Pressure Ulcer Prevention Doesn t Work (without culture change)

Pressure Ulcer Prevention Doesn t Work (without culture change) C. Tod Brindle, MSN, RN, ET, CWOCN, CLIN IV Nurse Clinician, VCU MEDICAL CENTER Wound Care Team

Disclosure Consultant for Molnlycke Healthcare LLC Speaker s Bureau Molnlycke Healthcare LLC Honorarium Endorsed speaker for: Medline, Inc Hollister, Inc

Objectives Describe 3 methods of knowledge transference across an organization. Describe the use of change theory and root cause analysis to aid organizational culture change. Discuss 3 categories to engage executive administration in pressure ulcer prevention. Describe 4 principles of data collection to drive interventions Describe 2 strategies for continuing education of new and existing staff. Discuss the challenges of staging pressure ulcers in the presence of moisture associated skin damage.

Organizational Culture and Sustaining Change Meet in the Middle

Beyond Our Walls Committee Administration Process Pressure Ulcer Minimization Equipment Research Education

Administration X SUSTAINED CHANGE Data Inspect Report Nursing/Physicians

EXECUTIVE LEADERS WOUND CARE TEAM PU Steering Committee C.S.I RN Units/Pts RN Practice Committees VALUE Analysis

Change A successful nurse leader identifies and accepts the prevailing culture before making changes. It s more difficult to change a culture at the level of basic beliefs, values, and perspectives. It s easier to change technical and administrative systems

Nurse Executives identifying, reassessing, and changing the culture of nursing in my organization. the changing role of the registered nurse. financial awareness and responsibility..

IOM Future of Nursing Recommendation #1 Nurses should practice to the full extent of their education and training. NOTE: Skin Health and Prevention is a basic RN responsibility Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine; Institute of Medicine. (2011)

Accountibility No snowflake in an avalanche ever feels responsible. Stanislaw Lec

Lewin s Change Theory Unfreezing Unfreezing is the process which involves finding a method of making it possible for people to let go of an old pattern that was counterproductive in some way Moving Increase Drivers, Decrease restraints This stage involves a process of change in thoughts, feeling, behavior, or all three, that is in some way more liberating or more productive. Refreezing Refreezing is establishing the change as a new habit, so that it now becomes the standard operating procedure. Kritsonis (2004)

(MOVING) Modified Root Cause Analysis What? When? What areas were impacted? Why? What contributed to the event? What human, equipment or communication factors contributed?

Ishikawa (1985; 1990)

Mini Root Cause Analysis 3 levels of improvement Organization Unit based Patient specific

ORGANIZATIONAL: Administrative Buy-in C-Suite Communication Financial Safety Emotional Materials Management Financial Safety RNM Communication Performance Evaluations Risk Management/Compliance Litigation/Safety/Quality Improvement

Pressure Ulcers: (DRIVERS) High Volume & High Cost U.S. acute care facilities treat approximately 2.5 million patients with PU per year Approximately 60,000 patients die each year of PU complications Approximately $11 billion per year is spent treating PU Cost to treat: $5-$70,000 per ulcer (Weir, 2007). Lyder 2012: Up to $250,000 for one infected ulcer Highest Litigation Case: Spinal Cord Injury Patient sued the hospital for developing stage 3 pressure ulcer during admission in Texas. Awarded $84,000,000.00 U.S. Ayello & Lyder, 2007

Budget Disparity C-Suite may be unaware of the entire scope of the problem within the facility. Data (physical harm to patient) + Cost to Treat+ Litigation= Investment of the Executive Administration Materials Management operates under a budget directed by the goals and scope of the organization. May often state, new beds, dressings, etc, are not in the budget. Don t spend more switch from treatment to prevention.

Financials (Padula, 2011; Russo, 2006)

C-Suite and Material Management (REFREEZE) Current Reimbursement/Lack of Reimbursement for HAPU Are your CODERS and Wound Care Team talking? Healthcare Reform Changes National Benchmarking* A Guide not a golden calf No national standard for reporting Internal Benchmarking Transparent, Honest, REAL Feedback/Reporting System Mutual Accountability HAPU Rates By location By unit By stage By device Photos Financial Impact

Materials Management: Evidence + Fiscal Responsibility Dressings Tables Specialty Beds Pads Devices: Need to report injuries to manufacturer Work Together Is Your Materials Manager a Nurse/Clinician? If not, biggest challenge you face may simply be education.

