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Back to the Basics: Impacting Patient Outcomes Through Evidence Based Practices to Reduce and Non-Vent HAP and HAPI

Kathleen M. Vollman MSN, RN, CCNS, FCCM, FAANClinical Nurse Specialist / Educator / Consultant

ADVANCING [email protected]

Northville Michiganwww.Vollman.com

© ADVANCING NURSING LLC 2017

Some Slides Courtesy of Barb Quinn

Disclosures for Kathleen Vollman

• Consultant-Michigan Hospital Association Keystone Center

• Consultant/Faculty for CUSP for MVP—AHRQ funded national study

• Subject matter expert CAUTI, CLABSI, HAPU, Sepsis, Safety culture

• Consultant and speaker bureau for Sage Products LLC

• Consultant and speaker bureau for Hill-Rom Inc

• Consultant and speaker bureau for Eloquest Healthcare

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Session Objectives

• Create the link of patient advocacy to the basic nursing care

• Define key fundamental evidence based nursing care practices that reduce non-vent HAP and hospital acquired skin injury

• Discuss strategies to overcome barriers

Notes on Hospitals: 1859

“It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.”

Florence Nightingale

Advocacy = Safety

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PROTECT THE PATIENT FROM BAD THINGS HAPPENING ON YOUR WATCH

Interventional Patient Hygiene

• Hygiene…the science and practice of the establishment and maintenance of health

• Interventional Patient Hygiene….nursing action plan directly focused on fortifying the patients host defense through proactive use of evidence based hygiene care strategies

Incontinence Associated Dermatitis Prevention

Program

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INTERVENTIONAL PATIENT HYGIENE(IPH)

Oral Care/ Mobility

VAP/HAP

Catheter Care

CA-UTI CA-BSI

Skin Care/ Bathing/Mobility

HASISSI

HAND

HYGIENE

Patient

Vollman KM. Intensive Crit Care Nurs, 2013;22(4): 152-154

Attitude &

Accountability

Factors Impacting theability to Achieve QualityNursing Outcomesat the Point of Care

Achieving the Use of the Evidence

ValueVollman KM. Intensive Crit Care Nurs, 2013;22(4): 152-154

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Building Resiliency Into Interventions

St ronges t

STRENGTH OFINTERVENTION

Weakest

9

Forcing functions and constraints

Automation and computerization

Standardization and protocols

Checklists and independent check systems

Rules and policies

Education and information

Vague warnings – Be more careful!

Why HAI's?Protecting Patients From HarmEstimates: 183 Hospitals in 10 States

HAI: 722,000/year

HAI-related deaths: 75,000/year

Hospitalized patients develop infection: 1 out of 25 (4%)

Death due to sepsis/septic shock: 700/day

Money spent: $45 billion/year

Increase risk of readmission:

27days vs. 59 days

Magill SS, et al. New England Journal of Med, 2014;370:1198-208

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Health Care Associated Infection Data

Measurement NHSN 20123742 hospitals in US

Estimated # of Infections

HAP/per 1000 patient days

157,500 (21.8%)

VAP/per 1000 vent days

Range of pooled means0.2 (Ped CVICU) -4.4 (Burn ICU)

49,900

CLA-BSI/per 1000 cath days

Range of pooled means 0.8 (CVICU)-3.4 (Burn ICU)Step-down-Ward0.3 (Adult Rehab)-2.4 (Burn)

15,600

CA-UTI/per 1000 cath days

Range of pooled means0.7 (Peds Surgical)-5.0 (Neuro ICU)0.0 (Well Baby) – 4.1 (Peds rehab)

35,600

Dudek MA, et al Am J Infect Control,2013;41:1148-1166Magill SS, et al. New England Journal of Med, 2014;370:1198-208

– 75% of HAI not related to devices (CAUTI, CLABSI, VAP)

• Recommendation:

– As device-related infections decrease, expand surveillance and prevention activities to include other HAIs

Magill SS, et al. New England Journal of Med, 2014;370:1198-208

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Economic Burden of HAI’s: Build The Business Case

• Generated point estimates for attributable cost & LOS

• 5 Major Infections=9.8 billion

• SSI’s, CLABSI’s, VAP/VAE, CAUTI’s, C-Diff

• SSI’s (33.7%)

• VAP (31.6%)

• CLA-BSI (18.9%)

• C-Diff (15.4%)

• CA-UTI <1%

SSI CLABSI VAP CAUTI C-Diff

$20,785 $45,814 $40,144 $896 $11,285

Per Case Basis

Zimlichman E, et al. JAMA Intern Med, 2013; 173:2039-46

50% HAI’s

Preventable

Missed Nursing Care

• “Any aspect of required patient care that is omitted (either in part or whole) or significantly delayed.”

