Transcript Presentation Title

AHA/HRET HEN:
Data and Coaching Webinar:
Pressure Ulcers
Data Review
Friday, June 29, 2012
2:00 – 2:30 PM, CDT
Welcome and Overview
• Welcome, thank you for joining us today!
• Housekeeping:
– This webinar is being recorded and will be archived.
– You will receive a PDF of today’s presentation, as well as a link for
the evaluation, a summary of Q&A and the polling questions and a
link for the recording.
– For additional questions: please reach out to your state lead – or
email us: [email protected].
– For additional resources and information: please visit our website:
www.hret-hen.org
• Agenda:
– Content Review
– Measurement Review
2
– Hospital Story
Objectives
1. Discuss strategies to identify patients at risk for skin
injury…use of subscales
2. Outline evidence-based strategies to assess and
prevent moisture related injury from incontinence
3. Demonstrate an understanding of the HAPU related
measures in the HRET Encyclopedia of Measures
4. Describe the HAPU measurement and data
requirements
5. Discuss a strategy to promote staff buy-in and
ownership
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Introductions
•
•
•
•
Jessica Blake, LSW, MA, HRET
Steve Tremain, MD, Cynosure Health
Cheryl Ruble, RN, MS, CNS, Cynosure Health
Kathleen M. Vollman MSN, RN, CCNS, FCCM,
FAAN, Advancing Nursing, LLC
• Charisse Coulombe, MS, MBA, HRET
• Liz Schulte, CAPM, CHES, BJC HealthCare
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Polling Question #1
How Many of You are Joining Us From:
Hospital type?
A. General Medical / Surgical
B. Teaching
C. Rural
D. Children’s
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Polling Question #2
How Many of You are Joining Us From:
Hospital size?
A. CAH
B. Not CAH, <100 beds
C. Not CAH, 100-299 beds
D. Not CAH, 300+ beds
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Polling Question #3
What best describes your facility:
A. We implemented strategies to prevent HAPU
and have seen significant reductions
B. We are just getting started with HAPU
prevention
C. We are struggling to find resources
D. We are struggling to obtain staff buy-in
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HAPU: Working Our Way Towards Zero
Kathleen M Vollman MSN, RN, CCNS, FCCM, FAAN
Clinical Nurse Specialist/Educator/Consultant
ADVANCING NURSING LLC
Northville, MI
[email protected]
www.vollman.com
Disclosures
 Sage Products Speaker
Bureau & Consultant
 Hill-Rom consultant
 Eloquest Healthcare
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Identify Patients at High Risk
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Risk Assessment on Admission,
Daily, Change in Patient Condition
• Use standard EBP risk assessment tool
• Research has shown risk assessment tools are more
accurate than RN assessment alone
• Braden Scale for Predicting Pressure Sore Risk
– Six subscales
• Rated 1-4
– Pressure on tissues
• Mobility, sensory perception, activity
– Tissue tolerance for pressure
• Nutrition, moisture, shear/friction
– Score 6-23
Available at: www.ihi.org; Macklebust, JA (2009) The Braden Scale reliable assessment to effective
interventions.
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It’s About the Sub-Scales
• Retrospective cohort analysis of 12,566 adult patients in
progressive & ICU settings for year 2007
• Identifying patients with HAPU Stage 2-4
• Data extracted: Demographic, Braden score, Braden
subscales on admission, LOS, ICU LOS, presence of acute
respiratory and renal failure
• Calculated time to event, # of HAPUs
• Results:
– 3.3% developed a HAPU
– Total Braden score predictive (C=0.71)
– Subscales predictive (C=0.83)
Tescher AN, et al. J WOCN. 2012;39(3):282-291
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Braden Score
Braden Sub-Scales
(C=0.83)
Friction Score of 1=126
times the risk
Multivariate model included 5 Braden subscales, surgery and acute respiratory
failure C=0.91 (mobility, activity and sensory perception more predictive when
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combined with moisture or shear/friction)
Polling Question #4
Are you using Braden sub-scales to target
specific prevention strategies?
A.
B.
C.
D.
Yes, we are using the sub-scales
We have started implementation of the sub-scales
No, we do not use the sub-scales
No, we use a different assessment tool
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Moisture Injury: Incontinence
Associated Dermatitis (IAD)
• An inflammatory response to the
injury of the skin’s water-proteinlipid matrix
– Caused by prolonged exposure to
urinary and fecal incontinence
• Top-down injury
• Physical signs on the perineum
and buttocks
– Erythema, swelling, oozing,
vesiculation, crusting and scaling
Brown, DS & Sears, M, OWM 1993;39:2-26
Gray M et al. OWN 2007;34(1):45-53
Doughty D, et al. JWOCN. 2012;39315
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Impact of Moisture
• Urinary and fecal incontinence are common
in the acute care setting, occurring in more
than one-third of hospitalized adults
• Humidity/Moisture:
– Strain at which the skin breaks is 4x greater
with excess moisture than with dry skin
– Moisture increases the risk of shear and
friction damage
Nicolopoulos CS, et al. Arch Dermatol Res. 1998;290:638-640
Bliss DZ, et al. Nurs Res.2000;49:101-108.
