GBMC Pressure Ulcer GBMC Pressure Ulcer Prevention ProgramPrevention Program

Marie Barry Marie Barry Masters in Masters in

Leadership/Management Leadership/Management CandidateCandidate

Stevenson UniversityStevenson University

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Objectives of a Pressure Ulcer Objectives of a Pressure Ulcer Prevention Program Prevention Program

► State why a pressure ulcer prevention is State why a pressure ulcer prevention is importantimportant

► Understand how GBMC can initiate and sustain Understand how GBMC can initiate and sustain a pressure ulcer prevention program hospital a pressure ulcer prevention program hospital widewide

► Identify best practice in order to diminish the Identify best practice in order to diminish the prevalence of hospital acquired pressure ulcersprevalence of hospital acquired pressure ulcers

► Identify strategies to overcome organizational Identify strategies to overcome organizational obstacles obstacles

► Learn how to disseminate new learningLearn how to disseminate new learning

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Why is pressure ulcer Why is pressure ulcer prevention important?prevention important?

► Pressure ulcers are preventablePressure ulcers are preventable► Pressure ulcer occurrence is a quality care Pressure ulcer occurrence is a quality care

indicatorindicator►Diminishes a person’s quality of lifeDiminishes a person’s quality of life► Increases a patient’s length of stayIncreases a patient’s length of stay► Reflects negatively on a healthcare Reflects negatively on a healthcare

organizationorganization► Creates organizational financial hardshipCreates organizational financial hardship► Prevention is listed as part of The Joint Prevention is listed as part of The Joint

Commission’s National Patient Safety GoalsCommission’s National Patient Safety Goals

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Pressure Ulcers listed by Pressure Ulcers listed by Medicare in 2007 as a “never Medicare in 2007 as a “never

event”event”

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Factors that contribute to the Factors that contribute to the development of hospital-development of hospital-acquired pressure ulcers:acquired pressure ulcers:

► Advanced ageAdvanced age► Inadequate patient mobilityInadequate patient mobility► Severity of illnessSeverity of illness► Chronic medical conditionsChronic medical conditions► IncontinenceIncontinence► Pain Pain ►MalnutritionMalnutrition► Cognitive declineCognitive decline► SICU, MICU, ICU patientsSICU, MICU, ICU patients

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Clinical areas with high Clinical areas with high pressure ulcer prevalencepressure ulcer prevalence

►ED-patients may wait up to four hours ED-patients may wait up to four hours before being placed in a hospital bedbefore being placed in a hospital bed

► ICU-life saving equipment limits ICU-life saving equipment limits mobilitymobility

►Critical care settingsCritical care settings►PACUPACU►Orthopedic unitOrthopedic unit►Geriatric unitGeriatric unit

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Diligent nursing care can Diligent nursing care can prevent nearly 100% of hospital-prevent nearly 100% of hospital-

acquired pressure ulcersacquired pressure ulcers

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Financial impactsFinancial impacts

► Rising prevalence over last 10 yearsRising prevalence over last 10 years► Rising healthcare costsRising healthcare costs►Hospital acquired pressure ulcers will no Hospital acquired pressure ulcers will no

longer be reimbursed by Medicare and longer be reimbursed by Medicare and MedicaidMedicaid

► Increases length of hospital stayIncreases length of hospital stay► Adds avoidable costs to the healthcare Adds avoidable costs to the healthcare

organizationorganization► Leads to increased litigationLeads to increased litigation► Pressure ulcer occurrences may negatively Pressure ulcer occurrences may negatively

impact future patient referralsimpact future patient referrals

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Potential Organizational Potential Organizational Cost SavingsCost Savings

►For each individual healthcare For each individual healthcare organization, between $3 million and $ organization, between $3 million and $ 4 million a year in unreimbursed 4 million a year in unreimbursed medical expensesmedical expenses

► Investment in pressure redistribution Investment in pressure redistribution mattresses had a ROI within 6 monthsmattresses had a ROI within 6 months

►Expensive litigationExpensive litigation

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How can GBMC initiate a How can GBMC initiate a Pressure Ulcer Prevention Pressure Ulcer Prevention

Program?Program?

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Assess GBMC readiness for the Assess GBMC readiness for the implementation of PUPimplementation of PUP

►Organizational change requires a system- Organizational change requires a system- wide approachwide approach

►Determine the level of the leadership Determine the level of the leadership commitment commitment

► Recognize barriers to change: workflow, Recognize barriers to change: workflow, communication, change in practice, timecommunication, change in practice, time

► Form small focus groupsForm small focus groups► Interdepartmental surveysInterdepartmental surveys► Use toolkit readiness checklist Use toolkit readiness checklist

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Strategies to solidify readiness Strategies to solidify readiness for a hospital-wide PUP programfor a hospital-wide PUP program

