turning matters - amazon s3 · turning matters: an innovative technology to reduce patient harm...

TURNING MATTERS:An Innovative Technology to Reduce Patient Harm

Beth W Jacobs, RN, CCM, CRRN

Susan McCulley, RN, MSN, NE-BC

Shari Goodman, RN, MSN, CRRN

MossRehab Spinal Cord System of Care

Elkins Park, PA

Speaker disclosure statement

Beth Jacobs, Susan McCulley & Shari Goodman are employees of MossRehab/Einstein Healthcare Network

• No off-label use will be discussed

• No industry relationships to disclose

• Supported by funding from the Albert Einstein Society Innovative Program, Einstein Healthcare Network, Philadelphia PA

Objective

• The participant will be able to describe the Leaf Monitoring System technology

• The participant will be able to list strategies to reduce the risk of hospital acquired pressure ulcers (HAPU)

Pressure ulcers are the most prevalent preventable hospital acquired condition

Why is it so devastating?

The healing process is slow and requires a great deal of care

What is the impact to society?

2.5 million individuals effected annually

• 60,000 result in death

• Increase of 6-10 days in length of stay (LOS)

• Average $8,730/pressure ulcer to treat

• If evolves to stage 4 >$100,000 to treat

$11.6 billion per year in healthcare cost

What is the impact to Moss?

• Patient recovery and health

• Patient satisfaction

• Patient/family litigation

“to respond to our patient’s needs and restore physical and emotional integrity for as many as we can reach”

Network strategic plan

Einstein Acute Hospital

• Nursing department-wide skin education in every skills day

• WOCNs provide extensive educational initiatives

• Incontinence pads and bath products purchased

• Over head lifts for turning/repositioning and early out of bed

MossRehab

• Pressure Ulcer Prevention (PUP) initiative in response to CMS reporting

• Mandated 4 hour education on pressure ulcer prevention, management, documentation

• Identified unit skin champions for daily support and sustainability

• Weekly bedside rehab team wound rounds

Daily prevention implemented• Skin inspection and assessment

• Repositioning devices

• HOB<30 if tolerable

• Encourage fluids/nutrition

• Get patient out of bed

• Range of motion

• Manage incontinence

• Limit diapers

• Redistribution surfaces

• Custom fitted seat cushions

• Cushion bony prominences

• Topical skin barrier

• Skin moisturizer

• Minimize linen layers

• Specialty beds

Overall outcomes

Acute hospital SICU

• Prevalence rate was above the national benchmark of 3.19% for

fiscal year 2015

Acute rehab SCI unit

• CMS extensive reporting of all pressure ulcer data since Oct 2012

• Incidence rate being calculated for three consecutive years

• 66% reduction in HAPU incidence rate for Moss’s entire 197 beds

• However SCI unit consistently has the overall highest volume of PUs

• National benchmark has not been established to date

Repositioning every 2 hours

An opportunity

• A technology to assist the nurses in their effort to reduce hospital acquired pressure ulcers (HAPU)

• Received an “Albert Einstein Society” Innovative Program grant

“The Society invests in the future of healthcare by supporting innovative healthcare programs that directly enhance patient care”

Patient Monitoring System

Leaf Healthcare sensor monitoring system

• Single-use wireless electronic sensor with battery life of 12 – 14 days

• Placed on the skin of the upper torso

• Monitors patient movements

• Assists staff in care planning and providing routine repositioning

• Innovative technology not offered in any other facility on the east coast

Patient sensor antennas Leaf interface

Real-time patient reposition monitoring

Display interface

• Discreetly positioned

• Useful information

at a glance

• Visual cues avoids nuisance alarm system

• Records turn history providing immediate feedback

Cost

• Installation of software, maintenance & education were free

• Expense was for purchase of sensors only

SICU ALOS is 6 days with 64 admissions/month

3 month pilot = 192 sensors

SCI unit ALOS is 18 days with 26 admissions/month

2 sensor will be needed per stay

3 month pilot = 156 sensors

Anticipated 40 replacement sensors

Goals

Patient centered focus

• Increase turning compliance will result in decreased incidence of HAPUs/worsening PUs

Improved patient health

Improved qualify of life

Reduced burden of care for patient’s families

Financial centered focus

• Reduced pressure ulcer related cost

• Reduced litigation expenditures

Implementation plan

• Equipment installation to begin August 2015

• Education of all RN/CNA staff on both units in September 2015

• 3 month pilot conducted September 22nd – December 24th

All patients admitted to both units would be included despite their diagnosis and medical status

