Partnering for the Prevention of Pressure Ulcers across the health care continuum

Saratoga County Partners for the Prevention of Pressure Ulcers

• Wesley Health Care Center• Saratoga Hospital• Saratoga Care Nursing Home• Maple wood Manor• Saratoga Public Health• Saratoga Community Hospice• Schuyler Ridge • Visiting Nurse Service of Saratoga and

Schenectady Counties

Saratoga County

• Primary Provider• Hospital• Rehabilitation/Nursing Home • Home

– County Public Health– Visiting Nurses– Hospice– Other Home Care Providers

Focus : “War on the Sore”

• Improving pressure ulcer prevention and treatment in nursing homes has become a statewide priority.

• CMS has placed this challenge on hospitals through the 5 million lives campaign

• 10/08 was the date for hospitals to be in compliance with identifying pressure ulcers on admission in order to receive payment

CMS est. improving pressure ulcer care as national priority

• New York State’s overall nursing home pressure ulcer prevalence rate is 32nd in the nation

• New York State’s aggregate pressure ulcer prevalence rate of 9.1 percent is higher than the national goal of 5 percent

DOH PROGRAM INTENT• “Improving communication, coordination,

and information transfer between providers when individuals move from one care setting to another”

Pressure Ulcers F 314

• “A resident who enters the facility without a pressure ulcer does not develop a pressure ulcer unless the individual’s clinical condition demonstrates that they were unavoidable.”

DOH PROGRAM INTENT

• “Improving consumer knowledge about pressure ulcer prevention and treatment”

Why we started our meetings (12/06)

To “ Partner for prevention”

• Share information and education• Improve communication• Provide cross-provider training on standards

of practice• Standardize data collection and reporting• Focus on early detection of risk factors

Partnering for PrevenGoalGoaltioGpa;s”: Take the lead!

Implement a standardized approach to “hand off” communications

Blaming, finger pointing and territorialism is not conducive to quality care for the patient!

Consider the prevention of pressure ulcers an organizational priority

• Focused on revised NPUAP definitions for staging• Gave consideration to the Braden Plus (all care

settings)• Considered the use of technology when

documenting and tracking Pressure Ulcers • Introduced the use of ultrasound to detect deep

tissue edema• Invited participation at the monthly Saratoga

meetings (sharing information from specialty units like the OR)

Progress made to date

• Determine when risk for pressure first occurs – Was the patient found on the floor at home? – How long was this patient in the ER on a

stretcher?– How long was surgery and was there significant

blood loss?

Create a “look back” when screening for Admission to Long Term Care

Saratoga Hospital

• Hospital– Emergency Department– Diagnostic Testing– Operating Room– Radiation Oncology Center (ROC)– ICU– General Unit Beds (D1, A3, C3)– Care Management

What steps need to be taken in the acute care?

• Identification of existing pressure ulcers on admission with accurate documentation and staging

• Risk assessments on admission and daily documentation

• Risk management (specialty beds, off loading pressure during surgery, better surface support in the ER)

• Improving communications between departments in the hospital and other providers

• Education of staff, patients and families

Saratoga HospitalEmergency Department

– Length of stretcher/wheelchair - surface time• Delay until Admission: (2 to 6 hours)• 22% admissions come through the ER

– Concerns with early identification of risk factors and prevention of pressure while in ER

Present on Admission

• The cost of healing one pressure ulcer is estimated between $25,000 and $50,000

• New level of priority with “POA” regulation from CMS– Skin assessment needs to be completed by a

“qualified trained individual” and documented on admission paper work

– The ER physician may refer to the RN assessment note for this documentation

– A “bed hold” is considered an admission – “Up coding” of the DRG will no longer be allowed

Saratoga Hospital solutions for improvement

• Invite other providers to our monthly meetings

• Educate to the Braden Plus

• Increase Braden assessments

• Enc. representatives attend from all areas of the hospital (ER, ICU, and the OR)