►Pilot a PUP on a high risk unitPilot a PUP on a high risk unit Demonstrate program success in order to Demonstrate program success in order to

obtain staff supportobtain staff support Collect and disseminate data of pressure Collect and disseminate data of pressure

ulcer prevalence ulcer prevalence Determine individuals interested in Determine individuals interested in

becoming unit-based championsbecoming unit-based champions Hospital-wide awareness campaigns Hospital-wide awareness campaigns

(posters, screen savers, town hall (posters, screen savers, town hall meetings, staff meetings)meetings, staff meetings)

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Strategies to overcomeStrategies to overcomeorganizational obstaclesorganizational obstacles

► Determine successful processes already in Determine successful processes already in placeplace

► Explain to staff the importance of program Explain to staff the importance of program implementation (Federal and State mandates)implementation (Federal and State mandates)

► Create urgency to key stakeholders (financial Create urgency to key stakeholders (financial and clinical benefits)and clinical benefits)

► Provide leadership and supportProvide leadership and support► Provide financial and supportive resourcesProvide financial and supportive resources► Listen to staffListen to staff

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Best practice to eradicate Best practice to eradicate pressure ulcerspressure ulcers

► Identify patients who are high risk by using Identify patients who are high risk by using the Braden scale & reassess every 12 hoursthe Braden scale & reassess every 12 hours

► Early interventionEarly intervention► Relieve pressure, reduce moistureRelieve pressure, reduce moisture► Reposition every 2 hoursReposition every 2 hours► Digital cameras to assist with documentationDigital cameras to assist with documentation► Hourly rounding to identify patient care needsHourly rounding to identify patient care needs► Educate interdepartmental key stakeholders Educate interdepartmental key stakeholders

on the importance of a pressure ulcer on the importance of a pressure ulcer prevention programprevention program

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Best practice to eradicate Best practice to eradicate pressure ulcerspressure ulcers

► Educate staff, patients, and familiesEducate staff, patients, and families► Assess skin integrity within four hours of Assess skin integrity within four hours of

admission to EDadmission to ED► Develop a daily skin care flow sheet Develop a daily skin care flow sheet ► Initiate a physician driven order set for high Initiate a physician driven order set for high

risk patientsrisk patients► Interdepartmental collaborationInterdepartmental collaboration► Utilize patient identifiers for high risk patientsUtilize patient identifiers for high risk patients► Revise policies and guidelines every 2 years Revise policies and guidelines every 2 years

and as neededand as needed► Wound care resource books on each unitWound care resource books on each unit

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Measure pressure ulcer ratesMeasure pressure ulcer rates

►Determine unit pressure ulcer rates for the last Determine unit pressure ulcer rates for the last 12 months12 months

► Identify units that require immediate Identify units that require immediate interventionintervention

► Use CMS guidelines to create policies and Use CMS guidelines to create policies and protocolsprotocols

► Acknowledge adverse eventsAcknowledge adverse events► Acknowledge legal action within the organizationAcknowledge legal action within the organization► Perform a root-cause analysis with each Perform a root-cause analysis with each

documented hospital-acquired pressure ulcerdocumented hospital-acquired pressure ulcer► Voluntary report to governmental agenciesVoluntary report to governmental agencies►Quarterly pressure ulcer prevalence studiesQuarterly pressure ulcer prevalence studies

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Education and communicationEducation and communication

►Pre-shift reportsPre-shift reports►Nurse-to-nurse reportsNurse-to-nurse reports► Interdepartmental reports Interdepartmental reports

(ED, OR, PACU, HD,(ED, OR, PACU, HD,

Out-patient services)Out-patient services)►Unit-based wound/ostomy resource bookUnit-based wound/ostomy resource book►Pressure ulcer prevention Pressure ulcer prevention

champions/teamschampions/teams

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Education and Education and communicationcommunication

►Simulation lab for competencies and Simulation lab for competencies and new nurse orientationnew nurse orientation

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Don’t reinvent the wheelDon’t reinvent the wheel

► Inter-facility collaborationInter-facility collaboration►Learn from their success and mistakesLearn from their success and mistakes

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OSF St. Francis Medical Center OSF St. Francis Medical Center inin

Peoria, ILPeoria, IL

►SOS campaign-SAVE OUR SKINSOS campaign-SAVE OUR SKIN►Every two hours, Olympic-style theme Every two hours, Olympic-style theme

music is piped over the audio system to music is piped over the audio system to remind staff it is time to reposition patientsremind staff it is time to reposition patients

►Nurses and techs receive a page every two Nurses and techs receive a page every two hours: “Please turn your patients now.”hours: “Please turn your patients now.”

