1. 1 On-Time Pressure Ulcer Healing in Long Term Care Track 4: Patient Safety – Improving Quality of Care in Nursing Homes and Long-Term Care Settings September 10, 2008 Presented by Siobhan Sharkey, MBA

2. 2 On-Time PrU Healing Objectives On-Time PrU Healing Objectives 1.Develop standardized pressure ulcer assessment documentation 2.Develop new reports to support clinical decision making related to pressure ulcer treatment & heal days 3.Translate data elements and clinical reports to HIT requirements 4.Analyze data to determine treatments that are associated with better outcomes.

3. 3 Participants High risk PrU quality measure >8%High risk PrU quality measure >8% Total of 25 skilled nursing facilitiesTotal of 25 skilled nursing facilities StateFacilitiesBeds CA10 81 – 143 OH785-100 AZ, NC, WI 3 75 – 223 NY, NJ, MA 5300-500

4. 4 Background Pressure ulcer healing–a measure of quality: CMS’ ultimate goal - use pressure ulcer healing rates as a publicly reported measure of nursing home quality.CMS’ ultimate goal - use pressure ulcer healing rates as a publicly reported measure of nursing home quality. Debate over how to define ‘healing.’Debate over how to define ‘healing.’ » Current definition in MDS 2.0 is reduction of ulcer stage. » ‘Down-coding’ stage as the measure of pressure ulcer improvement/healing has been shown to be inadequate (Miller, 1994; Berlowitz et al, 1997). » CMS plans to include a revised measure of pressure ulcer healing in MDS 3.0.

5. 5 Background No easily accessible decision support tools No standardized set of data elements to document weekly skin assessments and treatmentsNo standardized set of data elements to document weekly skin assessments and treatments No standardized measure of healing.No standardized measure of healing. » PUSH tool is promoted to measure healing » Research suggests that area (length x width) is a more realistic and feasible measure. Existing decision support tools consume large amounts of staff time AND do not assist wound nurses and front- line clinicians to monitor resident and pressure ulcer status and provide treatment based on best practice.Existing decision support tools consume large amounts of staff time AND do not assist wound nurses and front- line clinicians to monitor resident and pressure ulcer status and provide treatment based on best practice.

6. 6 Major Tasks 1. 1.Define standardize data elements related to wound and skin assessment and PrU treatments. 2. 2.Trial by actual users. Develop prototype documentation forms for wound nurse. 3. 3.Define clinical decision making reports. Design, test, and refine reports for clinical decision making related to PrU healing. 4. 4.Establish functional requirements for HIT. 5. 5.Collaborate with caregivers to implement new processes of care: documentation, use of clinical decision making reports.

7. 7 Standardized Data Elements: Wound Assessment Ulcer DimensionsUlcer Dimensions Wound EdgesWound Edges UnderminingUndermining TunnelingTunneling Necrotic Tissue TypeNecrotic Tissue Type Necrotic Tissue AmountNecrotic Tissue Amount Drainage/ Exudate TypeDrainage/ Exudate Type Drainage/ Exudate AmountDrainage/ Exudate Amount Peri Wound AreaPeri Wound Area Peri Wound EdemaPeri Wound Edema Peri Wound IndurationPeri Wound Induration GranulationGranulation EpithelializationEpithelialization PainPain Treatments Adjunctive Therapies Interventions Consultation Follow up Ulcer Status Current Visualization Ulcer Stage Resident Disposition

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9. 9 PrU Healing Reports Initial Definition 1.New and Existing Pressure Ulcer Report. Displays list of residents with new and existing ulcers that are being treated. 2.Stagnant or Worsening Ulcers Report. Displays list of residents with ulcers that have either not improved or worsened during previous 14 days. 3.Pressure Ulcer QI Monitoring Report. Tracks pressure ulcer statistics by ulcer stage and occurrence by nursing station; tracks ulcers > 30 days. 4.Detailed Report of Pressure Ulcer Wound Assessment and Treatment Information. Report displays longitudinal view over time (4 weeks) by resident for ulcers > 30 days.

10. 10 Defining Clinical Reports Example: QI Monitor How many pressure ulcers were treated this month on nursing Unit A? Unit B? Unit C? Unit D? How many ulcers were Stage I? Stage II? Stage III? Stage IV? Unstageable? How many ulcers healed? How many ulcers developed in-house? How many ulcers were treated for > 20 days? Which nursing unit has the most ulcers of 30 day or longer duration? What questions will the report answer for clinicians? For example:

11. 11 Defining Clinical Reports: Example Stagnant Ulcer Report Purpose statement: » » Provide information on ulcers that remain unhealed > 20 days: potential reasons for delayed healing, total number of treatments for each ulcer, if the treatment has not changed in 14 days, etc. Information from users detailed into HIT requirements: » » Display list of residents with pressure ulcers treated for more than 20 days and – –i) ulcer surface area is unimproved for two consecutive wound assessments, or – –ii) ulcer has worsened since last assessment. » » Clinical information is captured by 2 sources: i) CNA daily documentation ii) nurse documentation of wound assessment Gather input from multiple facilities and translate into HIT requirements. For example:

12. 12 Healing Reports Standardized Wound Assessment documentation QI Team Access timely information Consolidate documentation Front-line team members use reports in daily work Monitor progress Identify residents for review Information Technology Step 1 Step 2 Step 3 On-TimeOn-Time PrU Healing

13. 13 Facility Implementation Steps Implement standardized assessment facility-wideImplement standardized assessment facility-wide Confirm in-service strategyConfirm in-service strategy Confirm completeness and accuracy: participate in documentation audit with clinical expertConfirm completeness and accuracy: participate in documentation audit with clinical expert Coordinate with project facilitators to confirm HIT vendor meeting requirementsCoordinate with project facilitators to confirm HIT vendor meeting requirements Engage multiple disciplines, including rehab, dieticians, quality improvement teamEngage multiple disciplines, including rehab, dieticians, quality improvement team Establish plan to use reports: link with workflowEstablish plan to use reports: link with workflow

14. 14 Feedback on Documentation Completeness and Accuracy Missing areaMissing area » Incomplete due to hospitalization, resident refusal Stage II and 100% wound covered (epithelialization)Stage II and 100% wound covered (epithelialization) » The nurses are documenting Stg II and 100% covered for intact blister. Unstageable & no necrotic tissueUnstageable & no necrotic tissue » The nurses are documenting this when deep tissue injury (DTI) is suspected. Healed or closed?Healed or closed? » Several facility policies specify that Stage III and IV ulcers are documented as closed until nurse determines completely healed (2-8 weeks after closed).

15. 15 Engage Clinicians Preliminary Feedback Initial Stage FrequencyPercent I8816% II36067% III10 2% 2% IV16 3% 3% Unstageable6412% Ulcers in database as of August, 2008: Total of 538 ulcers

16. 16 Engage Clinicians Preliminary Feedback % Healed: Initial Stage II Ulcers Data: 5 facilities with more than 30 initial stage II ulcers How does % healed vary across facilities? Why?

17. 17 Use of Reports Linked to Wound Management Workflow Who is responsible for wound assessments, measurements, and treatment plan?

18. 18 Do you have a dedicated wound team? Use of Reports Linked to Wound Management Workflow

19. 19 Next Steps Establish plan to use reportsEstablish plan to use reports » Link reports with existing and new processes Engage multiple disciplines, including rehab, dieticians, quality improvement teamEngage multiple disciplines, including rehab, dieticians, quality improvement team