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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

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Page 1: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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

Page 2: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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

Page 3: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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)

Page 4: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

Pressure ulcers are the most prevalent preventable hospital acquired condition

Page 5: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

Why is it so devastating?

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

Page 6: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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

Page 7: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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”

Page 8: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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

Page 9: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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

Page 10: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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

Page 11: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

Repositioning every 2 hours

Page 12: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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”

Page 13: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

Patient Monitoring System

Page 14: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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

Page 15: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

Patient sensor antennas Leaf interface

Page 16: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

Real-time patient reposition monitoring

Page 17: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

Display interface

• Discreetly positioned

• Useful information

at a glance

• Visual cues avoids nuisance alarm system

• Records turn history providing immediate feedback

Page 18: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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

Page 19: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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

Page 20: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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

Page 21: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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

Page 22: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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

Page 23: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

SICU turn compliance 1 month

Page 24: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

Moss turn compliance 1 month

Page 25: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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

Page 26: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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

Page 27: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

Moss turn compliance overall

Page 28: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

SICU turn compliance overall

74%

Page 29: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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

Page 30: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

Pause turn alerts

SICU Moss

Page 31: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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

Page 32: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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

Page 33: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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

Page 34: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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

Page 35: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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

Page 36: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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

Clinical Coordinator

Spinal Cord System of Care

215-663-6119

[email protected]

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

?

Page 37: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

Theoretical Framework

Our Nursing Practice is Grounded in the

Theory of Human Caring

Page 38: TURNING MATTERS - Amazon S3 · TURNING MATTERS: An Innovative Technology to Reduce Patient Harm Beth W Jacobs, RN, CCM, CRRN Susan McCulley, RN, MSN, NE-BC ... upper torso •Monitors

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