Preventing Pressure Ulcers Tuesday May 6 2014 These presenters have nothing to disclose Kathy Duncan RN Annette Bartley RN Todays Host 2 Sarah Konstantino Project Assistant Institute for Healthcare Improvement IHI assists in programming activities for expeditions as well as ma ID: 527805
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Slide1
IHI Expedition
Preventing Pressure Ulcers
Tuesday, May 6, 2014
These presenters have nothing to disclose
Kathy Duncan, RN
Annette Bartley, RNSlide2
Today’s Host
2
Sarah Konstantino
, Project Assistant, Institute for Healthcare Improvement (IHI), assists in programming activities for expeditions, as well as maintaining Passport memberships, mentor hospital relations and collaboratives. Sarah is currently in the Co-Operative Education Program at Northeastern University in Boston, MA, where she majors in Business Administration with a concentration in Management and Health Science. She enjoys cooking, traveling, and fitness. Slide3
Audio Broadcast
3
You will see a box in the top left hand corner labeled “
Audio broadcast
.” If you are able to listen to the program using the
speakers on your computer
, you have connected successfully.Slide4
Phone Connection (Preferred)
4
To join by
phone
:
Click the button on the right hand side of the screen.
A pop-up box will appear with call in information.
Please dial the
phone number
, the
event number
and your
attendee ID
to connect correctly .Slide5
Audio Broadcast vs. Phone Connection
If you are using the
audio broadcast (through your computer) you will not
be able to speak during the WebEx to ask question. All questions will need to come through the chat.
If you are using the
phone connection
(through your telephone) you will be able to raise your hand, be unmuted, and ask questions during the session.Phone connection is preferred if you have access to a phone.5Slide6
WebEx Quick Reference
Welcome to today’s session!
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6
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When Chatting…
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All ParticipantsSlide8
Expedition Director
Kathy D. Duncan, RN,
Faculty, Institute for Healthcare Improvement (IHI), oversees multiple areas of content and is the clinical lead for IHI’s National Learning Network. Ms. Duncan also directs content development and provides spread expertise for IHI’s Project JOINTS as well as additional content direction for the Hospital Portfolio, directs a number of virtual learning webinar series, and manages IHI’s work in rural settings. Previously, she co-led the 5 Million Lives Campaign National Field Team and was faculty for the Improving Outcomes for High Risk and Critically Ill Patients Innovation Community. In addition to her leadership on the field team during the Campaign, Ms. Duncan was the content lead for several interventions in IHI’s 100,000 Lives and 5 Million Lives Campaigns. She also serves as a member of the Scientific Advisory Board for the American Heart Association’s Get with the Guidelines Resuscitation, NQF’s Coordination of Care Advisory Panel and NDNQI’s Pressure Ulcer Advisory Committee. Prior to joining IHI, Ms. Duncan led initiatives to decrease ICU mortality and morbidity as the Director of Critical Care for a large community
hospital.
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Overall Program Aim
The
aim of the Expedition is to provide participants with strategies for
preventing pressure ulcers that have been tried and tested in a variety of different contexts with great success
. Slide10
Expedition Objectives
At the end of this Expedition, participants will be able
to:Identify a range of simple tools and methods which will help you to prevent pressure ulcersTest strategies for identification of patients at risk for pressure ulcers
Implement reliable processes for pressure ulcer risk assessment and pressure ulcer preventionImplement reliable processes for pressure ulcer prevention strategiess
10Slide11
Schedule of Calls
Session
1: Getting to Zero – Strategies for SuccessDate:
Tuesday, April 22, 12:00 – 1:30 pm ET
Session 2: Identification and Assessment of Patients at Risk
Date: Tuesday, May 6, 12:00 – 1:00 pm ET Session 3: Developing Reliable Care ProcessesDate: Tuesday, May 27, 12:00 – 1:00 pm ET Session 4: Measurement for ImprovementDate:
Tuesday, June 10, 12:00 – 1:00 pm ET Session 5: Engaging Patients, Families, and the Community in Pressure Ulcer Prevention
Date: Tuesday, June 24, 12:00 – 1:00 pm ET Session 6: Generating Ideas from Frontline StaffDate: Tuesday, July 8, 12:00 – 1:00 pm ET
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Today’s Agenda
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Welcome and introduction
Discuss the action period assignment from call 1
Identification
and
assessment of patients at riskGuest presentations Action Period AssignmentSlide13
Faculty
Annette
Bartley is a registered nurse with over 30 years of experience in healthcare. She has held leadership roles in frontline clinical care, management and at director level. In 2006 she was awarded a Health Foundation Quality Improvement Fellowship spent at the US Institute for Healthcare Improvement (IHI), during which time she also completed a Masters in Public Health at Harvard University. Annette is now an Independent Quality Improvement Consultant responsible for developing, supporting and leading a number of highly successful quality improvement and patient safety initiatives across the UK at regional, and national level. Her work extends internationally and she is viewed as an authority on the prevention of avoidable pressure ulcers using quality improvement methodology. Annette’s passion is inspiring and supporting frontline care teams to reliably deliver high quality, safe, person centered care.