Materials Management Make the financial benefit real and as evidence based as possible. Example: Dressings for Prevention Evidence for One Dressing What about me-too This one is cheaper doesn t it do the same thing. Example: Sheets/Underpads Who catches the best feces?

Unit Specific Case Study What? (UNFREEZING) 2009-2010 PU prevalence studies revealed occipital PU were 4 th highest anatomical location (Driver) When: WCT consults were initiated between 72 hr- 12 days post admission. Wounds were first discovered 72 hr-12 days post admission

Unit Specific Case Study What areas were impacted? Primarily ICU Med Surg units Why? Causing Serious Harm to Patient Litigation Preventable!

Unit Specific Case Study What contributed to the event? OR procedure Length, Lack of Repositioning, Devices Braided hair What human, equipment or communication factors contributed? Anesthesia practice standard Inadequate intervention ROLLED TOWELS Folded Blankets

Results: People and Process People: Anesthesiologists Equipment: Z-Flo pillows (Moving) No towels or blankets Procedure/Process: Most intubated patients, exceptions Impact beyond OR (Refreezing) ICU Artic Patients Turning includes the head Braided hair

Example: Equipment (The Operating Room) OR Table Pads Standard (ineffective): 2 foam with vicryl cover or 2 static Gel. Options: Viscoelastic Foam Dyanmic: LAL vs Alternating Pressure FIS: Fluid Immersion Simulation Medical Director of OR Photos Spot Checks Positioners Specialty Beds Which ones? Standard in certain units? Bariatric Own vs. Rent

Product Evaluations and Successful Implementation Remedy Skin Repair Cream Prevalon Heel Boot Custom Wedges Incontinence Briefs Aspen Collars Breeze mobility system Underpads ET Tube Holders Chair Cushions Beds Silicone Nasal Cannula Mepilex Line Stretchers OR Table vendor off Medsurg Beds, mattresses Z-flo positioners Maxi-movers Maxi-sliders Trach Holders Sport LAL bed purchase for all ICU Ceiling Lift Systems Trach holders Up Next: Pediatric positioners Fluidized Pediatric LAL Crib Bariatric Beds positioners Purchase new bariatric surfaces OR Full body fluidized positioners. Cerner adaptations Prone Positioners

Organizational Culture and Sustaining Change NURSING and STAFF Continuing Education

Champions of Skin Integrity: C.S.I. Creehan, M., Brindle, CT. (2010) CSI: Who are you? Nursing Management; Sept: 50-53.

All right reserved to VCU Medical Center

NURSE MANAGER: Buy-in and Role Modeling

PHYSICIAN Buy-in: Information Technology Cerner dynamic band for PU Alert for provider documentation Detailed WCT Template and Digital Photos Daily PU Report Unit based, unit associated with PU Safety huddle Mini causal analysis House wide summary Daily check-in Spread accountability (Zaratkiewicz, et al, 2010; Hieb, 2007).

12 Session Approach to Pressure Ulcer Education

Organizational Case Study What? Medical Device Related Injuries Unfreeze Never seen as an issue (buried in the data) Reduced Sacrum and Heels= Identification of Device Problem Increasing sense of RN Pride over PU prevention practices caused concern for this new problem.

% HAPU Medical Device Related

5 2011-2012 VCU HAPU RATES 4 3 VCU HAPU Trend line 2 1 0 Feb- 11 Jun- 11 Aug- 11 Sep- 11 Oct- 11 Nov- 11 Dec- 11 Jan- 12 C.O.T.H. Benchmark 4 4 4 4 4 4 4 3.6 3.6 3.6 3.6 3.6 3.6 3.6 3.6 3.6 3.6 3.6 3.6 VCU HAPU Rate 3.7 3.9 2.67 3.97 3.5 4.16 4.00 1.57 3.44 2.06 2.25 3.7 2.67 2.14 1.92 2.52 1.84 3.06 3.86 VCU Stretch Target 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.1 2.1 2.1 Feb- 12 Mar- 12 Apr- 12 May- Jun- 12 12 Jul- 12 Aug- 12 Sep- 12 Oct- 12 Nov- 12 Dec- 12

