5/12/2015

1

npuap.org

NPUAP Mission

The National Pressure Ulcer Advisory Panel (NPUAP) serves as the authoritative voice for improved patient outcomes in pressure ulcer prevention and treatment through public policy, education and research.

International Guideline

NPUAP – in collaboration with the

European Pressure Ulcer Advisory

Panel (EPUAP) and the Pan Pacific

Pressure Injury Alliance (PPPIA) –

has worked to develop a NEW

pressure ulcer prevention and

treatment Clinical Practice

Guideline and a companion Quick

Reference Guide.

Purchase your copy today at

www.npuap.orgnpuap.org

5/12/2015

2

NPUAP Monograph

Released in November 2012, the 254-page,

24 chapter monograph, Pressure Ulcers:

Prevalence, Incidence and Implications for the

Future was authored by 27 experts from NPUAP

and invited authorities and edited by NPUAP

Alumna Dr. Barbara Pieper.

The monograph focuses on pressure ulcer rates

from all clinical settings and populations; rates in

special populations; a review of pressure ulcer

prevention programs; and a discussion of the state

of pressure ulcers in America over the last decade.

Purchase the monograph today at www.npuap.org

• Hard Copy $75

• E-version $49

• Individual Chapters $19 npuap.org

Save the date

npuap.org

Reducing Pressure Ulcers

from Medical Devices

Dr. Peggy Kalowes, RN PhD CNS FAHA

Dr. Joyce M. Black, PhD RN

5/12/2015

3

Save the date

npuap.org

25 – 29 September

www.wuwhs2016.com

5/12/2015

4

Quality Improvement Frameworks to Implement Evidence-based Practices for

Pressure Ulcer Prevention

William Padula, PhD, MS

University of Chicago

May 12, 2015

The Donabedian Model

Donabedian, JAMA 1988

The secret of quality is love. -Avedis Donabedian

Structure

ProcessOutcomes

5/12/2015

5

Hazards of Hospitalization in the Elderly

Creditor, Ann Intern Med 1993

Framework of Implementation and Dissemination

Gonzalez et al (2012). A Framework for Training Health Professionals in Implementation and Dissemination Science, Academic Med.

5/12/2015

6

Evidence-based Practices (EBPs) for Pressure Ulcer Prevention

a. Risk-assessment with Braden Scale

b. Patient repositioning

c. Managing moisture and incontinence

d. Monitoring nutrition

e. Modern support surfaces (beds, overlays)

f. Continual nursing education about EBPs

• It’s a Checklist

Braden, Res Nurs Hlth 1994; Ratliff, NPUAP 2004

Economic Burden

Berwick: Eliminating Waste in U.S. Health Care

Financial Impact of Pressure Ulcers

• Most costly hospital-acquired condition– Treatment: $500-130,000

– Malpractice settlements: $Millions

• $11 billion/year in U.S.– Direct

– Indirect

• Pressure Ulcers represent 0.3% of all healthcare

• $36-45 Billion spent on “failures of care delivery”

Berwick, JAMA 2012; Kuhn, Nurs Econ, 1992; Padula, Med Care 2011

5/12/2015

7

• Main comparators

– Do-Nothing: Inconsistent

EBPs implementation

– Prevention with EBPs

• Evidence-based practices for

pressure ulcer prevention are

cost-effective

– Invest $55/patient/day in EBPs

– Cost-saving

• *If practiced consistently*

Inpatient

Deep Tissue

Injury

Discharge

Pressure

Ulcer

Stage I/II

Death

Pressure

Ulcer

Stage III/IV

No

Complication

Nurse &

Monitor

Acute &

Chronic

Care

Surgery

Standard Care

Prevention

M

Markov Model

Stakeholders of QI

• Government– National Institutes of Health (NIH)– Agency for Healthcare Research and Quality (AHRQ)– Dept Health and Human Services (HHS)

• Payers– Centers for Medicare and Medicaid Services (CMS)– Commercial Payers

• Advocacy– Institute of Medicine (IOM)– Institute for Healthcare Improvement (IHI)– The Joint Commission (TJC), formerly the Joint Commission

on Accreditation of Healthcare Organizations (JCAHO)

5/12/2015

8

IOM Reports

• To Err is Human

– Human error is a natural occurrence and can lead to adverse events

– However, systematic flaws within the healthcare environment are what lead to medical error

– Systematic Improvement could reduce likelihood of compound human error that exposes patients to harm

IOM Reports

• First, Do No Harm

– Evidence-based directives

• Failure to employ indicated tests

• Error in performance of operation, procedure or test

• Inadequate monitoring of follow-up of preventive treatments

• “other” system failures

– Motivate health care stakeholders

5/12/2015

9

IOM Reports

• Crossing the Quality Chasm

– Calls for complete system redesign of U.S. Health Care

– Concept that medical errors cannot be “patched” up with straightforward recommendations