13Slide14
Faculty
Bevette
Griffin, RN, CWONGraduated from Saint Francis School of Nursing in Peoria, IL in 1973Worked from 1973 to 1989 as Staff RN/ Charge RN at OSF Saint Francis Medical Center
Working since 1989 as Ostomy/ Wound Care Nurse at OSF Saint Francis Medical CenterCertified
Ostomy
/ Wound Care Nurse through Wound
Ostomy Continence Certification Board since 199914Slide15
Action Period Assignment
W asked you to test the use of the Safety
Calendar.Review your pilot unit’s current performance. Ask five members of staff what the unit’s process for preventing pressure ulcer is and check whether their responses match. In addition, check if they are consistent with your local policy/protocol.
Check the charts of five patients and review the percentage compliance with risk assessment.We would welcome a couple of volunteers to share their learning from their pre-work
Please raise your
hands?Slide16
Identification
and Assessment of Patients at Risk
16Slide17
Risk Identification
Communication of
Risk status
Risk Assessment
Appropriate preventative
strategy implemented
Evaluation of outcome
What will success look like?
Partnership
with patient
Developing a System’s Based
A
pproachSlide18
Who is at Risk?
18Slide19
High Risk Groups
The presence of pressure ulcers has been associated with an increased risk of secondary infection and a two to four fold increase of risk of death in older people in intensive care units
(Bo M, Massaia M et al, 2003).Pressure ulcers can occur in any
patient but are more likely in certain high risk groups such as: The elderly, obese, malnourished and those with certain underlying conditions.
19Slide20
Anyone
can get a pressure sore whether they are aged 10 or aged 80. But the people who are most at risk are:
P
eople
who have trouble moving and cannot change position themselves
People who cannot feel pain over part or all of their body People who are incontinent People who are seriously ill, or have had surgery People who have a poor diet and don’t drink enough water People who are very young or very old People
who have damaged their spinal cord and can neither move nor feel their bottom and legs Older people who are ill or have suffered an injury like a broken hip
http://your-turn.org.uk/patients/what_is_PS.htm
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Patient Stories
Sarah aged 9 got a pressure sore on her heal after having an operation on her broken leg.
Josie aged 28 had a pressure sore after giving birth to her first child and having an epidural.James, aged 35 suffered a pressure sore on the back of his leg after changing to a new wheelchair.
Stan, age 73 got a pressure sore on his bottom after a bad chest infection kept him housebound for 2 months.
http
://
your-turn.org.uk/patients/what_is_PS.htm21Slide22
Risk
Factors
Limited Mobility
Impaired Mental Status Exposure to moisture
Urinary incontinence
Bowel
incontinenceWound exudateExcessive Perspiration +++Poor Nutritional StatusObesity Recent weight lossFeeding
assistance neededSkin conditionPressure ulcer
historySlide23
Risk of Pressure Ulcer by
Number of Risk Factors
Number of risk factors present
Mor, V et al Canadian J of Quality of CareSlide24
Risk Identification (Individual)
Consider
risk factors that are present -Shortness of breath, weight loss, inability to eat, orthopedic surgery (hip, knee) diabetes
Consider if patient cannot move voluntarily -Bedridden, chair ridden, coma, restrained, desaturation with movement, traction, pain
Consider
the history/
pattern of ulcer development -High risk? Or acquired, trapped in one place for extended time?Slide25
Risk Identification (unit/facility)
Patient Population
Specialty Surgery, Gastrointestinal, ICU, Pediatric)Age Pain
Urinary Catheters
Nasogastric Tubes
Oxygen cannula
Oxygen masksResourcesStaffingEquipment25Slide26
Risk Assessment
(NPUAP 2014)
26
Consider all bed-bound and chair-bound persons, or those whose ability to reposition is impaired, to be at risk for pressure ulcers.
Use
a valid, reliable and age appropriate method of risk assessment that ensures systematic evaluation of individual risk factors.
Assess all at-risk patients/residents at the time of admission to health care facilities, at regular intervals thereafter and with a change in condition. A schedule is helpful and should be based on individual acuity and the patient care setting.Acute care: assess on admission, reassess at least every 24 hours or sooner if the patient’s condition changesLong-term care: assess on admission, weekly for four weeks, then quarterly and whenever the resident’s condition changes
Home care: assess on admission and at every nurse visit.
Identify all individual risk factors (decreased mental status, exposure to moisture, incontinence, device related pressure, friction, shear, immobility, inactivity, nutritional deficits) to guide specific preventive treatments. Modify care according to the individual factors.Document risk assessment subscale scores and total scores and implement a risk-based prevention plan.
https://www.npuap.org/resources/educational-and-clinical-resources/pressure-ulcer-prevention-points/Slide27
Risk Assessment T
oolsIt is not what you use… it’s the way that you use it
Braden Risk Scale was developed in 1987 by Barbara Braden and Nancy Bergstrom.
Tested for reliability and validity with results published in Nursing Research in 1987.
