Eliminating Pressure Ulcers in Ascension Health

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1 Eliminating Pressure Ulcers in Ascension Health Cissy Shanks RN BSN CEN & Pam Kleinhelter RN MSN CNA-BC Nursing Managers St Vincent s Health System Jacksonville, Florida Objectives Participants will be able to: Apply the elements of a pressure ulcer prevention program to their respective organizations Utilize the four tactics included in the SKIN bundle Recognize the key barriers to a successful prevention program and identify appropriate recommended activities to address these barriers 2 Ascension Health 3 1

2 The Alarming Truth In 1999, the Institute of Medicine (IOM) reported that an estimated 98,000 individuals die in any given year from medical errors. If we apply the national average to Ascension Health: More than 15,000 people in our system could experience a clinical error this year. Of those, 750 to 1,500 patients will die That s 2 to 4 preventable deaths every day at Ascension Health 4 Ascension Health The Call to Action November 2002 Together we promise: Healthcare that works; Healthcare that is safe; Healthcare that leaves no one behind If not us, who? If not now, when? 5 Healthcare That Is Safe Defined by our Clinical Excellence Goal: The care we deliver will be safe and effective. We commit to having excellent clinical care with no preventable injuries or deaths in five years (by July 2008). 6 2

3 Eight Priorities for Action 1. Hospital Mortality 2. Nosocomial Infections Ventilator acquired pneumonia Catheter infections 3. Falls and fall injuries 4. Pressure ulcers 5. Birth trauma injuries to neonate 6. Surgical complications Post-op Deep Vein Thrombosis and Pulmonary Embolism Post-op hemorrhage Peri-op MI Foreign body left after surgery Surgical site infection 7. Adverse Drug Events 8. Joint Commission NPSGs *All Health ministries required to work on ADEs and NPSGs 7 Alpha / Pilot Responsibilities Eliminate injuries from priority for action in that health ministry Create blueprint for change Identifies best approach (specific strategies) for eliminating priority for action events Identifies clear metrics for measuring and monitoring progress The value proposition business case Suggested organizational structure Timelines Required infrastructure changes Lead effort (adapt blueprint change package) across rest of AH 8 Alpha Site St. Vincent s Medical Center Jacksonville, Florida Largest provider of adult inpatient services 19.3% market share 9 3

4 Alpha Site Admissions 26,600 Patient Days 135,000 Deliveries 2,200 Inpatient Surgery 6,800 Outpatient Surgery 9,000 Emergency Dept. Visits 61,000 Over 3400 associates employed 10 Pressure Ulcers: An Equal Opportunity Complication Like an iceberg the worst lies beneath Risk factors increase occurrence and severity A nearly preventable complication in most populations 11 St. Vincent s Experience Began alpha site work 2004 Aim: prevention of hospital acquired pressure ulcers 2004 Hill-Rom prevalence study and incidence study as baseline data Facility prevalence rate of 5.7% 12 4

5 Alpha Site Timeline June August September October November Expert meeting First 3 units go live with SKIN bundle Operational management involved 165 new surfaces All units involved 13 Alpha Site Perspective Identify team leader/champion Multidisciplinary Team Nursing Education Performance Improvement Pharmacy Dietary WOCN Nurses 14 Alpha Site Perspective Skin as organ system Branding (iceberg) Identification of patients at highest risk Prevention as Best Practice Nurse empowerment and pride of nursing practice SKIN Bundle 15 5

6 SKIN Bundle Surface Selection Keep Turning Incontinence Management Nutrition 16 Alpha Site Perspective Education Use multiple times and venues Incorporate all processes of initiation as teachable moments Don t assume knowledge base equal within disciplines Use newsletters to reinforce key elements 17 Operations Team Meets weekly Skin bundle compliance New facility acquired pressure ulcers Education Celebration 18 6

7 Lessons Learned Products TED Hose Diapers Disposable under pads Flexiseal OR warming blanket 19 Lessons Learned Operational processes Remember to assess all areas i.e. open heart, dialysis, OR and ED Appeal to pride of nursing practice Educate everyone Expect early spike Remember data availability Review all ulcers as opportunity to improve Pilots don t have to be perfect 20 Weekly Incidence 21 7

