AHA/HEN 2.0 HAPU WEBINAR NOT IN MY OR: PERIOPERATIVE PRESSURE ULCER PREVENTION

Transcription

1 AHA/HEN 2.0 HAPU WEBINAR NOT IN MY OR: PERIOPERATIVE PRESSURE ULCER PREVENTION June 14, :00 a.m. 12:00 p.m. CT 1

2 WELCOME AND INTRODUCTIONS Lauren Kaderabek, Program Manager, HRET 11:00 11:05 2

3 AGENDA FOR TODAY 3

4 HRET HEN RESOURCES 2016 Change Package Top 10 Checklist Resources HRET HEN Pressure Ulcer Topic website 4

5 ENCYCLOPEDIA OF MEASURES (EOM) Catalogued measure information available on the HRET HEN website HEN Core Topics (evaluation measures) HEN Core Process Measures HEN Additional Topics 5

6 SIGN UP TODAY: PRESSURE ULCERS LISTSERV Pressure Ulcers Analytics Listserv is available for: Sharing of: HRET Resources Publically Available Resources Best Practices Learnings from Subject Matter Experts Troubleshooting for Data Reporting and Analysis Sign Up Here 6

7 HEN DATA UPDATE Julia Heitzer, Data Analyst, HRET 11:05 11:10 7

8 PRESSURE ULCER RATE AND PREVALENCE Pressure Ulcer Rate, Stages 3+ (per 1,000 patients) Pressure Ulcer Prevalence, Hospital-Acquired-Stage 2+ Data submitted to AHA/HRET as of: 5/27/ Pressure Ulcer Rate, Stages 3+ (per 1,000 patients) Baseline Relative reduction, baseline to 1Q2016 (Jan, Feb, Mar) -4% Number (%) of hospitals reporting 1093 (84%) 1003 (77%) 1006 (78%) 1007 (78%) 879 (68%) 789 (61%) 608 (47%) 300 (23%) -- Pressure Ulcer Prevalence, Hospital-Acquired-Stage % Number (%) of hospitals reporting 1045 (81%) 856 (66%) 859 (66%) 949 (73%) 846 (65%) 822 (64%) 720 (56%) 366 (28%) -- Results for months in which data submission was less than 50% should be interpreted cautiously, as the data on which the results are based is not yet complete. 8

9 DEFINITIONS AND DATA CHALLENGES Jackie Conrad RN, MBA, Improvement Advisor, Cynosure Health 11:10 11:15 9

10 NPUAP NEW TERMINOLOGY Pressure injury replace Pressure ulcer Stage 1 and Deep Tissue Injury describes intact skin, not an ulcer, which led to confusion, and the need to change terminology. Arabic numbers will be used instead of Roman Numerals Suspected removed from Deep Tissue Injury diagnostic label. Additional definitions were added: Medical Device Related Pressure Injury Mucosal Membrane Pressure Injury 10

11 IMPLICATIONS FOR THE HEN HRET HEN will adopt the term Pressure Ulcer / Injury New NPUAP definitions adopted by WOCN May 25, WOCN s president awaiting updates from CMS and the ICD-10 coding group as the new definitions are implemented 11

12 STAGING DEFINITIONS Stage 1 Pressure injury: Non-blanchable erythema of intact skin. Stage 2 Pressure Injury: Partial thickness skin loss with exposed dermis Stage 3 Pressure Injury: Full thickness skin loss Stage 4 Pressure Injury: Full thickness skin and tissue loss Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Deep Tissue Pressure Injury: Persistent non-blachable deep red, maroon or purple discoloration 12

13 Definition Photo Corresponding Fruit Stage 1: Non-blanchable erythema of intact skin or changes is sensation, temperature or firmness that precede color change Stage 2: Partial thickness skin loss with exposed dermis or intact or ruptured serum filled blister. Stage 3: Full thickness skin loss, in which adipose is visible. Slough or eschar may be visible. Stage 4: Full thickness skin and tissue loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage or bone 13

14 Definition Photo Corresponding Fruit Unstageable Pressure Injury: Obscured fullthickness skin and tissue loss. Deep Tissue Pressure Injury: Persistent nonblachable deep red, maroon or purple discoloration. Pain and temperature changes precede color change. The wound may evolve rapidly or reverse without tissue loss. Mucosal Membrane Pressure Injury found on mucous membranes with history of medical device use in the area Medical Device Related Pressure Injury: etiology of injury from pressure from medical device 14

15 RESOURCES PrU 2 Implementation Guide for the NQF Endorsed Nursing-Sensitive Care Measure Set PrU 3 AHRQ Pressure Ulcer Rate Technical Specifications Version chspecs/psi_03_pressure_ulcer_rate.pdf National Pressure Ulcer Advisory Panel (NPUAP) Definitions and Guidelines Mackintosh R et al. Teaching the Fruits of Pressure Ulcer Staging. J Wound Ostomy Continence Nurs. 2014;41(4):