– Adjusting not only how EBPs reach the patient, but how clinical teams reorganize to ensure that EBPs are implemented consistently [without harmful variation]

Fallout of IOM Reports

• Create Center for Patient Safety within AHRQ

• A national system of mandatory and voluntary reporting of medical error within hospitals to create provider transparency

• Regulators need to raise standards– FDA

– The Joint Commission

• Healthcare organizations should create safety systems of safe, evidence-based practices

5/12/2015

10

IHI Campaigns

• 100,000 Lives– Encourage hospital adoption of…

• preset goals

• preset timeframe

– Garner a personal [hospital] sense of responsibility towards improving quality and patient safety

– Prevention of several hospital-acquired conditions (HACs)

• Surgical Site Infections (SSIs)

• Central Line Infections (CLABSI)

• Adverse Drug Events (ADEs)

IHI Campaigns

– Continue mission of 100,000 Lives

– Add 5 more preventable conditions• CAUTI, pressure ulcers, falls, etc.

– An effort to move past EBPs and into patient-centered care (PCC) to improve prevention

• Over 4,000 hospitals adopted this QI campaign

• HACs dropped as much as 72%

5/12/2015

11

Issue with EBP -> PCC in 2006

• Providers, especially nurses at the interface of change, not adhering to EBPs

– 64% of nurses read 1 or more specialty journals

– 53% read a nursing journal

– 20% did not read any professional journals

– 0% read a journal dedicated to publication of original research

The Joint Commission

• The regulatory body of hospital quality and performance

• Accredit payer reimbursements (e.g. CMS)

• Mandate adherence to EBPs

• Errors and preventable harms that occur are recorded and noted and associated to EBP implementation failures

• Misreporting quality/performance measures can jeorpardize accreditation

5/12/2015

12

CMS

• Largest single-payer in the U.S.– 46 million Medicare beneficiaries

– 50 million Medicaid eligible

• Powerful stance on reimbursement policy

• Has used reimbursement to influence QI– Nonpayment for harms

– Pay for performance

• Monitors quality/performance measures of health systems to deduct reimbursements

CMS Nonpayment Policy

• Spring, 2007: CMS announces nonpayment policy for hospital-acquired conditions

• October, 2008: Implementation of nonpayment policy for hospital-acquired conditions

• Present: Hospitals absorb costs for all hospital-acquired conditions– e.g. Pressure Ulcers; Falls; Ventilator-associated

Pneumonia; Catheter-associated UTI; Surgical-site Infections; MRSA; Central-line Infections; etc.2

– Theoretical redistribution of estimated $40+ billion per year3

5/12/2015

13

CMS Policy Updates: P4P

• 1% payment reduction to hospitals ranking in the lowest quartile of HAC prevention

• HAC including: PSI-03 Pressure Ulcer; PSI-06 Iatrogenic Pneumothorax; PSI-07 CLABSI; PSI-08 Hip Fracture; PSI-12 Pulmonary embolism and DVT; PSI-13 Sepsis; PSI-14 Wound Dehiscence: PSI-15 Accidental puncture/laceration

• Affects all hospitals reimbursed through the inpatient prospective payment system (IPPS)

Timeline of Culture of Improving Quality

7%

(Whittingon, 2004)

4.6%

(Bergquist-Beringer,

2009)

4.5%

(Lyder, 2012)

2-3% (Padula,

2013)

?

Significant Reductions in Pressure Ulcer Incidence since mid-2000s (Stotts, 2013)

Goal is 0%(The Joint

Commission)

$5436

$6721

$8905

$1285

$3469

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

$9,000

$10,000

AMI AMI + UTI AMI +Urosepsis

Reimbursement for AMI at University of Colorado Hospital, 2007

Wald, JAMA 2007

5/12/2015

14

Health care has developed EBPs for many patient safety issues

UHC Hospital Rates of HAPUsAHRQ PSI-3

CMS Policy Interruption

Padula, Jt Comm J Qual Pat Saf 2015

5/12/2015

15

Pressure Ulcer Prevention Protocol

Quality ImprovementDefinition

The combined and unceasing efforts of everyone – health care professionals, patients and their families, planners, administrators, educators – to make changes that lead to better patient outcomes, better systematic performance, and better professional services.