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Genesis Medical Center inGenesis Medical Center inDavenport, LADavenport, LA

►““TOE”: Turn, Overlay, ElevateTOE”: Turn, Overlay, Elevate►Turn the patient for preventionTurn the patient for prevention►Overlay beds/chairs with specials Overlay beds/chairs with specials

surfacessurfaces►Elevate bony prominences and heelsElevate bony prominences and heels

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Owensboro Medical Health Owensboro Medical Health System inSystem inKentuckyKentucky

► ““Four-eyed body check” on admissionFour-eyed body check” on admission► Two nurses check the patient head to toe Q Two nurses check the patient head to toe Q

24 hr24 hr► Patients can refuse which is documented in Patients can refuse which is documented in

the medical recordthe medical record►Wound rounds bi-weeklyWound rounds bi-weekly► Identify key people within the organizationIdentify key people within the organization► Be consistentBe consistent► Track outcomesTrack outcomes

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Pennsylvania hospitals Pennsylvania hospitals introduced a color of safetyintroduced a color of safety

►Color-coded wristbands communicate Color-coded wristbands communicate level of patient’s risklevel of patient’s risk

►Place a patient identifier outside of the Place a patient identifier outside of the patients doorpatients door

►Use color-coded stickers on patients Use color-coded stickers on patients chartscharts

►Be consistentBe consistent

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Color of SafetyColor of SafetyCommunicate and Educate Communicate and Educate

► Initiate wristbands upon admission or Initiate wristbands upon admission or changes in medical conditionchanges in medical condition

►Educate patients, staff, and family Educate patients, staff, and family regarding the purpose of wristbandsregarding the purpose of wristbands

►Coordinate signage: doors, chart, Coordinate signage: doors, chart, stickers to match wristband colorstickers to match wristband color

►Wristband education to facilitate inter-Wristband education to facilitate inter-departmental and inter-facility departmental and inter-facility communicationcommunication

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Staff remindersStaff reminders

►Place a clock with moveable hands as a Place a clock with moveable hands as a staff reminder to turn patientsstaff reminder to turn patients

►Sound system or chimes to indicate Sound system or chimes to indicate turningturning

►Automatic pager timers to direct care Automatic pager timers to direct care staffstaff

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Documentation Documentation

► Important in order to comply with Important in order to comply with state and governmental standardsstate and governmental standards

►To ensure quality patient care To ensure quality patient care ►Be consistentBe consistent►Use available technologyUse available technology►Photographic documentationPhotographic documentation►Key to the defense of legal actionKey to the defense of legal action

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Resources necessary for Resources necessary for implementationimplementation

► Ensure adequate resources:Ensure adequate resources: Non-clinical time for staff team meetingsNon-clinical time for staff team meetings Training and education of staffTraining and education of staff Leadership time to monitor and support teamsLeadership time to monitor and support teams Product and bed product educationProduct and bed product education Adequate staff coverage for staff educationAdequate staff coverage for staff education Funds for printed materialsFunds for printed materials Information technology changes -- Information technology changes --

documentation in electronic patient recorddocumentation in electronic patient record Performance Improvement -- data system to Performance Improvement -- data system to

accurately reflect pressure ulcer prevalenceaccurately reflect pressure ulcer prevalence

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Interdisciplinary teams are key Interdisciplinary teams are key to PUP successto PUP success

►Teams need a strong link with leadershipTeams need a strong link with leadership►Teams can generate enthusiastic and Teams can generate enthusiastic and

capable leaders with defined unit-based capable leaders with defined unit-based roles roles

►Responsible for reporting performance Responsible for reporting performance improvement data and monitoring unit improvement data and monitoring unit specific processspecific process

►Will be responsible for bringing evidence-Will be responsible for bringing evidence-based best practice to the bedsidebased best practice to the bedside

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Representatives on the PUP Representatives on the PUP teamteam

► Staff nursesStaff nurses► Risk managersRisk managers► Nursing assistantsNursing assistants► Registered dietitiansRegistered dietitians► Unit managersUnit managers► Unit secretaryUnit secretary► PhysiciansPhysicians► PT/OTPT/OT►Wound care nursesWound care nurses►Materials managerMaterials manager► IT departmentIT department

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Create a program to Create a program to disseminate learningdisseminate learning

►Wound care team will be the primary Wound care team will be the primary resource for staff, patients and familiesresource for staff, patients and families

► Unit-based team members will perform skin Unit-based team members will perform skin and pressure ulcer risk assessmentsand pressure ulcer risk assessments

► The interdisciplinary team will work with The interdisciplinary team will work with staff and leadership to develop and staff and leadership to develop and implement a PUP programimplement a PUP program

► Physician champions will educate residentsPhysician champions will educate residents► Use hospital-side identifiers for persons who Use hospital-side identifiers for persons who

are at high risk for developing pressure are at high risk for developing pressure ulcersulcers

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Pressure ulcer prevention Pressure ulcer prevention sustainabilitysustainability

► Wound care nurses and unit champions will Wound care nurses and unit champions will be responsible for maintaining best practicebe responsible for maintaining best practice

► Unit based teams will be expert resourcesUnit based teams will be expert resources► Continued leadership supportContinued leadership support► New employee orientationNew employee orientation► Yearly competency Yearly competency ► Unit-based PI studiesUnit-based PI studies► PostersPosters

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A pressure ulcer prevention A pressure ulcer prevention program requires a team in program requires a team in

order to achieve success and order to achieve success and sustainabilitysustainability