the anatomy of a pressure injury prevention program boise … · use of turning and positioning...
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Joyce Black, PhD, RN, CWCN, FAANUniversity of Nebraska Medical Center
Omaha, NE
Study of Adult Nursing Units using NDNQI data◦ 1381 hospitals from all 50 states from 2008-2010
Outcome data, changes in rates after ruling/payment change of: ◦ Pressure ulcers◦ Injurious falls◦ Central line associated bloodstream infections◦ Catheter-associated urinary tract infections
Waters, Daniels, Bazzoli et al. Effect of Medicare’s nonpayment for Hospital Acquired Conditions: lessons for future policy. JAMA 2015, 175 (3), 347-354
11% reduction in CLABSI’s - sustained 10% reduction in CAUTI’s – sustained .5% reduction in rates of falls - flat 1% reduction in rates of stage III and IV
pressure ulcers – sustained slow decline
“We acknowledge the concern that not all pressure ulcers are avoidable. However, we believe improving screening to identify ulcers on admission will improve quality of care.” Institutes of Medicine, 2007
Standardized practices had been developed and tested for CLABSI and CAUTI
Practice change was fewer steps Practice change may have only had to occur
once or once a day Practice change involved fewer people and
products
Pressure injury reduction requires more than admission assessments to change the outcomes!
Processes of care are more nebulous with some decisions made at the bedside
Nurses carry out assessment and planning but may not do the turning
However, the positive outcomes from multilayer foam dressings was just emerging!
Reduce the intensity of the pressure◦ Support surfaces◦ Multilayer foam dressing to reduce the pressure◦ Offload the heel
Reduce the duration of the pressure◦ Turning and repositioning
Reduce the effect of shear◦ Keeping the head of the bed low◦ Multilayer foam dressings to reduce shear forces
Improve the health of the skin◦ Giving nutrition and hydration ◦ Keeping the skin clean and dry◦ Protecting damaged skin
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Optimal Patient
Outcomes
Optimal Patient
Outcomes
Consistent Care Delivery
Consistent Care Delivery
Quality/PerformanceStrategy
Quality/PerformanceStrategy
Organizational Support on all levels
Organizational Support on all levels
EB Practice for HAPI PreventionEB Practice for HAPI Prevention
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Consider applying a polyurethane foam dressing to bony prominences (e.g., heels, sacrum) for the prevention of pressure ulcers in anatomical areas frequently subjected to friction and shear (B/1)
Lack of clarity in discussion about actual structure of dressing
Not all studies cited used polyurethane foamMany polyurethane foam dressings on the
marketImportant to know how they work and if they
can reduce pressure, shear or microclimateDressings do not replace the rest of prevention! (C/1)
Use of prophylactic dressings over bony prominences reduced the relative risk of pressure ulcers by 0.21 (p = 0.0006) ◦ Moore and Webster, The Cochrane Database of Systematic
Reviews, 2013, 8 (8) Use of prophylactic dressings reduce pressure
injury in immobile patients ◦ Clark, Systematic review of the use of dressings in the
prevention of pressure ulcers, Int Wound J 2014,11,(5),460-471
What is the effectiveness of implementing a single PI prevention in ICU compared to bundled intervention?
From; Tayyib, 2016, Systematic Review in Worldviews On Evidence Based Nursing
Santamaria (IWJ, 2015)◦ Dressing group 7/161◦ Control group 27/152 Diff stat sig at p = 0.002
Kalowes (AJCC, 2016)◦ Dressing group 1/184◦ Control group 7/183 Diff stat sig at p = 0.001
Quili (Chin J MS Nur, 2010)◦ Dressing group 0/26◦ Control group 3/26
8/371 with drsg ulcerated37/361 without drsg ulcerated
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Thul in ICU (2015)◦ Dressing 1/39◦ Control 19/83
Park in ICU (2014)◦ Dressing 3/52◦ Control 23/50
Brindle in OR/ICU (2012)◦ Dressing 1/50◦ Control 4/35
Cubit in General care (2012)◦ Dressing 1/51◦ Control 6/58
Brindle in ICU (2010)◦ Dressing 0/41◦ Control 3/52
Castelino in OR◦ Dressing 0/104◦ Control 12/114
6 /337 with dressings ulcerated67 /392 without dressings ulcerated
21 studies of patients in ICU◦ Inconsistent reporting of baseline and numbers of
patients being compared
Baker, 2014; Bateman, 2014; Bateman, 2013; Boesch, 2012; Cano, 2011; Castelano,2012; Chaiken,2012; Edwards, 2014; Gentry, 2010; Haggard, 2014; Hasley, 2015, Hsu, 2010; Johnstone, 2013; Kiely,2012; Koener, 2011; Kuo, 2014; Lentz, 2013; Muldoon,2010; Santamaria, 2015; VanCapellen, 2011; Walsh, 2012
100 patients planning on cardiac surgery◦ Randomly dressed with Mepilex Border Sacrum
preoperatively 15 lost to follow up 50 intervention 35 control◦ Following surgery, control group had dressing
removed 4 of 35 ulcerated – mostly DTPI◦ Treatment group stayed dressed 1 ulcerated after 12 days
Brindle and Weglin, JWOCN 2912
Determining what is “an OR acquired ulcer”◦ Seldom visible at
end of case Cautery, device and
prep solution burns visible early
How many of your PrI start in OR?