16 HOW TO PREVENT PERIOPERATIVE PRESSURE ULCERS Debra Fawcett, PhD, RN, Manager Infection Prevention, Eskenazi Health 11:15 11:35 16

17 OBJECTIVES 1. Describe the new Prevention of Perioperative Pressure Ulcers (Injury) Tool Kit 2. Describe the literature related to pressure ulcers (Injury) in the OR 3. Summarize why the tool kit is important 17

18 BACKGROUND AORN Survey >50% no prevention program > 50% no OR assessment Task Force Formed Experts Liaison Goals Strengthen perioperative PI efforts Encourage supplementation of any current PI efforts Provide supporting documents to assist in developing a PI prevention program in the OR To provide ready made educational materials for OR staff 18

19 WHAT IS THE RISK? Surgery is one of the times when a person not normally at risk for a pressure injury is placed at risk. (Gendron, 1988) 19

20 SKIN PHYSIOLOGY The skin contains a network of small blood vessels that have tiny muscles inside Deterioration occurs with aging in the structure of the skin and its functional ability As we age we see collagen loss of epidermal layers, decreased collagen and less thickness of the skin 20

21 INCIDENCE There is over 51.4 million surgeries per year currently Over 19.2 million people are over 65 years of age And there are now 37 million baby boomers All who may have to have surgery in the future 21

22 DEFINITION OF A PERIOPERATIVE PRESSURE INJURY A perioperative pressure ulcer is normally defined as any tissue related injury that presents within hours post-operatively and is associated with a surgical position (Black J., Fawcett, D., & Scott, S. 2015) 22

23 WHAT IS IN THE TOOLKIT? Webinars (5 min. each) Education Posters Risk assessment tools OR PI chart audit tool CEU s Assessment tools AORN also has a position statement regarding pressure injury in the OR 23

24 ASSESSMENT TOOLS Munro Scale Case studies Written instructions Webinar instructions Scott Triggers 2015 Tool Gap analysis template 24

25 STARTING POINT Often the ED-OR- PACU is now the point of entry for patients into the hospital These areas must have the awareness of skin and the tools to assess and take preventative measures Staff need to be aware of the time spent on suboptimal surfaces 25

26 THINGS THAT HELP Know what your OR mattress can do Make sure staff understand that positioning is a factor Put into place processes that will reduce the potential for PI in the OR Pay attention to skin and risk factors 26

27 REFERENCES 1. Black, J., Fawcett, D., & Scott, S. Ten top tips: preventing pressure ulcers in the surgical patient. Wounds International 2014:5(4). Accessed February Scott S, Progress and Challenges in Perioperative Pressure Ulcer Prevention. J Wound Ostomy Continence Nurs. 2015;42 (5); Chen H, Chen X, Wu J. The incidence of Pressure Ulcers in Surgical Patients of the Last 5 years. Wounds. 2012;24(9): National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guidelines. Emily Haesler (Ed.). Cambridge Media: Perth, Australia; Stiefel M, Nolan K. A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; (Available on Accessed December 7, Center for Medicare & Medicaid Services (CMS) Hospital Value Based Purchasing. 21 October (Available on Accessed December 7, Santamaria N., Gerdtz M., Sage S., McCann J., (et al) A randomized controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial. International wound journal. Jun 2015; 12(3):

28 EMERGING THERAPY: PROPHYLACTIC DRESSINGS NPUAP Recommendations: Consider applying a polyurethane foam dressing to bony prominences in the areas frequently subjected to friction and shear (B) Consider placement prior to prolonged procedures or continuous head elevation (B) Consider ease of application and removal and the ability to reassess the skin. Continue to use all of other preventative measures necessary when using prophylactic dressings (C) Black J, et al. International Wound Journal. 2014;doi:10.111/iwj National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention & treatment of pressure ulcers :clinical practice guideline. 28

29 HOSPITAL STORY Jennifer Barnes, BSN, RN, Chief Quality Officer, Stonewall Jackson Memorial Hospital 11:35 11:55 29

30 ABOUT US Stonewall Jackson is a small, independent, non-profit hospital located in Weston, West Virginia. Licensed for 70 beds High Medicare Population Interdisciplinary Pressure Ulcer Reduction Team in Place 30

31 DISCOVERY THAT LEAD TO IMPROVEMENT At the beginning of this project we asked front line staff about how they conduct their initial interview & assessment. Found that they were asking patients if they had any sores, wounds, scars, etc. Only if the patient said yes would they then do a visual inspection. Wounds were being discovered when staff would be assisting with hygiene the next morning and then be documented. We discovered that the structure of our initial interview & assessment did not flow easily. POA 31