• A predictor of patient outcomes

• Measures the process of nursing care

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Hospital Variation in Missed Nursing Care

Kalish, R. et al. (2012) Am Jour Med Quality, 26(4), 291-299.

Patient Perceptions of Missed Nursing Care

Kalisch, B et al. (2012). TJC Jour Qual Patient Safety,38(4), 161-167.

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Source Control: The Oral Cavity as a Risk Factor in NV-HAP

Definition: Hospital-Acquired Pneumonia

• Hospital-acquired pneumonia (HAP)– 48 hours

– Meets algorithm of criteria (CDC, 2003)

• Types of HAP– VAP

– NV-HAP

– Post op pneumonia

ATS (2005)CDC (2003)

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Build the Will: NV-HAP?

• HAP 1st most common HAI in U.S.– Increased morbidity 50% are not discharged back

home

– Increased mortality 18%-29%

– Extended LOS 4-9 days

– Increased Cost $28K to $109K

– 2x likely for readmission <30 day

Kollef, M.H. et.al. (2005). Chest. 128, 3854-3862.ATS, (2005). AmJ Respir Crit Care Med. 171, 388-416.Lynch (2001) Chest. 119, 373S-384S.Pennsylvania Dept. of Public Health (2010).

Slide courtesy of Barb Quinn

Compelling Incidence Data

Study Incidence Mortality +LOS Cost

J. Davis (2012)Pennsylvania

5,600 /3 yrs 18.9% Not queried $28,000

HCUP National database (P)

2/100 pts 14.5% 4 days $36,400

CDC (2014) 13% of all HAIs

19%-50% 4-9 days $40,000

Davis, Pt Safety Authority 2012 9(3).Giuliano,K. et al. (2016) APIC Podium 2016Magill, S.S. et.al. (2014) NEJM. 370(13), p 1198-1208


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Hospital-Acquired Pneumonia:Non-Ventilated versus Ventilated Patients in Pennsylvania”

• Purpose:– Compare VAP and NV-HAP incidence, outcomes

• Methods:– Pennsylvania Database queried

– All nosocomial pneumonia data sets (2009-2011)

Retrieved on 4/24/13 from http://patientsafetyauthority.org/Pages/Default.aspx

Results:

•Mortality•Incidence•Total deaths•Total cost•Wide‐spread

Retrieved on 4/24/13 from http://patientsafetyauthority.org/Pages/Default.aspx

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Incidence, Prevalence of NV-HAP: A Local Study (2010)

• Purpose:– Determine incidence and clinical factors of NV-HAP

• Method:– Descriptive, quasi-experimental study using retrospective

data

– Inclusion criteria:

• All adult discharges

• ICD-9 codes of pneumonia not POA

• AND met CDC definition of HAP

Quinn, B., Baker, D., et. al. (2013). Journal of Nursing Scholarship.

Hap ICD-9 Codes480.8

481482

482.1482.2

482.39482.41482.42482.82482.83482.89

483.8484.1484.6484.7

485486

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NV-HAP SMCS Research Findings: 2010

Incidence:• 115 adults

• 62% non-ICU

• 50% surgical

• Average age 66

• Common comorbidities: CAD, COPD, DM, GERD

• Common Risk Factors: Dependent for ADLs (80%)

CNS depressant meds (79%)