This burn occurred in the OR; visible at end of case
Prep solution burn
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Braden not predictive (He, Lie, 2014)
Anesthesia Severity Assessment Scores (ASA)◦ ASA ≥ 3 higher risk (O’Brien, 2013)
◦ 1 pt increase in ASA increases odds by 149% (Fred, 2012)
Use of CP bypass Time in OR◦ 2.5 hours of more◦ Every 30” after 4
hours increases risk by 33% (Schoonhoven, 2002)
Position on OR table◦ Prone
Low BMI/High BMI (O’Brien, 2012)
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Open heart cases baseline was16.7% incidence
71 patients having cardiac surgery
Following use of the dressing, zero patients ulcerated
Prone cases◦ 104 dressed Zero ulcers◦ 114 without dressings 12 ulcers
Braden does not predict heel ulcer risk well◦ Braden score 15 +/- 3
Aspects missing◦ Leg mobility Can vs does◦ Diabetes or Peripheral
neuropathy ◦ Vascular status or perfusion
Delmore, B. Risk factors associated with heel pressure ulcers in hospitalized patients. JWOCN 2015, 42 (3), 242-248
Does the patient movelegs independently?◦ Does versus can
Does the patient have normal or delayed capillary refill? Palpable pulses?
Does the patient have normal sensation?
Does the patient wear TEDs?
When these factors are present… patients are at risk
Heels need to be floated from the bed
Boots can be used◦ Often cannot ambulate◦ Often too hot to wear
Pillows can be used◦ Don’t stay under the calf◦ Migrate to under the knee◦ Fall off of the bed◦ Don’t fully elevate the heel◦ Are placed under the heel
• As organizational “Pressure Ulcer” rates decreased MDR PrIs became much more apparent
• MDRPrIs often were misidentified or “excused”• That’s just what happens
when...”• Not typically tracked, trended or
reported• May not be easy to prevent
• device may be an essential diagnostic/therapeutic component of treatment
• Although most are avoidable, not all are
What is a “medical device”? Fit the device to the patient◦ Measure devices for proper fit
Pretreat the skin with thin foam dressings ◦ Work with other disciplines to assure this
happens Remove or move daily to see the skin Be aware of edema Devices can be “lost” in bariatric
patient skin folds
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Not much data to support benefits of one surface over another
General recommendations◦ ICU = high immersion with low air loss◦ General units = foam with alternating pressure◦ Bariatric beds for those over 350 lbs
Early mobility programs call for extend sitting
Position patient for stability and ability to perform usual activities (SoE= C; SoR = )◦ Tilt the seat back to
prevent sliding◦ Place feet on foot rest or
foot stool
This patient is not safe in this chair, nor is he sitting on the chair cushion
Are not designed for pressure redistribution
Need a seat cushion Ulcers develop after 4-6
hours of sitting Patient needs repositioning
hourly if not moving or restrained
Call, Pedersen, Bill, et al. Enhancing pressure ulcer prevention using wound dressings: What are the modes of action? Int Wound J 2015, 12, 408-413
A powerful, validated tool for analyzing tissue deformationFinite Element Modelling
Within Wound care FE modelling can facilitates quantification of internal strains and stresses in weight bearing parts (heels and buttocks) ‐ Levy & Gefen, 2016
Red indicates elevated stress levels
Blue indicates no increase in stress
Multinational expert panel examined evidence on dressings for PIP and MDR PI prior to guidelines in 2014◦ Black, IWJ 2013
Black, IWJ 2014◦ Advocated for Mepilex
dressings to prevention
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Body position: clinical practice vs standard1
◦ Study of 74 patients in which the change in body position was recorded every 15 minutes for an average observation time of 7.7 hours◦ 49.3% of observed time showed no body position
change for >2 hrs, and 2.7% had every-2-hour demonstrable body position change
Positioning prevalence2
◦ Prospectively recorded, 2 days, 40 ICUs in the United Kingdom◦ Average time between turns, 4.85 hours
1.Krishnagopalan S, et al. Crit Care Med. 2002;30:2588-2592.2.Goldhill DR, et al. Anaesthesia. 2008;63:509-515.