Gray M, et al. Adv Skin Wound Care. 2002;15(4):170-175.17
• Assessment,
definitions,
grading, &
evidencebased
interventions
• Joan Junkin
Doughty, D, et al.
JWOCN;3,993:303-315
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IAD Assessment
IAD
Tool
Junkin J, Selek JL. J WOCN
2007;34(3):260-269
Junkin J, Selek JL. J WOCN 2007;34(3):260-269 19
Polling Question #5
Are you familiar with the term “incontinence
associated dermatitis,” used to describe
incontinence related moisture injury?
A. Yes
B. No
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EBP Recommendations to Reduce Injury From
Incontinence & Other Forms of Moisture
•
•
•
Clean the skin as soon as it becomes soiled
Use an incontinence pad and/or briefs to absorb/wick
away wetness from the skin
Use a protective cream or ointment on the skin to
protect it from wetness
–
•
•
Disposable barrier cloth prevents unprotected episodes (www.ihi.org 5
Million Lives Campaign)
Consideration of pouching device or a bowel
management system
Ensure an appropriate microclimate and breathability
with < 4 layers of linen
National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure ulcer prevention &
treatment: Clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.
Williamson, R, et al (2008). Linen Usage Impact on Pressure and Microclimate Management. Hill-Rom
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www.ihi.org
Achieving the Use of the Evidence
For Friction & Moisture
•
•
Factors impacting the
ability to achieve quality
nursing outcomes
at the point of care
Value
•
•
•
Resource & System
Breathable glide sheet/stays
Foam Wedges
Microclimate control
Reduce layers of linen
Wick away moisture body pad
Attitude &
Accountability
Vollman KM. Australian Crit Care, 2009;22(4): 152-154
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Questions?
• Let’s pause for questions…
?
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Pressure Ulcers
Data Management Strategy
Charisse Coulombe
Data Director, HRET
Why is Pressure Ulcer Data Needed?
• Measures are used to assess the impact of
changes
• To demonstrate hospitals have reduced their
rates of harm over the 2 year period for the
HEN project
• To monitor that interventions to reduce
pressure ulcers are working
– Part of the PDSA cycle
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What Pressure Ulcer Data is
Needed?
• At a minimum, 1 process measure and 1
outcome measure
– Process: Measures interactions between
healthcare practitioner and patient; a series of
actions, changes, or functions bringing about a
result
– Outcome: Measures change or the end result of
healthcare intervention
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Encyclopedia of Measures
• Technical manual to ensure the hospital's Pressure
Ulcer measure definitions align with the
comprehensive data system (CDS)
• Comprehensive details about measure
characteristics
–
–
–
–
–
–
Topic
Measure Name
Definition
Numerator, Denominator
Calculation specifications
Source(s)
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Pressure Ulcer Process Measures
• Patients with Pressure Ulcer Risk Assessment Completed
within 24 hours of Admission
• Patients with Skin Assessment Documented Within 24
Hours of Admission
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Pressure Ulcers Process Measure
Example
• Patients with Pressure Ulcer Risk Assessment
Completed within 24 hours of Admission
– Assesses the total number of patients that have a pressure
ulcer assessment completed within 24 hour of admission
– Numerator: Number of inpatients with documentation in
medical record of a complete pressure ulcer risk
assessment
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Pressure Ulcer Process Measure
Example
• Denominator: All inpatients admitted to
hospital or unit under surveillance
Number of
inpatients with
documentation in
medical record of a
complete pressure
ulcer risk
assessment
[Numerator]
All inpatients admitted to hospital or
unit under surveillance
[Denominator]
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Polling Question #6
6) Has your hospital selected your Pressure
Ulcer process measure?
A. Yes, selected and actively tracking
B. Yes, the measure has been selected
C. No, still researching which measure to select
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Pressure Ulcer Outcome Measures
• Patients with at least One Stage II or Greater
Nosocomial Pressure Ulcer (NSC 2)
• Patients with at least One Stage II Nosocomial
Pressure Ulcer (subset NSC 2)
• Patients with at least One Stage III or Greater
Nosocomial Pressure Ulcer (subset NSC 2)
• Decubitus Ulcer - Adult (AHRQ PSI 3)
• Pressure Ulcer - Pediatric (AHRQ PDI 2)
• Pressure Ulcer (MCR FFS) (CMS HAC)
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Scenarios
• 8 year old Kyle was admitted to a community hospital for orthopedic
surgery. During his stay he developed a decubitus ulcer.
– For the Pressure Ulcer - Pediatric (AHRQ PDI 2) measure, Kyle would
be included in the numerator and in the denominator.
• Sara is an inpatient at a local hospital, and has been identified has having a
Stage II Pressure Ulcer during a prevalence study on inpatient pressure
ulcers.
– For the Patients with at least One Stage II Nosocomial Pressure Ulcer
(subset NSC 2) measure, Sara would be included in the numerator and
the denominator.
• If Sara did not have a State II Pressure Ulcer, she would not be
included in the numerator, but would be included in the
denominator.
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Polling Question #7
7) Has your hospital selected your Pressure
Ulcers outcome measure(s)?