32 TESTS OF CHANGE & WHAT WE LEARNED STANDARDIZE CARE: A complete review of wound care products was completed. Products were standardized. Wound care specialists from our supply company assisted with standardization. 32

33 TESTS OF CHANGE & WHAT WE LEARNED STANDARDIZE CARE: Nursing services launched a turning schedule for high risk patients linking time on clock and position of patient. This leads to easy auditing. 33

34 TESTS OF CHANGE & WHAT WE LEARNED EDUCATE Education on pressure ulcer staging is now required as part of annual training and we use the resource from NDNQI. Training was implemented concerning the importance of thorough skin assessments at admission and during every stay on every patient. 34

35 TESTS OF CHANGE & WHAT WE LEARNED IMPROVE DOCUMENTATION Photo documentation takes place on all wounds or skin breakdown. These are attached to the medical record. Frequency of photos Tips 6 distance 35

36 TESTS OF CHANGE & WHAT WE LEARNED ENGAGE THE INTERDISCIPLINARY TEAM Dietician receives a trigger for patient who are high risk Physical Therapy gets involved if a wound is found to be stage III or greater Rehab Dietary Nursing 36

37 INSPECT WHAT YOU EXPECT PROCESS MEASURES MONITORED IN REAL TIME Pressure ulcers are part of daily surveillance for our Infection Control Nurse Daily review of all inpatient charts Direct feedback to staff Early intervention on Stage 1 Admission Assessments are reviewed to assure the first thorough skin assessment takes place 37

38 BARRIERS AND HOW WE RESOLVED We had some difficulty with our Electronic Health Record with integrating photos into EMR Clinical IT aided in resolving the issues Clinical IT played a key role in image uploading We discovered at the beginning that many nurses did not understand the staging of pressure ulcers Providing education and guidance was essential The tools through NDNQI aided in this effort Not knowing what products to use on what stage of a wound was identified as a gap This is where the supply rep really helped our team and then assisted in product standardization 38

39 OUR RESULTS Current Data 39

40 ADVICE FOR OTHERS Have the right people involved in your multidisciplinary team. Focus on their individual contributions to help resolve issues and not on what others should be doing Education is key. Connect back to purpose Express value for the work Include unlicensed staff Use technology to your advantage. Our providers really bought into the wound photography. Placing the image within the medical record allows them to track the progress of healing or the declining of wounds. Partner with vendors and other outside resources. Bringing in the representative for our wound supplies to the team assured that staff knew what products were designed for what wound type. 40

41 WRAP UP AND NEXT STEPS You can t do improvement alone it takes a team and that team has to have the right mindset. Everyone must bring a what can I do? attitude to the table. Most of all, front line staff have to understand the importance of what you are asking them to do. We are not done we are still working on rolling out dressing change carts that are set up by wound stage. QUESTIONS? CONTACT INFORMATION: Jennifer Barnes, BSN Chief Quality Officer jbarnes@stonewallhospital.net (office) 41

42 BRING IT HOME Lauren Kaderabek, Program Manager, HRET 11:55 12:00 42

43 PHYSICIAN LEADER ACTION ITEMS What are you going to do by next Tuesday? Assess current state of application of skin protective measures in the OR assess awareness, skill and equipment What are you going to do in the next month? Partner with OR staff to implement a risk screening tool for OR patients 43

44 UNIT-BASED TEAM ACTION ITEMS What are you going to do by next Tuesday? Assess current admission documentation process to determine the reliability in conducting full body skin assessment upon admission Conduct a gap analysis in the OR and ED regarding positioning equipment Include total ER, Pre-OP, Intraoperative and post operative time quality reviews of pressure ulcer/injury What are you going to do in the next month? Utilize the AORN OR pressure Injury audit tool to review current documentation practices Implement improvements based upon findings in gap analysis and quality reviews 44

45 HOSPITAL LEADERS ACTION ITEMS What are you going to do by next Tuesday? Share the AORN Pressure Ulcer/Injury Tool Kit with OR Leadership What are you going to do in the next month? Partner with OR and ED leadership to acquire positioning wedges and pressure reduction surface for ED and OR 45

46 PFE LEADS ACTION ITEMS What are you going to do by next Tuesday? Evaluate patient education materials regarding maintaining healthy skin in the hospital What are you going to do in the next month? Utilize a patient story of an individual that developed a pressure ulcer / injury that was caused in the OR to engage front line OR staff in pressure injury/ulcer prevention 46

47 UPCOMING WEBINARS HRET/HEN 2.0 ADE Webinar: Opioids and Hypoglycemia June 16 11:00 12:00 p.m. CT HRET/HEN 2.0 Data Webinar June 21 11:00 12:00 p.m. CT HRET/HEN 2.0 Falls Webinar July 7 11:00 12:00 p.m. CT 47

48 QUESTIONS? 48

49 THANK YOU! Find more information on our website: Questions/Comments: 49