrace the concept of a JUST culture Avoiding blaming people for failure Critically examine processes which result in failure Commitment Patient Safety First Communication Most process failures result from lack of communication Documentation

41 Documentation 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 up Must 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)

42 Education is Essential
Administration Clinical staff All settings inpatient, outpatient, ICU, LTC, Rehab, home, etc. Ancillary staff housekeeping, engineering, volunteers, etc. Patient Caregivers / family members Community

43 All Initiatives should be Evidence-Based
Sources of Evidence: External Evidence Robust research Strength of evidence Quality – Quantity – Validity - Reliability Internal Evidence PI/QI methods Applicable to your situation?

44 Having Evidence Based Protocols
Taken from AAWC presentation “Developing a Comprehensive Content Validated Pressure Ulcer Guideline” (2012) on - Susan Girolami & Laura Bolton (Co-Chairs).

45 PUP Guidelines

46 AAWC Wound Care Specialty Council
Significant Findings of Mean Content Validity for PU Prevention Guidelines (Sandwich) Documentation Interdisciplinary Approach Risk Assessment Nutritional Assessment Hydration & Nutrition plan of care Medical/surgical history Psychosocial/quality of life Environmental factors (fall risk) Rehabilitation & restorative programs Position to manage pressure, shear, friction Off-loading beds, chairs, OR equipment Physical Exam Skin inspection & Maintenance Education

47 PUP Efforts: Do providers want more PUP education? If so, How should this education be delivered?

48 2014 VA Wound Provider’s Survey
140 Almost 50% said NO

49 VERY 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 weekly Minor injuries (abrasions, skin tears) 81% 66% Pressure ulcers 72% 73% Moisture related dermatitis and incontinence associated dermatitis 65% 53% Acute wounds 62% 55% Chronic wounds 61% 79% Surgical wounds 60% 51% Venous leg ulcers 52% Traumatic wounds 44% 21% Diabetic foot ulcers 41% Arterial ulcers/Peripheral Arterial Disease (PAD) 38% 43%

50 Top 10 Topics of Interest for Clinical Education
VA Wound Provider’s Survey 1 Current research findings regarding chronic wounds and wound care 2 Identifying and treating unusual wounds 3 New products available for dressings and topical treatments 4 Biological wound therapies (e.g., stem cell, personalized wound treatments, skin substitutes, wound matrices) 5 Infection and reducing bioburden/biofilm 6 Overview of advanced wound therapies (negative pressure, hyperbaric oxygen therapy, electrical stimulation, ultrasound, etc.) 7 How to achieve a multi-disciplinary approach to wound management 8 Legal issues with chronic, non-healing wounds or pressure ulcers 9 Pressure ulcer prevention, treatment or management 10 Vascular 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.

51 Educational 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)

52 Preferred method for receiving training, updates, CEUs, CME, or in-services (n=303)
# of respondents Face-to-face trainings or workshops 245 Attending professional conferences 225 Simulation learning in-person 152 Interactive computer modules with case scenarios 133 Self-study online 73 Self-study written materials 65 Online gaming modules where you can play a game while you are learning 51

53 PUP Efforts: What Does recent Research Evidence (scientific literature) contribute to PUP efforts?

54 Clinical Pearls about Evaluating Research Evidence
Know where to look in articles Abstract: 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?

55 Looking for Evidence Evidence Syntheses versus Evidence Summaries
Meta-Analyses and Systematic Reviews Decision Support Tools online Best Practices versus Evidence-Based Guidelines Evidence-Based Guidelines Primary Studies Evidence-based text-books, professional organizations, expert opinion PI/QI

56 Association for Advancement of Wound Care Guideline Department
Evidence Tables: Association for Advancement of Wound Care Guideline Department Pressure Ulcer Care Initiative References Updated August 16, 2011. PU Evidence Table 8.1 derived from 13 PU Guidelines (56 pages): AAWC PU Guidelines:

57 Example from Evidence Table

58 PUP 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 hospitals Total sample with PU was 94,758; without PU was 6,610,787 Identified top 45 risk factors in acute care which included 25 medical diagnoses at 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 Scale 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:

59 Fogerty 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)

60 PUP 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 scores Niederhauser et al – Systematic Review of 12 studies Comprehensive PUP programs can be effective but sites need to rigorously evaluate their programs and publish their results Sullivan & Schoelles 2013 – Systematic Review of 26 implementation studies Key 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 interventions SR 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 important Falise 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

61 Pieper & Kirsner 2013 Pieper, 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 record Terminology 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 ulcers Levine 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.

62 Risk Assessment Pancorbo-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, , 49179 33 studies met criteria Table 5 Accumulated analysis of indicators of validity *Weighted average. Scale n studies N total Patients Sensitivity (%)* Specificity PPV(%)* NPV(%)* Efficacy Braden (1987) US 20 6443 57.1 67.5 22.9 91.0 66.7 Norton (1962) UK 5 2008 46.8 61.8 18.4 87.0 60.2 Waterlow (1985) UK 6 2246 82.4 27.4 16.0 89.0 34.4 Clinical Judgment 3 302 50.6 60.1 32.9 75.9 58.0

63 Pancorbo-Hidalgo Conclusions
Lack of evidence that use of risk assessment scales decreases pressure ulcer incidence Braden 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 judgement Waterlow Scale has good sensitivity but low specificity Take home message: Something is better than nothing

64 Other Difficulties with PUP Documentation and Research Evidence
Cowan et al – Veteran Sample Key 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 Review Only 15% older adults at risk for PU had supportive device doc by day 3 Study of 2,425 MCR pts in acute care: only 23% of immobile patients were documented “at risk” of PU Medical 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 sample Poor 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)

65 Discerning 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?)

66 Summary: Helpful tips to making a successful PUP program
PUP Efforts: Summary: Helpful tips to making a successful PUP program

67 Implementing 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?

68 Remember ABCDE Administrative support Bundling care practices
Creating culture of change, commitment, and communication Documentation Education and Evidence-Based

69 References Baranoski 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 facilities Cowan, 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.

70 Fogerty, 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.

71 Niederhauser et al. 2012 – Systematic Review of 12 studies
Sullivan & Schoelles 2013 Falise et al PHHP Honor’s Thesis (in press)


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