A. Yes, selected and actively tracking
B. Yes, the measure has been selected
C. No, still researching which measure to select
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What Happens if the Hospital Collects a Pressure Ulcer
Measure that isn’t in the Encyclopedia of Measures?
• Data system allows the hospital to create an
organization-defined measure
– Hospital specifies the numerator and denominator
definitions in addition to entering their data
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Example of Pressure Ulcer Organization
Defined Measures
• Measure Definition: Patients with high risk
score for Braden Scale (>18)
– Numerator: Number of patients with high risk
score for Braden Scale
– Denominator: Number of patients eligible for
Braden Scale screen
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Polling Question #8
8) Who is currently reviewing Pressure Ulcer data
on a monthly basis?
A. Board of Directors/Quality Committee of Board
B. Senior Leadership of your hospital/system (e.g.
CEO, VPs)
C. Nursing only
D. Interdisciplinary Team that includes Nursing,
Wound Care, Infection Control, Dietary, Physical
Therapy, Medical Staff
E. All of the above
F. Combination of A, B, C, D
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What Pressure Ulcer data is
Submitted?
– Baseline
• Timeframe flexible
• Can submit 1 year, 6 months, 1 month, etc.
• Data set that will be used for comparison to the
measurement period(s)
– Measurement (2 years)
• Submitted in monthly increments
• Data set that will be compared to the baseline to
determine if improvement is occurring
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Pressure Ulcer
Data Collection & Submission
– Current:
• Hospital directly enters all Pressure Ulcer data into CDS
– In Progress:
• If your state has a state-level data warehouse that
collects Pressure Ulcer data, working to get the data
uploaded to CDS by HRET
– Notes:
• Only collecting aggregate hospital-level data (not unit
level, or patient level)
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Questions?
• Let’s pause for questions…
?
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Next Up! Coaching
• Thank you for joining us for
the Data session of the
webinar.
• We will now transition into the
Coaching session of the
webinar.
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AHA/HRET HEN:
Data and Coaching Webinar:
Pressure Ulcers
Coaching Review
Friday, June 29
2:30 – 3:00 PM, CDT
When the right solution is not enough:
Emphasizing methods in pressure ulcer
prevention improvement
Liz Schulte, CAPM, CHES,
Project Manager, BJC HealthCare,
St. Louis, MO
About Us
• BJC Healthcare is one of the largest nonprofit health care
organizations in the United States. Through our 13 hospitals
and multiple community health locations, we deliver services
to urban, suburban and rural residents primarily in the greater
St. Louis, southern Illinois and mid-Missouri regions.
2011 BJC Statistics:
•
Employees
27,984
•
Physicians
4,269
•
Staffed Beds
3,508
•
Hospital Admissions
150,602
•
ED Visits
481,385
•
Net Revenue
$3.6 billion
•
Charity Care
$252.3 million
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What Did We Test?
• Process improvement of the hospital acquired
pressure ulcer prevention process in three high
event volume units
• Pilot process focused on three standard criteria:
– Turning at risk patients every two hours
– Daily event tracking and immediate analysis
– Standard prevention education for staff, patients and
families
• Implementation method: Provide all three pilot
units with the same “what,” but gave each the
freedom to develop the “how”
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What Have We Learned So Far?
• Implementing with
standard criteria and a
custom process
increased staff buy-in
and process ownership
• Sustained attention to
event analysis can
proliferate benefits of
process improvement
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What Barriers
Did We Encounter?
• Competing priorities at hospital and unit level
– Numerous initiatives and internal infancy of
portfolio management
• Nursing management turnover
– For this project, unit managers were the primary
drivers for process compliance and accountability
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How Did We Overcome
These Barriers?
• Detailed process documentation and standard
work
• Acceptance/Change management tools
– Finding the “what’s in it for me” (WIIFM) during
each stakeholder engagement
• Unit and hospital champions
– Strong subject matter experts and mid-level
leadership
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What Can Others Learn
From Our Journey?
• Application of the Pareto principle in pilot site
selection
– Three pilot sites showed a combined 58% decrease in
hospital acquired pressure ulcers; equated to a 30%
decrease system wide in the same time period
• Most powerful tools for success:
– Collaboration
– Project plan/schedule
– Issue tracking and elevation
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Do Not Try This At Home
(Suggestions for What Not to Do…)
• Stick to the plan or allow for wiggle room?
Sometimes it’s hard to tell…
• Even when the right path is clear or easy,
don’t forget to ask why (and write down the
answer)
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Teach Back
• Questions?
• Summary
• Next Steps: implementing standard criteria on top
25 units contributing to overall hospital acquired
pressure ulcer rate by end of 2012
• For more information on the solutions from this
project: http://wcqi.asq.org/team-competition/pdf/BJCHealthcare.pdf
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Wrap Up and Next Steps
• Next TOC
• Reminders:
– LISTSERV®
• Email [email protected] if you are not part of the
LISTSERV® and would like to be added
– Progress Reports are due at the end of each month (to
the LISTSERV®)
– Visit the HRET HEN website: http://www.hrethen.org/ for information, resources and events
• Thank you for joining us!
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