-Quality by Design

5/12/2015

16

Key Terms in QI

• Evidence-based Practices vs. Quality Improvement– Evidence-based Practices

• Must be implemented in order to achieve better outcomes

• Guidelines that should be followed

– Quality Improvement• Tools designed to increase effective implementation of EBPs

• A theoretical framework of tools and resources

• Lead to systematic change for improved adherence to evidence-based practice

• Implement vs. Adopt– Implement = evidence-based practices

• Institutionalized by CMS and The Joint Commission

• Measured quality indicators

– Adopt = quality improvement interventions• Establishing a culture of better care

• Up to individual practitioners to develop

QI Best-practice Framework

5/12/2015

17

QI Adoption in 53 UHC Hospitals

Overall Between domains

Trends in Scope of QI strategies

(N=55)

0

0.2

0.4

0.6

0.8

1

1 6 11 16 21

Quarter (January, 2007 - June, 2012)

Pro

po

rtio

n o

f H

osp

itals

Hospitals with 0 domains

Hospitals with 1 domain

Hospitals with 2 domains

Hospitals with 3 domains

Hospitals with 4 domains

Padula, Wordviews Evid Based Nurs (In Press)

Longitudinal Data Analysis

• Effect Size Analysis– Changes in HAPU rates associated with QI adoption– Unadjusted comparison of clinically meaningful QI interventions

according to CMS reduction threshold: 1 HAPU case per 1,000

• Mixed-effects Poisson Regression– Counts of HAPU rates over time, nested in Hospitals– Random intercept– Random effect: CMS nonpayment policy– Adjusted comparison of statistically significant QI interventions– Outcome Measures:

• Associations between QI interventions and HAPU counts• Empirical Bayes estimates of hospital-level rates

Padula, BMJ Qual Saf 2012

5/12/2015

18

Unadjusted Effect Size Analysis

Padula, Jt CommJ Qual Pat Saf2015

Combinations of QI Interventions

QI Intervention

Leadership

Initiatives

Visual Tools HAPU

Staging

Skin Care Nutrition

Leadership Initiatives x x x x x

Visual Tools 0.0011 x x x x

HAPU Staging 0.0013 0.0011 x x x

Skin Care 0.0013 0.0012 0.0014 x x

Nutrition 0.0013 0.0012 0.0012 0.0013 x

BOLDED effect sizes indicate statistical significance at the 95% confidence-level. HAPU

indicates Hospital-acquired Pressure Ulcer; QI, Quality Improvement.

5/12/2015

19

Unadjusted Effect Size Analysis

• 5 QI interventions found to have clinically meaningful impact on prevention

– Leadership Initiatives to present data in clinics

– Visual Tools (e.g. checklists, posters)

– Updates to HAPU staging protocol

– Use of new skin care products or creams

– Emphasis on patient nutrition

Padula, Jt Comm J Qual Pat Saf 2015

Mixed-effects Poisson Regression

• Adjusting for QI interventions

• Relative treatment effects of effective QI interventions over time

Poisson[E(Yij)] = (β0 + ui0) + β1quarterj + β2QIij + (β3 + ui1) × policyj + …+ Ζij

Poisson[E(Yij)] = (β0 + ui0) + β1quarterj + β2QIij + (β3 + ui1) × policyj + …

+ β5quarterj × QIij + β6policyj × QIij + Ζij

Hedeker & Gibbons, Longitudinal Data Analysis 2006

5/12/2015

20

ME Results – all QI interventions

Padula, Hospital Med 2015

ME Results - Updates to EBPs

Mixed-effects Poisson Regression Model

Hospital-level empirical Bayes estimates

Padula, Hospital Med 2015

EBP Updates associated with 1 HAPU case Reduction per Year = $130,000

5/12/2015

21

Limitations

• Fair response rate (30.5%; 55 / 180 hospitals)

• Reporting bias from survey responses

• Recall bias for QI interventions dating back 4-5 years

• Difficult to imply all HAPU outcomes on adoption of QI interventions

• Results of QI adoption are co-linear to CMS policy

Conclusions

• Hospital Implications

– Updates to EBPs leads to improve patient outcomes

– Identifies the best QI interventions to explore for HAPU prevention

– Effective QI strategy to bundle with EBPs:

• Leadership: Leadership Initiatives

• P&I: Visual Tools; HAPU Staging; Nutrition; Skin Care

• CMS nonpayment policy provided incentive for hospitals to prevent HAPUs

• Model framework for CER of QI and HACs– Utilize the best-practice framework: Leadership, Staff, IT, Perform &

Improve

– Reapply to other areas: Falls; CAUTI; Pain management; C. Difficile

5/12/2015

22

Final Thoughts

• Every system is perfectly designed to get the results it gets.– Paul Batalden, MD

Co-founder of IHI

• Any indication of a forced concept or practice upon clinicians receives pushback…– Peter Pronovost, MD, PhD

Director of Armstrong Inst.

CEU Information

To earn the 1.0 continuing education credit from

today’s webinar please visit the link below.

This information will also be emailed out to

participants at the conclusion of the webinar.

https://www.blueq-

surveys.creighton.edu/se.ashx?s=46BEEE7F640F

6849

npuap.org