Quinn, B. et al. Journal of Nursing Scholarship, 2014. 46(1):11-19

Cost:• $4.6 million

• 23 deaths

• Mean Extended LOS 9 days

• 1035 extra days

24,482 patients and 94,247 patient days

NV-HAP Study #1: Conclusions

• HAP is occurring in nonventilated patients

• Costing lives and dollars

• Patients are at risk on ALL units

• Preventative nursing care is missed

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Impact of NV-HAP in the ICU

HAPPI-2 Preliminary Data• 23 hospitals in U.S.; 2014 data; 1306 total cases

– 28% occurred in ICU– 26% occurred on Med/Surg units and were transferred to

ICU– 54% of all NV-HAP cases spend some time in the ICU – 33% transferred to ICU died– 42% transferred to ICU survived but were discharged to a

higher level of care; 25% home

Impact of NV-HAP on one year mortality:• Any length of time spent in an ICU increases mortality of elderly patients

who survive to discharge

Quinn & Baker (2016) pend. Pub.Vivek et al. (2016) CC Med, 655-662.Slide courtesy of Barb Quinn

ICU-Acquired pneumonia: VAP vs. NV-HAP

• Methods:– Prospective study of 135 consecutive episodes over 3 years of adults

with ICU-acquired pneumonia

– Compared clinical and microbiological characteristics of VAP and NV-HAP

• Results for VAP & NV-HAP were not statistically different:– Pathogens

– Comorbid conditions,

– Severity parameters,

– Mortality, and

– Hospital length of stay

• Among NV-HAP patients, 79 (52%) needed subsequent intubation

Esperatti et al (2010) Am J Respir Crit Care Med. Vol 182, p 1533-1539.Slide courtesy of Barb Quinn

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Where is the Highest Risk for NVHAP?

0

0.5

1

1.5

2

2.5

Vent Med/Surg NV-ICU

Rate of Nonventilator Hospital-Acquired Pneumonia

Vent

Med/Surg

NV-ICU

NV-HAP per 1000 patient days


Reducing Risk of NV-HAP Through Evidence Based

Fundamental Nursing Care Strategies

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Pathogenesis Prevention

Germs in Mouth

• Dental plaque provides microhabitat• Bacteria replicate 5X/24 hrs

Aspirated into Lungs

• Most common route• 50% of healthy adults micro-aspirate

in sleep

Weak Defenses

• Poor cough• Immunosuppressed• Multiple co-morbidities


Healthcare Acquired Pneumonia

• Risk Factor Categories– Factors that increase

bacterial burden or colonization

– Factors that increase risk of aspiration

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Micro Aspiration During Sleep in Healthy Subjects

• Prospective duplicate full-night studies

• 10 normal male’s 22-55 yrs of age

• Methods: – Radioactive 99mTc tracer inserted into the nasopharynx

– Lung scans conducted immediately following final awakening

– No difference in sleep efficacy btwn 2 study nights

• Results:– 50% of subjects had tracer in the pulmonary parenchyma upon

final awakening

– No difference in age, time spent in bed, efficacy of sleep, apnea-hyponea index, arousal plus awakening index or % sleep in the supine position between subjects that aspirated and those that did not.

Gleeson K, et al. Chest. 1997;111:1266-72

Addressing Risk

Germs in Mouth

• Comprehensive oral care

Aspirated• Aspiration prevention strategies

Weak Host

• Strengthen host defenses

Reduce Risk Factors HAP

ATS Guidelines (2005)CDC Guidelines (2003)

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Risk Factors for Oral Bacteria in the Hospital

• Poor oral health in the U.S. (CDC, 2011)

• Increased bacteria counts• Plaque, gingivitis, tooth decay

• Reduced salivary flow

• 24-48 hours for HAP pathogens in mouth

• If aspirated =100,000,000 bacteria/ml saliva into lungs

Langmore, S. et.al. (1998). Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia. 13, 69‐81.

Scannapieco FA, Stewart EM, Mylotte JM. Colonization ofdental plaque by respiratory pathogens in medical intensivecare patients. Crit Care Med. 1992;20:740‐745.