Medical Device Related Injuries

Organizational Case Study What? Medical Device Related Injuries Respiratory Devices Oxygen Cannula Tubing (intervention/success) Trach Faceplates (intervention/success) Trach Ties (intervention/success) CPAP, BiPAP (intervention/success) ET Tubes ET securement NG Tubes

Organizational Case Study When? Every month What areas were impacted? All ICUs and OR Why? What contributed to the event? Inconsistent care Multiple choices Lack of clearly defined roles (RN vs RT)

Organizational Case Study (REMOVE RESTRAINTS) What human, equipment or communication factors contributed? RT vs RN role Culture No standardized equipment No accountability for policy No documentation

Results Inter-Professional Education Respiratory Therapy Joint Education Modules Yearly/Mandatory competency for RN s and RT s. Next: Anesthesia Product Trial and Implementation New ETT Securement Devices Consultation with Outside Hospitals who have solved NGT problems Silicone Foam introduced to RT carts. IT: Documentation (standardized)

PU Patient Case Study PUddle PU M&M rounds

Know and Understand YOUR Data What is the Benchmark you are using? What are the national figures? What are your numbers? How does reporting, data collection and census affect your outcomes? Are you making progress? CC C10 CSICU 10.0% 10.0% 16.7% 0.0% 9.0% 7.7% 27.3% 11.1% CC NDNQI Adult Critical Care-Mean 8.7% 8.7% 9.1% 8.1% 8.3% 8.3% 7.9% 13.5%

Unfreeze, Move, Refreeze Staff: Pressure Ulcer M&M Rounds!

Unfreeze, Move, Refreeze: Pressure Ulcer M&M Rounds!

ADVANCED PRESSURE ULCER EDUCATION BOOT CAMP helping new CSI Team members learn the ropes Provided By. Sue Creehan, BSN, RN, CWON Program Manager, VCUHS Wound Care Team Chair, CSI Team

NEXT STEP Be unrelenting!

12 Session Approach

Competencies Via super user Train the Trainer classes. 4 Hour Lecture Training Session (4 CEUs) 1 Hour Hands On- Demo Lab Unit/Specialty Specific Turning Devices Dressings for Prevention Trainer Competencies for all unit RNs Training tools/case studies Part of Orientation/Yearly Competency Hospital Orientation

Example: MOISTURE ASSOCIATED SKIN DAMAGE

Moisture Associated Skin Damage Caused by prolonged exposure to various sources of moisture AND chemical combination of the moisture source, friction, and microbial pathogens*. 4 Conditions that result in MASD: Incontinence Associated Dermatitis (IAD) Intertriginous Dermatitis (ITD) Periwound Moisture-Associated Dermatitis Peristomal Moisture-Associated Dermatitis 1. Gray M, Black J, Baharestani M, Bliss D, et al. Moisture Associated Skin Damage. JWOCN. 2011; 38 (3): 233-241. 2..Black J, Gray M, Bliss D, Kennedy-Evans K, et al. MASD Part 2: Incontinence-Associated Dermatitis and Interiginous Dermatitis. JWOCN. 2011; 38 (4): 359-370. 3. Colwell J, Ratliff C, Goldberg M, Baherestani M, et al. MASD Part 3: Peristomal Moisture Associated Dermatitis and Periwound Moisture-Associated Dermatitis. JWOCN. 2011; 38 (5): 541-553.

Factors intensifying moisture damage: Type and chemical composition of fluid. Sweat, Urine, Stool, Wound Exudate Friction Skin folds, clothing, adhesives/tape removal Obesity Skin changes, ph, impaired heat exchange Microorganisms Skin flora, Stool flora, Cross Contamination 1. Gray M, Black J, Baharestani M, Bliss D, et al. Moisture Associated Skin Damage. JWOCN. 2011; 38 (3): 233-241. 2..Black J, Gray M, Bliss D, Kennedy-Evans K, et al. MASD Part 2: Incontinence-Associated Dermatitis and Interiginous Dermatitis. JWOCN. 2011; 38 (4): 359-370. 3. Colwell J, Ratliff C, Goldberg M, Baherestani M, et al. MASD Part 3: Peristomal Moisture Associated Dermatitis and Periwound Moisture-Associated Dermatitis. JWOCN. 2011; 38 (5): 541-553.

