Intermountain-led CMS Hospital Engagement Network

Pressure Ulcer PreventionSeptember 23, 2014

Affinity Call

Marlyn Conti , BSN, MM, CPHQPatient Safety Initiatives Manager

Intermountain Healthcare

Outline for Discussion

• Review of the HEN Pressure Ulcer work • Q1 2014 Data review• “Just-one-thing” Recommendations• 2012 Participant survey• 2014 Participant survey• Next steps

Overall Progress Through Q1 2014

Intermountain HEN 2012-Q1 2014 Pressure Ulcer PSI 3

Patients with Stage III, Stage IV or unstageable pressure ulcers

Intermountain HEN 2012-Q1 2014 Pressure Ulcer PSI 3

Patients with Stage III, Stage IV or un-stageable pressure ulcers

Intermountain HEN 2012-Q1 2014 Pressure Ulcer >= Stage 3

Stage 3 or greater from the prevalence survey

Intermountain HEN 2012-Q1 2014 Pressure Ulcer >= Stage 3

Stage 3 or greater from the prevalence survey Decline in denominator in Q1 2014 is due to anomalous data

Intermountain HEN 2012-Q1 2014 Pressure Ulcer >= Stage 2

=> Stage 2 added in 2014

Intermountain HEN 2012-Q1 2014 Pressure Ulcer >= Stage 2

=> Stage 2 added in 2014

Intermountain HEN 2012-Q1 2014 Pressure Ulcer Prevalence

All stages from the prevalence survey

Intermountain HEN 2012-Q1 2014 Pressure Ulcer Prevalence

All stages from the prevalence survey Decline in denominator in Q1 2014 is due to anomalous data

High Performing Hospital Highlight…

Most Improvement

BAYLOR HEART AND VASCULAR HOSPITAL

BAYLOR MEDICAL CENTER AT WAXAHACHIE

THE HEART HOSPITAL BAYLOR PLANO

DENVER HEALTH MEDICAL CENTER

CASSIA REGIONAL MEDICAL CENTER

DELTA COMMUNITY MEDICAL CENTER

SANPETE VALLEY HOSPITAL - CAH

BAYLOR MEDICAL CENTER AT IRVING

LDS HOSPITAL

BAYLOR REGIONAL MEDICAL CENTER AT PLANO

Pressure Ulcers Prevalence

Lowest Rates

THE HEART HOSPITAL BAYLOR PLANO

BAYLOR MEDICAL CENTER AT WAXAHACHIE

ST PATRICK HOSPITAL

UPPER CONNECTICUT VALLEY HOSPITAL

SCOTT & WHITE HOSPITAL-ROUND ROCK

BAYLOR HEART AND VASCULAR HOSPITAL

SCOTT & WHITE CONTINUING CARE HOSPITAL

THE ORTHOPEDIC SPECIALTY HOSPITAL

HEBER VALLEY MEDICAL CENTER

DELTA COMMUNITY MEDICAL CENTER

Just One Thing MatrixRecommendations

Getting Started Working Harder Ahead of the Curve

Appoint a leadership supported team or work groupto drive improvement & education SWAT (or champion) teams that includes unit nurse.(moderate-high level of evidence)

Adopt decision algorithms for nursing staff to select appropriate surfaces , physical therapy and dietary referrals(moderate-high level of evidence)

Establish monthly prevalence studies or collect incidence data from electronic medical records, then feed that data back to the SWAT teams.(moderate-high level of evidence)

Intermountain SKIN Bundle

Participant Survey 2012

38% sites at Improvement stage, 26% challenges, 24% sustaining

Participant Survey 2012

SSI VTE ADE CAUTI CLABSI VAP PU Falls Readmit0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

4.584.88 4.87 4.73

6.26

7.87

5.13

3.27 3.27

IH HEN HAC Ranking

Pressure Ulcers ranked at 3rd at 5.13 for priority by the participating hospital

2014 Pressure Ulcer Survey Report

Carlos BarbagelataIntermountain Institute for Healthcare Delivery Research9/23/14

1. Do you have a team assigned to work on Pressure Ulcer prevention?

Answer Response %Yes 15 79%No 4 21%

Total 19 100%

1a. Is your pressure ulcer prevention team multidisciplinary? (if yes, which disciplines are

included)

Answer Response %Yes 7 50%No 7 50%Total 14 100%

Yes

Bedside RN, Dietician, Infection Control

RN Manager

Nursing, Physical Therapy, dietary

Wound Care/Ostomy

RN, RRT, PT

WOC/RRT/HCI/PT/Transport/Nutrition

Administration, Nursing, RT, WOC

1b. How frequently does your Ulcer Prevention team meet? (Check all that apply)

Answer Response %Other (e.g. for RCA, as-needed, etc.)