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Significant Independent Predictors of Aspiration Pneumonia

Dependant for feedingDependant for oral careNumber of decayed teethTube feedingMultiple medical diagnosesNumber of medicationsDry mouthSmoking

Langmore SE. et al. Dysphagia 1998;13:69-81

Oral Cavity & VAP

• 89 critically ill patients• Examined microbial

colonization of the oropharynx through out ICU stay

• Used pulse field gel electrophoresis to compare chromosomal DNA

• Results:• Diagnosed 31 VAPs• 28 of 31 VAP’s the

causative organism was identical via DNA analysis

• 49 elderly nursing home residents admitted to the hospital

• Examined baseline dental plaque scores & microorganism within dental plaque

• Used pulse field gel electrophoresis to compare chromosomal DNA

• Results• 14/49 adults developed

pneumonia• 10 of 14 pneumonias, the

causative organism was identical via DNA analysis

El-Solh AA. Chest. 2004;126:1575-1582

Garrouste-Orgeas et. al. Am J Respir Crit Care Med. 1997;156:1647-1655

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Formation of Biofilm Over 13 Hours

http://helios.bto.ed.ac.uk/bto/microbes/biofilm.htmLoesche, W. 2012

Impact of Oral Care on HAP

Kaneoka A, et al Infect. Control Hosp. Epidemiol, 2015;36(8):899-906

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Does Compliance Make A Difference?

Oral care compliance & use of the ventilator bundle resulted in a 89.7% reduction in VAP

Hutchins K, et al. Amer J of Infect Control. 2009;37(7):590-597.

Phase 2: Could NV‐HAP be decreased simply brushing the patient’s teeth?

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SMCS HAP Prevention Plan

Phase 1: Oral Care

• Formation of new quality team: Hospital-Acquired Pneumonia Prevention Initiative (HAPPI)

• New oral care protocol to include non-ventilated patients

• New oral care products and equipment for all patients

• Staff education and in-services on products

• Ongoing monitoring and measurement– Monthly audits

Quinn B, et al. J of Nursing Scholarship, 2014, 46(1):11-19

Gap Analysis

Best Practice Our Gaps Action To Take

Comprehensive oral care for all (CDC, SHEA)

ICU vent patients only Develop inclusive oral care protocol

Oral CHG (0.12%)periop adult CV surgery and vent pts. (CDC, ATS, IHI).

Not using CHG on these patients.

Added to preprinted orders, and to protocol

Therapeutic oral care tools (ADA)

Poor quality oral care tools. Absence of denture care supplies.

New tools and supplies.


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Protocol – Plain & Simple

Patient Type Tools Procedure Frequency

Self Care / Assist

Brush, paste, rinse, moisturizer

Provide toolsBrush 1-2 minutesRinse

4 X / day

Dependent / Aspiration Risk

Suctiontoothbrush kit (4)

Package instructions 4 X / day

Dependent / Vent

ICU Suction toothbrush kit (6)

Package instructions 6 X / day

Dentures Tools +CleanserAdhesive

Remove dentures & soakBrush gums, mouthRinse

4X / day


Provide Meaningful Data

0

0.5

1

1.5

2

2.5

3

0.0

1.0

2.0

3.0

4.0

Mea

n O

ral C

are

HA

P C

ases

SGH Ortho - Association of Mean Oral Care to HAP Frequency

Number HAP CasesMean Oral Care

Ortho Unit had ZERO HAP cases in the last 4 months of 2013!!

Great WORK!!

Remember, the goal is to provide and document oral care after each meal and before bedtime.

Used with permission from Barbara Quinn

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Frequency of Oral Care: Increased in the ICU

0

0.5

1

1.5

2

2.5

3

3.5

4

baseline Mar-13

Frequency of Oral Care for Non-vented patients in the ICU 300%


Mean Frequency of Oral Care in Relationship to NV- HAP


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Oral Care Frequency Per 24 Hours –All Units

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

X-bar chart mean oral care May, 2012 through December, 2013 (excludes months with < 10 cases)

Mean OralCare

Baseline


NV-HAP Incidence 50 % Decrease from Baseline

0

2

4

6

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10

12

14

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20

JAN

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FE

B 2

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MA

R 2

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AP

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JUL

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AU

G 2

010

SE

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OC

T 2

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NO

V 2

010

DE

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MA

Y 2

012

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2

JUL

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AU

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SE

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OC

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012

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FE

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013

MA

R 2

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AP

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3

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NO

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013

DE

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013

Nu

mb

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tor

HA

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ases

Month/Year

Control chart for NV-HAP January 2010 to December 2013

UCL

LCL

Average

Oral CareBaseline


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Open Heart Surgery Patients: NV-HAP Reduced 75%

Oral chlorhexidine periop started


Return on Investment

60 NV-HAP avoided Jan 1 – Dec. 31 2013

$2,400,000 cost avoided

- 117,600 cost increase for supplies

$2,282,400 return on investment

•8 lives saved


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HAP Significant Trend DownwardJan 2010-June 2014


Making it Happen: Comprehensive Oral Care with and Antiseptic

• Create visual cues to show evidence of compliance

• Overcoming barriers: formal education, strategies for addressing barriers (Dale CM, et al. AJCC,2016;25:249-256)

• Date and time the oral care kits

• Assign product change over to one shift

• Include oral care/more than CHG in order sets and on documentation

• Teach family and patient how to perform

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It is not enough to do your best; you must know what to do, and THEN do your best.