A
larger multi-site study was conducted to determine the reliability and validity of the tool in a variety of
settings. Results were published in Nursing Research in 1998. A follow-up report in Nursing Research in 2002 demonstrated that the tool could be used in Black and White subjects with similar validity. The Braden Scale offers the best balance between sensitivity and specificity and highest prediction capacity
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Risk Assessment
Assess pressure ulcer risk on admission for ALL patients within 2 hours (as soon as possible!)
Re-assess skin at least daily (depending on individual risk) or when patients needs changes.Initiate and maintain correct and suitable preventative
measures.
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Need to Reduce Complexity
Gut Instinct- Is the patient at risk?
YES or NO?Pre-Pressure Ulcer Risk Assessment (PPURA) - NHS Scotland
http://
www.healthcareimprovementscotland.org/programmes/patient_safety/tissue_viability_resources/pura_pressure_ulcer_assessment.aspx
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Engage Patients and Family
Involve patients and families in pressure ulcer prevention at the earliest opportunities
Develop a contract of careWhat can we do together to help prevent pressure ulcers
Patient Information leaflets
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Predictable Risk
Utilize patient ‘At risk’ cards to quickly identify those at increased risk
http://www.your-turn.org.uk/index.php/the-your-turn-campaign/what-is-it/
http://www.youtube.com/watch?v=rqpN7YKTlUw
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Making the Connection
32
Risk assessment
Communicate
Preventative action
Measure impactSlide33
Communication
VerbalWritten
Visual
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PDSA Changes
Patient risk cardsPatient and family contracts
Visual cuesSafety briefing/huddlesMovement /activity sessions100 days free campaign….
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Questions?
35
Raise your hand
Use the ChatSlide36
Guest Presentations
36Slide37
THE JOURNEY TO DECREASE HOSPITAL ACQUIRED PRESSURE ULCERS
Bevette Griffin RN,CWON
OSF SAINT FRANCIS MEDICAL CENTER, PEORIA, ILLINOISSlide38
Bevette Griffin, RN, CWON
Graduated from Saint Francis School of Nursing in Peoria, IL in 1973
Worked from 1973 to 1989 as Staff RN/ Charge RN at OSF Saint Francis Medical Center
Working since 1989 as
Ostomy
/ Wound Care Nurse at OSF Saint Francis Medical Center
Certified Ostomy/ Wound Care Nurse through Wound Ostomy Continence Certification Board since 1999
OSF Saint Francis Medical Center
And
Children’s Hospital of Illinois
Peoria, IL
600+
Bed Level 1 Trauma CenterSlide39
HISTORY
Decreasing HAPU’s was one of the first 6-Sigma projects adopted by OSF Saint Francis Medical Center in 2002.Pressure ulcer incidence was 9.4% when the project started.
Initial goal was to decrease the incidence of HAPU’s by 50%.3 root causes were identified: accountability, knowledge deficit and communicationSlide40
IMPROVEMENTS
Accountability: Ultimate ownership to the staff RN, NCM as the process owner, chart audits with action plans and collaborative turning effort
Knowledge Deficits: Revised the skin breakdown prevention protocol, educated staff
housewide, SOS team establishedCommunication Deficits:
SOS champion became the “ skin expert” on their units, SOS signs posted outside the door, overhead music and pages for turn reminders,
pt
and family education bookletsSlide41
2002-present
Gradual decrease in HAPU’s to below 2% quarterly since June 2011,reported to NDNQI.Constant challenges: Making skin a priority and creating a culture of preventionSlide42
PRESENT QUALITY IMPROVEMENT PROCESS
All HAPU’s are assessed by the WOCN nurses for accuracy ( with the staging and IF they are really from pressure)
All HAPU’s are reviewed on the unit level , by the unit council and an action plan is made. Then reviewed by the Evidence Based Practice council and the question is asked: Was the HAPU avoidable or unavoidable?Slide43
RECENT ADDITIONS
2 RN’s will assess every
pt upon admission and transferUnit “huddles” list patients with low Braden scoresReport sheets have Braden score on themTrial on sacral dressings to decrease shear
EICU-another pair of eyes for assessmentBedpan pagesContinue “no-lift” culture and promoting early activitySlide44
PRESENT CHALLENGES
Device related HAPU’s ( NG tubes, FMV, catheters) Correct staging and documentation of pressure ulcers on admission by Physicians and nursing staff
Transitioning the use of the sacral dressing to all the ICU’sKeeping the SOS initiative live and wellSlide45
QUESTIONS?
Please feel free to contact me at : Bevette.e.griffin@osfhealthcare.orgSlide46
Action Period
Assignment
Undertake at least one small test of change (PDSA) taking one or more of the ideas /changes you have heard presented on to-days callTest it in your area on a small scaleIdentify what you learnt and how you will build upon this learning
Identify a local strategy for promoting pressure ulcer prevention awareness across the multi-disciplinary team and with patients and families
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Expedition Communications
Listserv for session communications: PressureUlcersExpedition@ls.ihi.org
To add colleagues, email us at info@ihi.org Pose questions, share resources, discuss barriers or successes
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Next Session
48
Annette Bartley, RN
Kathy Duncan, RN
Karen Cole
: Claxton-Hepburn Medical Center
Stephanie Calcasola: Baystate Medical Center