8 Raising the Bar in 2007 Prevalence Study All Ascension Health Hospitals participated in 2007 prevalence study 39% had ZERO facility acquired pressure ulcers 45% had ZERO facility acquired pressure ulcers excluding Stage I 49% had less than 2% facility acquired pressure ulcers 66% had less than 2% facility acquired pressure ulcers excluding Stage I Lowest system rate in the international study 22 Creating a Mosaic of Care Summit Sharing Results E-Learning Modules Vetting new tactics Providing the evidence Integrating the work Gaining Consensus Toolkit Sustainability Data CNO leadership Celebrating Success 23 Results Facility acquired prevalence 10% 8% 6% 4% 2% 8.3% 6.4% 4.7% 4.1% 4.3% 3.4% 2.7% 2.8% 0% Including Stage 1 Excluding Stage 1 ASCENSION 2005 ASCENSION 2006 ASCENSION 2007 ASCENSION IPUP Facility acquired including stage I 6.2% excluding stage I 3.8% 24 8

9 Pressure Ulcer Rate per Month by Reporting Hospitals June 2008 SVMC = 0.44 Ascension Health = Essential Component for Success Skin operations group Meets weekly Nursing Leadership 26 Alpha Site. The second generation Skin failure Skin Operations Skin Bundle Intact Multiple co-morbidities Suspicions Hypotension Skin color History of pressure ulcer 02 saturations below 92 Vasopressors Literature search and Chart audits October 2005 May

10 Skin Failure Defined Acute An event in which skin and underlying tissue die due to hypoperfusion concurrent with a critical illness. Chronic An event in which skin and underlying tissue die due to hypoperfusion concurrent with a chronic disease state End-Stage An event in which skin and underlying tissue die due to hypoperfusion concurrent with end of life 28 Database Form 29 Data Collection Tool 30 10

11 Incidence of Skin Failure in HAPU July 1, February 28, All HAPU 117 All skin failure and Kennedy ulcers 39 Skin failure excluding Kennedy ulcers and Bundle gaps Average Braden scores for both groups Skin Failure Non-Skin Failure Percent of acute and chronic conditions observed in non- Skin failure HAPU 35.0% 28.8%% 32.2% Chronic conditions 30.0% 25.0% Acute conditions 25.4% 20.0% 16.9% 15.0% 10.0% 5.0% 3.4% 5.1% 0.0% Cardiac CHF Hepatic Pulmonary PVD Renal Sepsis Shock 33 11

12 Percent of acute and chronic conditions observed in patients with skin failure with HAPU 70.0% 65.2% Chronic conditions 60.0% 56.5% Acute conditions 50.0% 43.5% 47.8% 39.1% 40.0% 30.0% 26.1% 21.7% 20.0% 8.7% 10.0% 4.3% 4.3% 4.3% 4.3% 0.0% Cardiac CHF Hepatic Pulmonary PVD Renal Sepsis Shock 34 Measures of Oxygen saturation and use of Vasopressors observed in patients with and without skin failure 30% 25% 26% Skin Failure Non-skin Failure 20% 17% 15% 9% 10% 10% 5% 0% Oxygen saturation 92 or less Vasopressor use 35 Percent of patients with and without skin failure with systolic pressure of 90 or less for one hour or more 45% 40% 35% 43% Skin Failure Non-Skin Failure 30% 25% 20% 17% 15% 10% 5% 0% Hypotensive hours 36 12

13 Tests of significance Acute Renal conditions z test comparing sample proportions = 2.9, p = 0.01 Significant Acute Pulmonary conditions z test comparing sample proportions = 2.0, p =.05 Significant Acute Cardiac conditions z test > 3.0, p <.01 Significant 37 Results Mortality z test comparing sample proportions = 2.73, p < 0.01 Significant Hypotension z test comparing sample proportions = 2.51, p =0.01 Significant Chronic Pulmonary conditions z test comparing sample proportions > 4.0, p <.01 Significant Chronic Cardiac conditions z test comparing sample proportions > 3.0, p<.01 Significant 38 Conclusions and next steps Skin failure is real Between 19.6 % and 33% of total hospital acquired pressure ulcers may be a result of skin failure Caveats Low volume study Cardiac conditions Implications for the future Research Litigation Pay for performance 39 13

14 Questions and contact information Pam Kleinhelter RN MSN CNA-BC Helana (Cissy) Shanks RN BSN CEN 40 14

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