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

Pressure Ulcer Reduction and Prevention Project Congratulations

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

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

Pressure Ulcers: What we all need to know More likely to occur among those over 65 years of age--By 2030---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

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 $9.1-11.6 billion per annum

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 257 412 Med. Beneficiaries with pressure ulcers, for which the average DRG payment was 37 to 43 thousand dollars.

Pressure Ulcers: What we all need to know Incidence rates: 0.4-38% hospitals 2.2-23.9% 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

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

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

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 2007 --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

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

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?

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.

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.

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.

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

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

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.

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.

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.

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

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

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

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

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

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

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”.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 2005 RCT with strength of evidence a A International P. U. Guidelines, EPUAP/NPUAP Draft 2009

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

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

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

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

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

So in the End, the new Guidelines are More Comprehensive More Detail More Evidence Based ACCOUNTABLE International P. U. Guidelines, EPUAP/NPUAP Draft 2009

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