~ W. Edwards Deming

Evidence Based Practices to Reduce Hospital Acquired Pressure Injuries

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Background of the Problem HAPU are the 4th leading preventable medical error in the United

States 2.5 million patients are treated annually in Acute Care NDNQI data base: critical care: 7% med-surg: 1-3.3% Acute care: 0-12%, critical care: 3.3% to 53.4% (International

Guidelines) Most severe pressure ulcer: sacrum (44.8%) or the heels (24.2%) Pressure ulcers cost $9.1-$11.6 billion per year in the US.

Cost of individual patient care ranges from $20,900 to 151,700 per pressure ulcer 17,000 lawsuits are related to pressure ulcers annually

60,000 persons die from pressure ulcer complications each yr. National health care cost $10.5-17.8 billon dollars for 2010

http://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool1.html#11

Dorner, B., Posthauer, M.E., Thomas, D. (2009), www.npuap.org/newroom.htmWhittington K, Briones R. Advances in Skin & Wound Care. 2004;17:490-4.

Reddy, M,et al. JAMA, 2006; 296(8): 974-984Vanderwee KM, et al., Eval Clin Pract 13(2):227-32. 2007

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention & treatment of pressure ulcers :clinical practice guideline. Emily Haesler (Ed)

Cambridge Media: Osborne Park: Western Austrlia;2014.

Moisture Injury: Incontinence Associated Dermatitis

• Inflammatory response to the injury of the water-protein-lipid matrix of the skin– Caused from prolonged exposure

to urinary and fecal incontinence

• Top-down injury

• Physical signs on the perineum & buttocks – Erythema, swelling, oozing,

vesiculation, crusting and scaling

• Skin breaks 4x more easily with excess moisture than dry skin

Brown DS & Sears M, OWM 1993;39:2-26Gray M et al OWN 2007;34(1):45-53.

Doughty D, et al. JWOCN. 2012;39(3):303-315

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IAD: Multisite Epidemiological Study• 5342 patients in 424 facilities in Acute & Long Term Care in US

• Prevalence study– To measure the prevalence of IAD in the acute care setting,

– To describe clinical characteristics of IAD, and

– To analyze the relationship between IAD and prevalence of sacral/coccygeal pressure ulcers

• Results: 1716 patients incontinent (44%)– 57% both FI and UI, 27% FI, 15% UI

– 24% IAD rate• 60% mild

• 27% moderate

• 5% severe

– 73% was facility acquired

– ICU a 36% rate

– IAD 5x more likely to develop a HAPUGiuliana K. Presented at the CAACN September 25-27th Winnipeg, Manitoba, CA

Gray M. Presenting a Wound Care Conference, 2016, New York City, NY

The Goal: Patient & Caregiver Safety

Safe Patient

Handling

Prevention of Pressure Injuries

Patient Progressive

Mobility

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Pressure & Shear as a Risk Factor

Sacrum & Heels

EBP Recommendations to Achieve Offloading & Reduce Pressure (A)

• Turn & reposition every (2) hours (avoid positioning patients on a pressure ulcer)– Repositioning should be undertaken to reduce the duration &

magnitude of pressure over vulnerable areas

– Consider right surface with right frequency*

– Cushioning devices to maintain alignment /30 ° side-lying & prevent pressure on boney prominences

• Between pillows and wedges, the wedge system was more effective in reducing pressure in the sacral area (healthy subjects) (Bush T, et al. WOCN, 2015;42(4):338-345)

– Assess whether actual offloading has occurred

– Use lifting device or other aids to reposition & make it easy to achieve the turn

• Reger SI et al, OWM, 2007;53(10):50-58, www.ihi.org• National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific

Pressure Injury Alliance. Prevention & treatment of pressure ulcers :clinical practice guideline. Emily Haesler (Ed) Cambridge Media: Osborne Park: Western Austrlia;2014

• *McNichol L, et al. J Wound Ostomy Continence Nurse, 2015;42(1):19-37.