Application of sensors were considered a standard part of our practice

Nursing education

• Optimal patient positioning to achieve 20 degree turn

off-loading angle

• Appropriate use of WEDGE and pillows

• Orientation to the system technology

• Patient sensor application and protocols

• Management of monitoring and warning capabilities

• General problem solving with ‘live’ Leaf Healthcare support

3 month monitoring

• Concurrent monitoring of individual patient and unit specific compliance

• Daily reports shared with all nursing staff

• Immediate identification of areas of opportunity for improvement in nursing practice

• Weekly project leadership meetings to evaluate outcomes and refine the process

• Nursing survey at one month & post pilot closure regarding nursing perceptions and application of the system

SICU turn compliance 1 month

Moss turn compliance 1 month

Initial challenges

• First two weeks a lot of “noise”

• High census and turn over in SICU

• Application tricks to assure adherence

• Nurses questioning if the system accurately recorded when 20 degree turn angle was achieved

• Upright OOB monitoring in rehab

• Skin adhesive of sensor

• Patient refusals

Pilot modifications

• The first two weeks were treated as a “wash out” period and not included in the data analysis

• Allocated volume of sensors was adjusted

• Upright OOB monitoring was removed from analysis at Moss

Moss turn compliance overall

SICU turn compliance overall

74%

Repositioning preference

19.4%

63.6%

17.0%

Team 1

LEFT BACK RIGHT

16.3%

61.7%

22.0%

Team 2

LEFT BACK RIGHT

16.0%

62.1%

21.9%

Team 3

LEFT BACK RIGHT

26.1%

49.0%

24.9%

LEFT BACK RIGHT

SICU

Moss

Pause turn alerts

SICU Moss

Pressure ulcers

10 SCI patients had 14 relevant pressure ulcers in rehab

• Present on admission (POA) - 11

• 9 - healed

• 1 - unstageable on admission and discharge

• 1 - stage 1 Worsened to stage 2 (most likely was evolving)

• HAPU (HAPU) - 3

• 2 - healed

• 1 - stage 2 on discharge

Nursing survey questionsDo you believe the Leaf Sensor

increases your regularity of patient turning to assist with preventing pressure ulcers?

0

10

20

30

40

50

60

70

80

90

1 month Closure

Yes No

Is the wedge helpful for achieving adequate

repositioning?

0

10

20

30

40

50

60

70

80

1 month Closure

Yes No

Sensor system advantages

• Real-time feedback of nursing care delivery

• Visual monitor color system encourages timely correction of practice

• Achieving adequate off loading with validation of 20 degree turn position

• Turn position % encourages even use of left, right and supine

• Flexibility of Leaf Healthcare to adjust data analysis in a variety of ways

• Analysis by team assignment

• Analysis by shift assignment

Long term challenges

• Patient refusal

• Education and re-education of patients

• Need for inclusion/exclusion criteria

• Despite both units had high risk populations

• More independent patients became upset with night time disruption

• System was not optimized to accurately monitor decompression time interval for wheelchair bound patients

• In rehab patients move more freely around the hospital moving in and out of system range

Summary & conclusions

• As a network we were well above the national average but did not meet our projected 90% compliance criteria

• There was a correlation between patient medical acuity (CMI) and the presence of PUs

• Enrollment numbers were not statistically significant to correlate to an improved or worsening prevalence/incidence rate on either unit

• Inability to show direct correlation to reduction in prevalence/incidence resulted in decision to not purchase the system

• Network-wide decision to purchase wedges implemented for high risk patients with Braden score of 18 and below effective June 1st

For more information contact Beth Jacobs, RN, CCM, CRRN

Clinical Coordinator

Spinal Cord System of Care

215-663-6119

bjacobs@einstein.edu

Thank you to Leaf Healthcare® for their support of this project

?

Theoretical Framework

Our Nursing Practice is Grounded in the

Theory of Human Caring

Works cited

• Doucette M. Pressure Ulcer Prevention. Adv for Nurses 2015 May;8-11

• Gunningberg L. Are patients with or at risk of pressure ulcers allocated appropriate prevention measures? Int J Nurs Pract 2005;11:58067

• Lyder, et al. Hospital-acquired pressure ulcers: results from the national Medicare Patient Safety Monitoring System study. J Am Geriatr Soc. 2012

Sep;60(9):1603-8

• Moore Z, et al. A randomised controlled clinical trial of repositioning, using the 30 degree tilt, for the prevention of pressure ulcers. J Clinc Nsg 2011; 20:2633-2644

• Schutt S, et al. Advancing pressure ulcer prevention efforts: Innovative technology improves compliance with patient turning protocols. 2014 ANCC Magnet

Conf

• Voz A, et al. Who is turning the patients? A survey study. J Wound Ostomy Cont Nsg

2011;38(4):413-418