Don t think MASD is a big deal? Intertriginous Dermatitis in posterior skin folds of an obese patient with diabetes mellitus Necrotizing Soft Tissue Infection

Extended Protection against MASD: Microorganisms Candida is not the only bug around Intestinal, skin Edwards, Cuddigan, Black 2008: Study evaluated skin folds on admission: S. Aureus Pseudomonas Enterococcus Streptococcus Proteus Mirabilus GABHS (pediatrics) VRE Ecoli Edwards C, Cuddingan J, Black J. Indentification of Organisms Colonized at Site of Interiginous Dermatitis in Hospitalized Patients. Toronto, Ontario, Canada: World Union of wound Healing Societies 2008.

Pressure Ulcers: Ischemia vs. IAD: Moisture/Inflammation Pressure Ulcer Occurs from bottom up Caused by pressure, friction and shear Involves ischemia Usually over bony prominence Usually regularly shaped with distinct edges Partial or full thickness, necrotic tissue Skin erythema is nonblanchable. IAD Occurs from top down Caused by moisture and chemical denudation Involves inflammation Skin may appear shiny and wet Usually in skin folds, gluteal fold, perineal area or and around containment device Shape and edges often irregular Partial thickness

MASD vs. Pressure MASD PRESSURE

Full thickness conversion and location in the presence of MASD? Pressure + Shear Protease destruction, ph changes, chemical burn

IAD and PU: Treatment and Prevention of Recurrence

IAD with candidiasis + pressure

IAD Guide in Toolkit

ITD Guide in Toolkit

Remove Restraints: Accessible Info

Nursing Assistant/ Patient Care Associate Back to Basics: Can t stage or diagnose Still teach staging (knowledge transfer/ Sound the alarm! Edify their contribution to prevention! Make their dirty job be the most important thing for your patients! Unfreeze I can t do anything, I just clean up the mess. Move: Education to show value and importance of consistent care and intervention Refreeze: Care partners teaching care partners, members on IDRs.

Back to Basics: Care Partner Pressure Ulcer Education REMEMBER The Basics are: 1.Turn 2.Clean 3.Feed The Goal is: Pressure Ulcer Prevention! Vilma D Mello-Fernandes MSN, RN, CWON, Clin III Ann King MSN, RN, CWON, Clin IV Patrick Alridge BA, RN, CWON Clin II Seanna Eggleston BSN, RN Clin III

WCT: Impact Your Community! Knowledge Transference: Beyond the Walls Publications/Posters WCT Times = statewide distribution Stepping Stones to Excellence in Wound Care Local, Regional, National, International Presentations Mission Work/Outreach: Correctional Facilities, Impoverished Countries, etc. Collaboratives: VHQC VPURT Utilizing External Consultants to Critique Practice

References Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine; Institute of Medicine. (2011) The Future of Nursing: Leading Change, Advancing Health. Washington, DC, National Acadamies Press. Creehan, M., Brindle, CT. (2010) CSI: Who are you? Nursing Management; Sept: 50-53. Defloor T. (2005) Hieb, Barry (2007) Stop the Bleeding; Use IT to Achieve Sustained Value in Healthcare, Industry Research ID Number:G00144534. Ishikawa, Kaoru (1985) [First published in Japanese 1981]. What is Total Quality Control? The Japanese Way [Originally titled: TQC towa Nanika Nipponteki Hinshitsu Kanri]. D. J. Lu (trans.). New Jersey: Prentice Hall. Ishikawa, Kaoru (1990). Introduction to Quality Control. J. H. Loftus (trans.). Tokyo: 3A Corporation. Kritsonis A. Comparison of Change Theories. International Journal of Scholarly Academic Intellectual Diversity; 8:1, 2004-2005. Schoonhoven L, Defloor T, Gropdonck, M. (2002) Zaratkiewicz, S., Whitney, J., Lowe, J., Taylor, S., O Donnell, F., Minton-Foltz, P., (2010) Development and Implementation of a Hospital-acquired Pressure Ulcer Incidence Tracking System and Algorithm. Journal for Healthcare Quality; Vol 1, No.1, pp. 1-8.