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EBP Recommendations to Reduce Shear & Friction

• Loose covers & increased immersion in the support medium increase contact area

• Prophylactic dressings: emerging science

• Use lifting/transfer devices & other aids to reduce shear & friction.• Mechanical lifts

• Transfer sheets

• 2-4 person lifts

• Turn & assist features on beds

– Do not leave moving and handling equip underneath the patient

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention & treatment of pressure ulcers :clinical practice

guideline. Emily Haesler (Ed) Cambridge Media: Osborne Park: Western Austrlia;2014.

Prophylactic Dressings: Emerging Therapies

• Consider applying a polyurethane foam dressing to bony prominences in the areas frequently subjected to friction and share (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.12197 National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention & treatment of pressure ulcers :clinical practice

guideline. Emily Haesler (Ed) Cambridge Media: Osborne Park: Western Austrlia;2

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Systematic Review: Use of Prophylactic Dressing in Pressure Injury Prevention• 21 studies met the criteria for review

• 2 RCTs, 9 had a comparator arm, five cohort studies, 1 within-subject design where prophylactic dressings were applied to one trochanter with the other trochanter dressing free

Clark M, Black J, et al. Int Wound J 2014; 11:460–471

Evaluated nasal bridge device injury prevention

Evaluated sacral pressure ulcer prevention

EBP Recommendations to Reduce Shear & Friction

• Loose covers & increased immersion in the support medium increase contact area

• Prophylactic dressings: emerging science

• Use lifting/transfer devices & other aids to reduce shear & friction.• Mechanical lifts

• Transfer sheets

• 2-4 person lifts

• Turn & assist features on beds

• Breathable slide stay in bed glide sheet

– Do not leave moving and handling equip underneath the patient

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention & treatment of pressure ulcers :clinical practice

guideline. Emily Haesler (Ed) Cambridge Media: Osborne Park: Western Austrlia;2014.

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Current Practice: Turn & Reposition

Draw Sheet/Pillows/Layers of Linen Lift Device

Specialty Bed Disposable Slide Sheets

Breathable Glide Sheet

REPOSITIONING THE PATIENT

CAREGIVERINJURY

• 50% of nurses required to do repositioning suffered back pain

• High physical demand tasks

• 31.3% up in bed or side to side

• 37.7% transfers in bed • 40% of critical care unit caregivers performed repositioning tasks more

than six times per shift

• Number one injury causation activity: Repositioning patients in bed

Smedley J, et al. J Occupation & Environmental Med,1995;51:160-163)(Knibbe J, et al. Ergonomics1996;39:186-198)Harber P, et al. J Occupational Medicine, 27;518-524)Fragala G. AAOHN, 2011;59:1-6

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Injury Facts

• Back and other musculoskeletal “injuries” are the result of repeated exposure to

ergonomic risk factors rather than a

single, instantaneous event

• In an eight hour shift, the cumulative weight that nurses lift equal to an average of 1.8 tons per day

Tuohy-Main, K. (1997). Geriaction, 15, 10-14)

Number, Incidence Rate, & Median Days Away From Work for Occupational Injuries RN’s with Musculoskeletal Disorders in US, 2003 – 2014

Bureau of Labor Statistics, U.S. Department of Labor, February 14, 2011. Numbers for local andstate government Unavailable prior to 2008/Nov 2011, Release 10:00 a.m. (EST) Thursday, November 8, 2012, 2013 data http://www.bls.gov/news.release/pdf/osh2.pdf. Accessed 01/07/2016 http://www.bls.gov/news.release/pdf/osh2.pdf

2010 Private industry RNs 9,260 53.7 62011 Private industry RN’s 10,210 8

2013 Private Industry RN 9820 56.2 7

2014 Private Industry RN 9820 55.3 9

2014 Private Industry NA 18,510 6

* Incidence rate per 10,000 FTE

*

2012 Private industry RN’s 9900 58.58

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Attitude &

Accountability

Factors Impacting theability to Achieve QualityNursing Outcomesat the Point of Care