• Consider the implementation of a TRACER Methodology

NDNQI Pressure Ulcer Tutorialwww.nursingquality.org/NDNQIPressureUlcerTraining/index.htm

NPUAP: Suspected Deep Tissue Injury

• “Pressure related injury to subcutaneous tissue under intact skin”

• Goal: Detect edema under intact skin before damage is irreversible

Scanning of the heels

Entering into the computer

Normal AbnormalNormal compared to abnormal

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Saratoga County Public Health

Standards of Wound Care

January 27, 2009

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Medicare PPS and Homecare

• The implementation of the Medicare Prospective Payment System (PPS) in 2000 presented several new challenges to home care agencies.

• Under this new system current wound care practices created a tremendous financial burden strain on resources within the home healthcare system.

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OASIS DATA

• As cited by the Remington Report, “According to current OASIS (Outcome and ASsessment Information Set) data, there will have been an estimated 7.7 million home care admissions in 2007. Nearly one-half million of those patients have pressure ulcers upon admission. “

• Of the patients admitted to home care with a pressure ulcer, 79% have a stage 1 or 2 ulcer. A total of 20.6% have a stage 3 or 4 ulcer.

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Home Care Challenges

• At the time of PPS implementation, a typical wound care order was “QD or BID wet to dry dressings.” This type of wound care consumed substantial nursing time, often resulted in lower patient outcomes, and had an adverse financial impact on home care agencies.

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Finding Solutions• In 2003, Saratoga County Public Health joined forces with

other local home care agencies to address these pressing issues.

• The goal of this group was to create standards of wound care that were followed by area home care agencies and consistently communicated to physicians offices and other referral sources.

• Objectives included: improved patient outcomes; decreased burden on home care staff; and reduce home care agency financial losses.

• The end result was a standard wound care order form which all area home care providers were encouraged to use .

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Wound Care Committee• Following the establishment of the standard

Wound Care Form, Saratoga County Public Health developed a Wound Care Committee.

• The committee provides ongoing guidance and expertise to fellow field nurses and helps to develop wound care policies and procedures.

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Braden Scale

• The Braden Scale was reviewed and is the committee’s tool of choice for indepth skin assessment across the care continuum.

• Our current computerized clinical documentation system contains an integumentary section which includes the Braden scale.

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Braden Scale Reference Guide

• We require our nurses to complete the Braden Scale upon start of care (SOC), every sixty days upon recertification, and upon resumption of care (ROC).

• A Braden Scale Reference Guide (that incorporates the Braden Plus) was developed to assist nursing staff with identifying risk factors and educating patients and families about the potential for skin breakdown.

• Within each area of the Braden Scale, there are asterisked spaces to document specific details regarding a patient’s health status and skin status.

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Saratoga County Public Health is committed to achieving and maintaining

the highest standards of care.

We will continue to collaborate with healthcare providers

across the care continuum to address issues and find

solutions to them.

Schuyler Ridge

• Challenges and solutions

Maple Wood Manor

• Using Technology for the tracking of pressure ulcers

Tasks to be completed within 24 hours:

• Nurses note• Initial Wound Assessment• Risk Assessment• CCP initiated and updated• Treatment in Treatment Book• Information on Day Report• MD Orders for treatment• Interdisciplinary Notification of all departments of

the pressure ulcer

Pressure Ulcer Computer Program

• Microsoft Access Program

• Utilizes a database (table)

• Generates forms based on database

• Prevents repetition of information/forms

• Stores data/history regarding ulcer

DATABASE INCUDES

1. Nutrition information2. Lab information3. Supplements, calories and

weight4. Total protein, albumin and

lymph count5. Protein needs6. Date of next wound

rounds7. Description of Ulcers

DATABASE

1. Can store information on up to 2 ulcers

2. Site/stage

3. Measurements

4. Onset Date

5. Admitted with info

6. Treatment

Pressure Ulcer Table Query Last Name First Name Room # U-1 Site U-1 Stage U-1 Onset U-1 Admit With U-1 Length U-1 Width U-1 Depth U-2 Site Gary Lt Buttock 2 1/12/09 Yes Area resolved Rt buttockx2