8 57%

Once a Month 7 50%2–3 Times a Month 0 0%Once a Week 0 0%

Other (e.g. for RCA, as-needed, etc.)Quarterly meetings prior to quarterly prevalence studiesRCA done, as well as monthly meetingsAs-Needed

1c. Does your pressure ulcer prevention team have resources to collect/interpret/review data?

(If yes, please explain below)

Answer Response %Yes 13 93%No 1 7%

Total 14 100%

YesOnline education using NDNQI tool, survey review, quarterly data collection, analysis by quality lead and teamP&I, floor staff are assigned to be on the committee and help with survey results. Pressure Ulcer Tracking Sheet, Weekly skin assessmentsWound Care/OstomyProvided with corporate data. Collect and evaluate internal dataPrevalence StudyWOC, RN Mgr/Supv, HCIincident reports and NDNQI

2. Do you provide hospital-acquired pressure ulcer reports foruse by hospital staff and teams? (If yes,

please describe how reports are distributed or made available)

Answer Response %Yes 15 83%No 3 17%Total 18 100%

Yes

Available on system report center, can be accessed by unit staff, taken to governing board, patient safety council and medical staff quality councils

Intermountain generated, Reports portal

We have used P&I results each quarter and send to the managers of each floor and reported in hospital quality reports.

Standard Corp Reports

Discussed with staff in staff meetings

WOC to RN Mgr to Unit Staff

They are placed on our swat team space and sent to managers, and reviewed in our PCC meeting

Reports are available upon request or via email

HAPU team to RN Mgr to Unit Staff

RCA and unit-based outcome graphs

2a. Do your reports include prevalence, incidence, or both?

Answer Response %Both 11 73%Prevalence 3 20%Incidence 1 7%Total 15 100%

2b. How are reports updated or made available?

Answer Response %

Other (please specify) 11 73%

Once a Month 5 33%

2-3 Times a Month 0 0%

Once a Week 0 0%

Other (please specify)

Unit boards updated weekly

Quarterly surveys

Quarterly e-mailed report

As-needed

Quarterly after P&I survey

2c. Could you share an example of how the reports are used by hospital staff/teams?

Text Response

Used for Quality Assurance and Performance Improvement. Nursing Manager shares with unit staff

Track and trend unit performance. Recommend more follow up with Wound Care specialists if units seeing an increase in ulcers

Continuing education to discuss what preventions may have been done sooner (HAPU identified earlier).

Discuss at staff/unit meetings

Reviewed by the hospital managers and quality team for process improvement. It could be improved to be reported more frequently. We also use the hospital event reporting system for all 3 & 4 pressure ulcers and DTI. The manager will have to comment on the patient immediately.

When a pressure ulcer is found the team discusses the best approach to care for the p.u.. Also each staff member is to be on alert for possible breakdown and take action before a pressure ulcer starts. All pateints have some form of pressure ulcer prevention.

It shows what hospital acquired ulcers were found, which units and what the ulcer was. The managers are then able to review the documentation and find ways to prevent it in the future. It is also used as quality improvement throughout our hospital.

Incident reports are completed on all pressure ulcers (hospital-acquired and present on admission). Hospital acquired ulcers are sent to each unit's manager for review and a RCA is completed. A meeting is held to discuss significant occurences, the RCA is reviewed by the multidisciplinary team, and a remedial plan is determined to prevent reoccurence.

3. What tools do you use to educate staff about assessment and properly staging pressure ulcers?

(check all that apply)

Answer Response %Posters 10 59%Fact Sheets 13 76%Assigned Computer-Based Training 13 76%EMR Reminders 9 53%Care Process Models 7 41%Other 2 12%

OtherBraden scale in EHR for PrU documentationSwat meeting education, swat members take education back to floor nurses

4. Do you have skin and/or pressure ulcer assessment prompts embedded in your Electronic

Medical Record (EMR)?

Answer Response %Yes 16 94%No 1 6%Total 17 100%

4a. How often are the staff prompted to repeat the assessment?

Answer Response %Every 12 hours 11 69%Every 24 hours 3 19%Other 2 13%Every 8 hours 0 0%Total 16 100%

OtherOn admisson and then criteria basedShift assessment

4b. What EMR vendor is being used?

Text ResponseInternalInternally developed system. Transistioning to Cerner over next 18 monthsCurrently Tandem (Intermountain EMR) soon to change to Cerner/Intermountain EMR (iCentra)We use Tandem at this time and transitioning to iCentraCurrently a home grown EMR. Changing to a Cerner Hybrid program within the next year.Tandem/ Help1Allscripts Cerner

4c. What type of assessment is being used?