Achieving the Use of the Evidence For Pressure Ulcer Reduction

ValueVollman KM. Intensive Care

Nurse.2013;29(5):250-5

Resource & System

•Breathable glide sheet/st•Foam Wedges•Microclimate control•Reduce layers of linen•Wick away moisture body•Protects the caregiver

Comparative Study of Two Methods of Turning & Positioning

• Non randomized comparison design

• 59 neuro/trauma ICU mechanically ventilated patients

• Compared SOC: pillows/draw sheet vs turn and position system (breathable glide sheet/foam wedges/wick away pad)

• Measured PU incidence, turning effectiveness & nursing resources

Powers J, J Wound Ostomy Continence Nur, 2016;43(1):46-50

Demographic Comparison

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Comparative Study of Two Methods of Turning & Positioning

• Results:– Nurse satisfaction 87% versus 34%

– 30 turn achieved versus 15.4 in SOC/7.12 degree difference at 1hr (p<.0001)

SOC PPS P

PU development 6 1a .04

# of timespatients pulled up in bed

3.28 2.58 .03

# of staff required to turn patient

1.97 1.35 <.0001

Powers J, J Wound Ostomy Continence Nur, 2016;43(1):46-501a PU development with 24hrs of admission

Safe Patient Handling Initiative: Decreases Staff Musculoskeletal Injuries & Patient Pressure Ulcers

Way H Presented at the 2014 Safe Patient Handling East Conference on March 27, 2014

28%

$247,500savings

58%

$184,720savings

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EBP Recommendations to AchieveOffloading & Reduce Pressure

• Turn & reposition every 2 hours (avoid positioning patients on a pressure ulcer)– Use active support surfaces for patients at higher risk

of development where frequent manual turning may be difficult

– Microclimate management– Heel Protection– Early Mobility programs– Seated support surfaces for patients with limit mobility

when sitting in a chair

Reger SI et al, OWM, 2007;53(10):50-58, www.ihi.orgNational Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention &

treatment of pressure ulcers :clinical practice guideline. Emily Haesler (Ed) Cambridge Media: Osborne Park: Western Austrlia;2014


– Ensure the heels are free of the bed surface• Heal-protection devices should elevate the heel

completely (off-load) in such a way as to distribute weight along the calf

• The knee would be in slight flexion

• Remove device periodically to assess the skin

Reger SI et al, OWM, 2007;53(10):50-58, www.ihi.orgNational Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention & treatment of

pressure ulcers :clinical practice guideline. Emily Haesler (Ed) Cambridge Media: Osborne Park: Western Austrlia;2014

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Heel PadsHeel Protectors

Miller SK, et al WOCN, 2015;42(4):346-351

Successful Prevention of Heel Ulcers and Plantar Contracture in the High Risk Ventilated

Patients

• Sedated patient > 5 days• May or may not be intubated• Braden equal to or less than 16

• Skin assessment and Braden completed on admission

• All pts who met criteria were measured for ROM of the ankle with goniometer, then every other day until pt did not meet criteria

• Heel appearance, Braden and Ramsey scores were assessed every other day and documented

• Identified and trained ICU nurses completed the assessments

Study Inclusion Criteria

Procedure

Results

Meyers T. J WOCN 2010;37(4):372-378

53 sedated patients over a 7 month period

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Sustainability of Heel Injury Reduction: QI Project

• 490 bed facility

• Evidence based quality Improvement initiative

• 4 tier Process• Partnership

• Comprehensive product review

• Education & engagement

• Support structures & processes

Hanna-Bull D. WOCN, 2016;43(2):129-132

5.8%

5.8%4.2%

72% Reduction

In-Bed Technology

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– Microclimate management– Early Mobility programs– Seated support surfaces for patients with limit mobility

when sitting in a chair



Any Work on Skin Should Be Incorporated into a Progressive

Mobility Protocol

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Outcomes of Early Mobility Program