Martha Rt heel 2 1/13/09 NO 4.0cm 4.0cm open blister

Dorothy Coccyx 2 1/3/09 NO 3.0cm 0.5cm 0.1cm

Helen Lt Buttock 2 1/15/09 No 2.0cm 0.7cm 0cm

Eugenia Rt inner Buttock 2 1/9/09 NO 2.0cm 1.8cm superficial

Veronica lt medial foot DTI 11/25/08 NO 1.3CM 0.3CM DK TISSUE

Robert left lateral buttock 2 12/28/08 no 1 1.0cm 0.1cm

Lou Rt buttock 2 1/2/09 NO 0.8cm 0.2cm <0.1cm

Luella Lt Trochanter 3 5/16/08 NO 0.7cm 2.0cm 0.8cm

Pressure Ulcer Table Query U-2

Stage U-2

Onset U-2 Admit

With U-2 Length U-2 Width U-2 Depth

Next Rounds Supplements

2 9/12/09 Yes 1.0cm 0.5cm

1.0cm 0.5cm

superficial 1/23/09

1/23/09

1/23/09 4 OZ. ENSURE + HS

1/23/09

1/23/09 4 OZ. ENSURE TID BETWEEN MEALS

1/23/09 8 OZ. ARGINADE AM+PM

1/23/09 CALORIC DENSE FOODS AT B+L,8 OZ. YOGURT L.

1/16/09 1/23/09 4 oz. GLUCERNA SHAKE @ HS

1/23/09 4 oz. ENSURE PLUS TID WITH MEALS/ 4 oz. BREEZE HS/ARGINADE AM AND PM

The Braden Scale does not address every risk factor!

• Interventions to help one issue may heighten the risk for another

Prevention is key!

• Determine risk– Braden Scale

• Sensory Perception• Moisture• Activity• Mobility• Nutrition• Friction/Shear

Wesley Health Care Center’s “Braden Plus”

Additional factors to considerRecent hospitalizationBony deformitiesSplint usage (orthotics) ObesityLow blood pressureUsage of oxygenG tubeEnd stage renal diseaseUnstable diabeticContracturesResident refuses interventions

Orthotics as an intervention

• Prevent “foot drop”• Address external rotation of the extremity• Prevent progression of contractures• “Off load” pressure from the heel area• Special foot wear needed (ex. cast shoe)• To immobilize extremity due to fracture

Multipodis splint to “off load” pressure from heel

Posterior lower leg wound from multipodis splint (arrow points to heel area)

Going into 2009

• Create a booklet for family and patient information on pressure ulcers

• Seek to establish measureable baselines to assess effectiveness of collaboration on pt. outcomes

• Develop a tracking tool to be used in the hospital

• Develop a standard transfer form

• Collaborate on improving education for all caregivers across the continuum of care

• Publish the results of this initiative

Partnering with Excelsior College

• DOH Grant for the prevention of pressure ulcers

Pressure UlcersResource tools for clinicians

Presented by:Linda Smith

EQUIP Quality Improvement Analyst

National Pressure Ulcer Advisory Panel

• The NPUAP is an independent not-for-profit professional organization dedicated to the prevention and management of pressure ulcers.

http://www.npuap.org/

National Guideline Clearinghouse

• This governmental site provides guidelines for prevention and management of pressure ulcers.

http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=3860&nbr=3071

IPRO’s Pressure Ulcer Toolkit

• IPRO's Nursing Home Quality Improvement (NHQI) clinical resource and quality improvement material on pressure ulcers.

http://projects.ipro.org/index/nhqi_toolkit_pressure_ulcers