Decreasing Hospital Acquired Pressure Ulcers (HAPU) Through the Implementation of an Evidence-Based (EB) Prevention Bundle Susan Solmos RN, MSN WOCN , Judy Doty RN, MSN, Katherine Pakieser-Reed RN, PhD University of Chicago Medicine

Background

Aims

The Intervention

Lessons Learned • To reduce the prevalence of HAPUs to below the National Database of Nursing Quality Indicators (NDNQI) 25th percentile for academic medical centers

• An analysis of current practices, processes and outcomes was conducted by the WOCN (RN). The WOCN led a SWOT analysis of current HAPU prevention interventions with a team of staff RNs from units throughout the hospital. This analysis confirmed areas of strengths and weaknesses, as well as areas where opportunities or “quick wins” might occur. Based on this analysis a comprehensive, EB HAPU Prevention bundle was developed and implemented. 1.  Comprehensive Skin Assessment

•Improve differential assessment of PU in dark and light skinned patients •Improve differential assessment of PU vs Moisture Associated Skin Damage (MASD) as MASD is often misidentified/staged as a PU -All new RN hires receive training on differential assessment -1,059 RNs received Computer Based Training (CBT) on differential assessment -486 RNS attended in-servicing on skin assessment/differential assessment 2.  Perform Routine Pressure Ulcer Risk Assessment

•Increase awareness of subscale score as an indicator of risk •Improve identification of additional risk factors •Tailor prevention interventions to Braden Subscale -All new RN/NSA hires receive training on Braden Scale/PU prevention -1,159 nursing staff (RN/NSA) completed the CBT on Braden Scale/PU prevention -1 hour pressure ulcer prevention course completed by all NSAs - 486 RNs attended in-servicing on Braden Scale/PU prevention 3.Management of Moisture •Briefs used to contain incontinence can lead to MASD and increase risk of HAPU development • Lack of incontinence pad to wick moisture -Disposable incontinence pad trial underway 4.Repositioning

•Lack of wedges, pillows for repositioning -Positioning wedges obtained for inpatient units

• A comprehensive EB Prevention Bundle can effectively decrease the prevalence of HAPU. • Multiple methods of education may be necessary to implement an EB bundle (e.g., CBT, in-services, posters, Skin Care Team/unit level champions). • The validation of potential MASD/HAPU by an experienced WOCN was successful in not only identifying the high prevalence of MASD, but also in accurately portraying the prevalence of HAPU.

Next Steps

Results

• Following implementation of the EB Prevention Bundle, consistent decreases in HAPU rates were noted month over month. • Outperformed 25th percentile March/April 2014 • MASD has been identified as a clinical challenge, which if not addressed will effect the successful reduction of HAPUs.

Patients with pressure ulcers (PU) have poor outcomes, including severe pain.1 •Approximately 60,000 patients die from pressure ulcers each year.1 •Patients with darkly pigmented skin have a significantly greater risk of pressure ulcer (PU) development2 and are more likely to die than patients with light skin.3

The development of HAPU can have a significant financial impact to healthcare organizations including loss of payment and potential litigation. •Medicare does not pay for hospital-acquired Stage III-IV pressure ulcers. •The cost of a Stage IV HAPU patient averaged $129,248 during 1 hospital stay.4

•Pressure ulcer lawsuits are second only to wrongful death with more than 17,000 pressure lawsuits filed each year.1 HAPU is a harm event identified as a key measure of quality in the UCM Annual Operating Plan.

• Implement EB Prevention Bundle in the adult ED and Peri-Operative Services areas. • Tailor EB Prevention Bundle for specific patient populations (e.g, transplant, critical care, etc.). • Develop EB Prevention Bundle for pediatric population.

References: 1. Agency for Healthcare Research and Quality (July 2011). AHRQ toolkit helps to prevent hospital-acquired pressure ulcers: Research Activities. (AHRQ Publication No. 371). Retrieved from: http://www.ahrq.gov/news/newsletters/research-activities/jul11/0711RA46.html 2. Fogerty M., Guy J., Barbul A., Nanney L.B., & Abumrad N.N. 2009. African Americans show increased risk for pressure ulcers: A retrospective analysis of acute care hospitals in America. Wound Repair and Regeneration. 2009 (17), 678-684. DOI:10.1111/j.1524-475X.2009.00522.x 3. Lyder C. (May/June 2009). Closing the Skin Assessment Disparity Gap Between Patients With Light and Darkly Pigmented Skin. JWOCN. 36(3), 285. 5. Lyder, C., Wang, Y., Metersky, M., Curry, M., Kliman, R., Verzier, N.R.,,& Hunt, D.R.. (2012).Hospital-Acquired Pressure Ulcers: Results from the National Medicare Patient Safety Monitoring System Study. JAGS; 60: 1603-1608. DOI: 10.1111/j.1532-5415.2012.04106.x 4. Brem, H., Maggi, J., Nierman, D., Rolnitzky, L., Bell, D., Rennert, R.,…Vladeck, B. (2010). High cost of stage IV pressure ulcers. The American Journal of Surgery, 200, 473-477. doi:10.1016/j.amsirg.2009.12.021

Contact Susan Solmos susan.solmos@uchospitals.edu

40.00%  

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60.00%  

70.00%  

80.00%  

90.00%  

100.00%  

Week  1  Week  2  Week  3  Week  4  Week  5  Week  6  Week  7  Week  8  

G4P   Std.  Campaign   Baseline  

40.00%  

50.00%  

60.00%  

70.00%  

80.00%  

90.00%  

100.00%  

Week  1  Week  2  Week  3  Week  4  Week  5  Week  6  Week  7  Week  8  

G4P   Std.  Campaign   Baseline  

Baseline: 58.0% Standard HH Campaign: 72.3%, p<0.001 Giving for Performance: 83.9%, p=0.003

5. Support Surface

•Identify and replace damaged surfaces -With Purchasing and EVS, created formal process to evaluate/track surfaces -Funding obtained for 360 new surfaces 6. Reduce incidence of Stage III-IV due to shearing force •Increase staff awareness of silicone dressing protocol •Evaluate inclusion criteria which is currently too restrictive -Working with Purchasing to evaluate alternative dressings and cost 7.HAPU Awareness/Root Cause •Create formal process for analysis/reporting -WOCN analyzes each HAPU occurrence from Prevalence Survey 8.  Education/Awareness of Patient/Family Member Create patient/family education brochure -Brochure created and distributed 9.Redesign of Skin Care Team -Evaluate role/requirements of Skin Care Team members -Didactic and clinical training planned for all members including competencies 10.Validation of all identified HAPU/MASD during Prevalence Survey Perform WOCN validation to increase reliability -Beginning January 2014, validation of all patients identified during survey

Total  #  Pa)ents  with  a  HAPU  Pre-­‐  and  Post-­‐Bundle  Implementa)on  

Bundle implementation

HAPU Rates

Target 25th percentile