• incidence of skin injury

• time on the ventilator

• incidence of VAP

• days of sedation

• delirium

• ambulatory distance

• Improved function

Bassett R, et al. Intensive & Crit Care Nurs, 2012;28:88-97Staudinger t, et al. Crit Care Med, 2010;38.Abroung F, et al. Critical Care, 2011;15:R6Morris PE, et al. Crit Care Med, 2008;36:2238-2243 Pohlman MC, et al. Crit Care Med, 2010;38:2089-2094Schweickert WD, et al. Lancet, 373(9678):1874-82. Thomsen GE, et al. CCM 2008;36;1119-1124Winkelman C et al, CCN,2010;30:36-60Dickinson S et al. Crit Care Nurs Q, 2013;36:127-140




– Microclimate management– Early Mobility programs– Safe handling for out of bed & chair positioning



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Out of Bed Technology

Current Seating Positioning Challenges

Shear/Friction

Airway & Epiglottiscompressed

Potential fall risk

Sacral Pressure

Frequent repositioning & potential caregiver injuryBody

Alignment

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Repositioning Patients in Chairs: An Improved Method (SPS)• Study the exertion required

for 3 methods of repositioning patients in chairs

• 31 care giver volunteers

• Each one trial of all 3 reposition methods

• Reported perceived exertion using the Borg tool, a validated scale.

Fragala G, et al. Workplace Health & Safety;61:141-144

Method 1: 2 care givers using old method of repositioning246% greater exertion than SPS

Method 2: 2 caregivers with SPSMethod 3: 1 caregiver with SPS

52% greater exertion than method 2

PREVENTION STRATEGIES FOR IAD

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Evidence-Based Components of an IAD Prevention Program

• Skin care products used for prevention or treatment of IAD should be selected based on consideration of individual ingredients in addition to consideration of broad product categories such as cleanser, moisturizer, or skin protectant. (Grade C)– A skin protectant or disposable cloth that combines a pH balance

no rinse cleanser, emollient-based moisturizer, and skin protectant is recommended for prevention of IAD in persons with urinary or fecal incontinence and for treatment of IAD, especially when the skin is denuded. (Grade B)

– Commercially available skin protectants vary in their ability to protect the skin from irritants, prevent maceration, and maintain skin health. More research is needed (Grade B)

EBP Recommendations to Reduce Injury From Incontinence & Other Forms of

Moisture

• Clean the skin as soon as it becomes soiled.

• Use an incontinence pad and/or briefs that wick away

• Use a protective cream or ointment– Disposable barrier cloth recommend by IHI & IAD consensus

group

• Ensure an appropriate microclimate & breathability

• < 4 layers of linen

• Barrier & wick away material under adipose and breast tissue

• Support or retraction of the adipose tissue (i.e. KanguruWeb)

• Pouching device or a bowel management system

National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure ulcer prevention & treatment :clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.

Williamson, R, et al (2008) Linen Usage Impact on Pressure and Microclimate Management. Hill-Rom www.ihi.org

Doughty D, et al. JWOCN. 2012;39(3):303-315

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IAD/HAPU Reduction Study

• Prospective, descriptive study

• 2 Neuro units

• Phase 1: prevalence of incontinence & incidence of IAD & HAPU

• Phase 2: Intervention• Use of a 1 step cleanser/barrier product

• Education on IAD/HAPU

• Results:• Phase 1: incontinent 42.5%, IAD 29.4%, HAPU 29.4%, LOS 7.3

(2-14 days), Braden 14.4

• Phase 2: incontinent 54.3%, IAD & HAPU 0, LOS 7.4 (2-14), Braden 12.74

Hall K, et al. Ostomy Wound Management, 2015;61(7):26-30

Prevention of MDR’s-HAPI

Haugen V, Perspectives; 2016 http://www.perspectivesinnursing.org/current.html

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Intact Skin Is In: Making it Happen

• Advocacy

• Braden subscales

• Skin rounds/time frequency

• Hand-off communication

• The right products and processes-pressure/shear/moisture/prevent skin tear and medical adhesive related injuries

• Quarterly prevalence/incidence of PU & IAD

• Skin liaison/champion nurses

• Creative strategies to reinforce protocol use• Visual cues in the room or medical record

• Rewards for increase compliance

• Yearly competencies on beds or positioning aids to ensure correct and maximum utilization

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Driving Change

Structure

Process

Outcomes

• Gap analysis• Build the Will• Protocol

Development

• Make it Prescriptive

• Overcoming barriers

• Daily Integration

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