Text ResponseBraden, "naked man" on admissions to document any non HAPU, Braden Score, Overall wound/skin assessmentBraden, BradenQHead-to-toe

5. What is the one intervention that has had the most impact in reducing pressure ulcers at your site

in the past two years?Text Response

Upgraded mattressesHourly rounding on patientsStandardized pressure reduction surface mattresses with an option for an air pump is the standard for all beds. New bed surfacesNursing Staff Education TAPS or PUPRepositioning of patients and the use of specialty mattresses.Pressure reducing mattresses for all patientsWound Care/Ostomy rounds on all ICU patients daily and teaches "real" patient turning. Also, implementing the use of foam wedgesEducation regarding use of skin care creams and lotion for prevention. We did a big initiative to stock each unit with the correct products in a way that it is easy for staff to access and use. Then we did a big education on how to use the products in a way that will prevent skin issues. It has really helped to reduce our hospital acquired ulcers.Turning Q 2 hrs when patient does not or is unable to reposition themselves.A heightened focus on pressure ulcer prevention from the top down with admin support across the full spectrum of care.

6. What is the most innovative approach that you feel has contributed to reducing pressure ulcers?

Text ResponsePressure reducing mattresses, pumps, and increased education with staff.Not "innovated", but continued education, wound care nurses, implementation of "SWAT" teamsTAPS-Turn & positioning systemsI think that the continual education to nursing staff about the importance of it and outcomes has been the most beneficial. We have sent the wound nurses to the ICU rounds for the patients on the specialty beds to assess wounds at the time of the unit assessment and that has helped.

Our organization created a standard for using the PUP dressing and that has assisted as well in the OR cases and ICU cases from what we can tell so far. Waffle (EHOB) mattressess and sealsSetting up our clean utility rooms so that the skin care products are all in the same area, easy to grab all of them at one time without searching forever to find them.Assessment-based intervention and monitoringSkin care assessment at shift change (both AM & PM) for low Braden scored patientsPartnering with respiratory therapy to address respiratory device related pressure ulcers

7. To help us measure progress, please indicate your facility's program status since starting the HEN collaboration to reduce pressure ulcers. What level

do you feel your facility is at?

Answer Response %Working Harder 9 53%Getting Started 4 24%Ahead of the Curve 4 24%Total 17 100%

A. "Getting Started": This level consists of identifying areas that need the most attention and appointing a leader that will help drive improvement and education SWAT (or champion) teams.

B. "Working Harder": This level focuses on adopting decision algorithms for RNs to select appropriate surfaces and independently make decisions. C. "Ahead of the Curve": This level focuses on establishing monthly prevalence studies or incidence rates from Electronic Medical Records (EMR), then feed that data back to the SWAT teams.

8. What barriers are you experiencing that are preventing you from achieving your goals to

reduce pressure ulcers.Text Response

Resources - both people and time - to do more frequent prevalence studies and to add incidence. Many competing priorities with change in EMR. Not a "barrier" - time for continued education & stressing the importanceLack of resources to continually turn and reposition patients. Nutrition support (although we now have a clinical dietician that is advancing our nutrition care), lack of RN wound specialistStaff turnover, supply cost, compromised patients in ICU that lose perfusionAcurate reporting of weekly skin assessment findings. Failure to recognize the beginning of skin breakdown. Up until approx 1.5y ago - did not have a FT Wound/Ostomy RNRate of turnover of staff. In the last 2 years we have had a large amount of new nurses hired and it is difficult to educate them on proper prevention measures, especially if they are on the night shift. We used to be a part of the nurse residency educaion program, but were cut because of not enough time in their program. I see a difference in the nurses coming from the program, they dont know essential info to prevent pressure ulcers as they did in the past.Resources both time and moneyAcuity and staffing issuesIt is difficult to get time with nurses for education.

9. What is your role at your facility?

Text ResponseMember of pressure ulcer prevention team.Patient Safety Coordinator/Quality ConsultantClinical Effectiveness - Operations for Baylor Scott & White Health, NTX HAPU Council ICU managerWound Care Nurse ManagerQuality LeadMed/Surg coordinatorCertified Wound, Ostomy and Continence nurse. I lead the SWAT team and perform P&I studies quarterly and coordinate education throughout the facility regarding new skin and wound care products.ManagerStaff RN and wound championData CollectorWound Specialty NurseWound Care Specialist.Operations - Clinical EffectivenessWOCN

10. What is the size of your facility?

Answer Response %>200 people 10 59%50 - 99 people 3 18%100 - 200 people 3 18%20 - 49 people 1 6%Total 17 100%

There’s still time to complete the survey!

If the survey has not been completed for you hospital or organization, please go to:

https://csbsutah.co1.qualtrics.com/SE/?SID=SV_1XD83SpQdlnNw9f

We follow up and develop a resource guide based on the survey responses to be shared across the HEN

2014 plans for improvement

• Quarterly Affinity Calls • 2015 CMS HEN contract renewals - unknown• Sustainability?• Collect and share best practices across our network

hospitals & system in a single document