Q 2 hr turning with interface pressure map to highlight areas of pressure◦ Sig reduction in PI
over stage 2
◦ Behrendt, 2014
Q 2hr turning with a turn team◦ Sig reduction in PI
over stage 2
◦ Still, 2014
Study of residents in long term care on foam mattresses◦ 942 Residents at moderate to high risk for PI◦ Turned randomly Q 2,3 and 4 hrs◦ Compliance with turning measured
Outcomes◦ Pressure injury formation was the same at all frequencies Q 2 hr = 2.5% Q 3 hr = 0.6% Q 4 hr = 3.1%
◦ Pressure injury formation did not differ by riskHigh risk = 1.8%
Moderate risk = 2.1%Bergstrom, et al, 2013 JAGS
Turning to 30 degrees may be difficult◦ Quality of pillows◦ Number of pillows
Use of wedges Use of turning and positioning systems Improved outcomes with use of a turn and
position system (Powers, 2016)◦ Fewer pressure ulcers (6 in SOC, 1 in PPS, p = .042)◦ Angle of turn better (31° in PPS, 22° in SOC)◦ Patients remained in position after 1 hour
Incontinent patients risk for PI higher◦ Prevalence increased from 4.1% to 16.3% ◦ Incidence also higher from 2.6% to 13.6%
Multiple layers of linen each increase the pressure on the sacrum regardless of HOB elevation ◦ Pressure at sacrum on LAL increased from 20 to 64%◦ Pressure at sacrum on foam increased from 6 to 29%
Lachenbruch, Ribble. Pressure Ulcer Risk in the Incontinent Patient. JWOCN. 2016, 43 (3), 235-241.Williamson, Lachenbruch, The effect of multiple layers of linens on surface interface pressure: results of a laboratory study. Ostomy Wound Management 2013, 59 (6), 38-47
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Recognize their world view◦ Numbers and dollars◦ Be aware of pressure injury data in your facility◦ Move root cause analysis findings into quality
improvement plans How many of your PI start in OR? ER? ICU? Target education and interventions to the staff in high
risk areas
Present current HAPI/FAPI rates and cost◦ Stage 1 and 2 = $2,770.54◦ Stage 3 and 4 = $71,500.00 to $127,000.00
Cost Data from: Padula, Mishra, Makic et al. Improving the quality of pressure ulcer
care with prevention: A cost effective analysis. Med Care 2011, 49(4), 385-392
Brem, Maggi, Neirman et al. High cost of stage IV pressure ulcers. Am J Surg ,2010 200 (4), 473-477
Current hospital rate is 2.5% ◦ 2% stage 1 and 2 and 0.5% stage 3 and 4
Annual acute admissions are 24,557
◦ 491 stage 1 and 2 at $2,771. = $1,360,561◦ 61 stage 3 and 4 x $71,500. = $4,361,500◦ 61 stage 3 and 4 x $127,000. = $7,747,000
Total spent on HAPI last year = $13,469,061.00
Usage and cost data for high cost and/or high volume items
Clinician request for new products
World class companies provide 40 hours of training for their “reps” yearly◦ How much training does your
team get?
Create a list of attributes for the product◦ What do you want the product to do? Or not do?◦ Create a grid that lists Clinical benefits Safety features Ease of use Look at 360 degrees of product use◦ Involve direct caregivers (Magnet)◦ Development of grid provides data devoid of opinion
and emotion Decision becomes transparent
Cost per item now x volume = annual expense
Cost per new item x volume (can remain the same or change) = projected expense
Hopefully, will show annual savings
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What is the cost of the problem you are trying to solve?◦ What is your annual pressure ulcer incidence and
actual number of patients with ulcers?◦ What are pressure ulcers costing your system?
◦ Compute the number of cases you would need to prevent to recoup your cost
Look for studies that show Number Needed to Treat (NNT) Values◦ the number of patients you need to treat to prevent
one additional bad outcome (pressure ulcer) ◦ Study of silicone dressings for prevention of
pressure ulcers in ICU reported a NNT of 10 10 patients would be treated with dressings to prevent
1 pressure ulcer (Santamaria, 2013)
Team needs to examine options for products Measure products performance and
attributes against the grid Choose best 2-3 Ask companies to trial the products◦ Will need staff training on products
Monitor performance of new product◦ Is it doing what you want it to do?◦ Are you seeing the results you want to see?
Root Cause Analysis on all Full Thickness HAPI Goal to determine when and where ulcer began◦ Not to blame, but to guide care and focus education
Start with first notation of PI, stage, location◦ Go back into the record and examine events 48 hours for DTPI 72 -96 hours for Stage 3,4 and Unstageable ◦ Consider location of ulcer and determine position of
patient at the time pressure was applied to body◦ Ask “could anything been done differently at that
time?”
Guide Communication about Risk Plans◦ How does the bedside caregiver know how, when
and where to position patient?◦ Do staff know how to turn patients without causing
back injury?◦ Does nurse know and when to examine skin
beneath preventive dressing?◦ How does the nurse obtain speciality beds during
off hours?◦ How well is nutrition being addressed?◦ How is skin care being provided? And by whom?
Additional training◦ Information available in
real time Additional recognition◦ This button became a
coveted item Several have gone on to
become wound nurses!
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Optimal Patient
Outcomes
Optimal Patient
Outcomes
Consistent Care Delivery Consistent
Care Delivery
Quality/PerformanceStrategy
Quality/PerformanceStrategy
Organizational Support on All Levels
Organizational Support on All Levels
EB Practice for HAPI PreventionEB Practice for HAPI Prevention