Transcript www.txquality.org

While we wait to begin the conference,
please answer this polling question:
Please tell us your primary work area:
Hospital
Nursing Home
Hospice
Home Health
Physician Office
Outpatient Office
Dialysis Center
Other
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Stopping Pressure Ulcers
One Root Cause at a Time
June 27, 2012
Today’s Presenter
Melody A. Malone, PT, CPHQ
Quality Improvement Consultant
TMF Health Quality Institute
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About TMF
TMF Health Quality Institute focuses on
improving lives by improving the quality
of health care through contracts with federal,
state and local governments, as well as private
organizations. For more than 40 years, TMF has
helped health care providers and practitioners
in a variety of settings improve care for their
patients.
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TMF is the Quality Improvement
Organization (QIO) for Texas
About the QIO Program
 Leading rapid, large-scale change in health
quality:
•
•
•
•
•
Goals are bolder.
The patient is at the center.
All improvers are welcome.
Everyone teaches and learns.
Greater value is fostered.
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Objectives
 The learner will be able to:
• Facilitate completion of the Facility-Acquired
Pressure Ulcer (FA PU) Investigation Tool
• Identify potential areas for root causes
• Identify potential areas for systems
improvement
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Pressure Ulcer Definition
Any lesion caused by unrelieved pressure
resulting in damage of underlying tissues.
Source: F314 42 CFR 483.25(c), U.S. Department of Health & Human Services Agency for Healthcare
Research and Policy. www.ahrq.gov. National Pressure Ulcer Advisory Panel Monograph (pp. 181).
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Polling Question:
Do you have
facility-acquired
pressure ulcers
in your setting?
 Yes
 No
 I don’t know
 Doesn’t apply
in my setting
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Quiz…
Why focus on pressure ulcers?
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Actual harm to the patient!
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Facility-Acquired Pressure Ulcers
 Develop in the health care facility AFTER
admission
 FA PUs cause:
•
•
•
•
Pain to the resident
Scarring of the body
Increased risk of infection
Increased costs of care
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National Partnership for Patients Goal
 “Keep patients from getting injured or sicker.
By the end of 2013, preventable hospitalacquired conditions would decrease by 40%
compared to 2010.”
Partnership for Patients. U.S. Department of Health & Human Services. April 2011. Retrieved from:
http://www.healthcare.gov/news/factsheets/2011/04/partnership04122011a.html
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Pressure ulcers are a problem!
 NH Quality Measure: High-risk residents with
PUs in Texas: 7.4% 1
• 4,007 HR residents with a PU out of 54,479
• 87,533 nursing home residents in Texas 2
1 Facility
Quality Measure (2011 Q4)
2 Regulatory Services Fiscal Year 2011 Annual Report January 2012
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Pressure ulcers are a problem!
 12% hospitalized patients developed at least
1 pressure ulcer during the stay
• 383 surgical patients out of 3,225
Tschannen, D., Bates, O., Talsma, A. and Guo, Y. Patient-specific and Surgical Characteristics in the
Development of Pressure Ulcers. American Journal of Critical Care
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Nursing Homes in TMF’s Previous
QIO Contract
Reduced FA PUs from
 39% (237) December 2009 to
 32% (130) June 2011
*47 nursing homes
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How do we change this and…
Keep it fixed?
We focus on quality
improvement (QI).
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If Pressure Ulcers are “IN”
 Then nothing can be “OUT”
 If all systems are GO – no pressure ulcers!
 Got pressure ulcers?
You’ve got systems failures!
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Root Cause
The most fundamental reason a
problem has occurred
(When performance does not meet expectations)
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Facility-Acquired PU Investigation Tool
 Incident report and root cause analysis tool
 Privileged & Confidential Work Product of the
QAA Committee
 Takes the focus off the individual and puts it
on the system
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Facility-Acquired PU Investigation Tool
 Compile and analyze:
• Clinical
• Environmental
• Operational issues
that contributed to the development of a
pressure ulcer
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Facility-Acquired PU Investigation Tool
 Focus the team to:
• Gain the ability to anticipate issues for risk
identification
• Enhance staff knowledge
• Take action to implement interventions
• Boost the ability to sustain improvements
• Critical thinking
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Nursing Home Results
 Three nursing homes (NH) during three years:
• 1 NH achieved > 400 days between the
development of an FA PU.
• 1 NH achieved two cycles of > 100 days
between the development of an FA PU.
• 1 NH achieved one cycle of 100+ days.
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Nursing Home Results, continued
 Plus, they had other significant periods of
time between new FA PUs, such as:
69, 76, 78, 103 and 148 days
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Process for Use of the Tool
 Begin tool when PU is identified – day 1
• Resident/patient changes start today!
 Designated individual completes tool –
day 1 or 2
• Wound nurse or nursing leadership
 Team reviews the tool – day 1, 2 or 3
 Tests of change identified and plan
developed
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Facility-Acquired PU Investigation Tool
Privileged Confidential Work Product of the QAA Committee
Page 1, First Quarter
Resident name:
Melody Malone
Room number:
Date ulcer identified:
409
Time ulcer
identified:
4/14/2011
Date of last full body skin assessment: 4/6/11
7:30 AM
YES
NO
Was ulcer found at this time? (circle)
Ulcer is properly diagnosed as a pressure ulcer?
If NO, what type of ulcer is it?
(circle)
Arterial ulcer
YES
Diabetic neuropathic ulcer
Venous insufficiency ulcer
Is the new ulcer in a site of a previously healed ulcer of any type? (circle)
Location of ulcer:
Sacrum
(circle)
Other:________________________
YES
Stage of PU at discovery:
YES
Is resident diabetic?
NO
NO
IF yes, have blood sugars been within resident's
usual range? (circle)
NO
2
YES
NO
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Facility-Acquired PU Investigation Tool
Privileged Confidential Work Product of the QAA Committee
Page 1, Second Quarter
Prevention strategies that WERE in place PRIOR to ulcer development: (circle & add comments)
Mattress/Bed:
Overlay on mattress
Specialty Bed
Conventional
Replacement
Is bed
functioning/used
properly?
Other:
YES
NO
YES
NO
Chair
cushion:
YES
NO
Was it really
done?
Turning and repositioning program:
Heels
floated:
Low Air Loss
YES
NO
Fit/Function
properly:
YES
NO
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Facility-Acquired PU Investigation Tool
Privileged Confidential Work Product of the QAA Committee
Page 1, Third Quarter
Nutritional interventions (list/circle):
Protein powder/liquid:
Multi-vitamin
Daily
Bid
Vitamin C
Tid
Zinc
Protein supplement:
Daily
Other:_________
Bid
Tid
Other:
Is nutritional intake what RD recommends?
Last 3 weights:
YES
NO
Date:
Weight:
Date:
Weight:
Date:
Weight:
4/3/11
206.6
3/1/11
205.1
1/28/11
207.3
Last RD Visit:
4/19/2011
Laboratory Test History: {Note if lab value is: H = high / L = low / N = normal}
Date:
Value:
3/19/11
{H/L/N}
Date:
Value:
________
{H/L/N}
Date:
Value:
________
{H/L/N}
Date:
Value:
________
{H/L/N}
_______
______
_______
______
_______
______
_______
______
Serum Albumin:
2.4
L
_______
______
_______
______
_______
______
Total Protein:
5.6
L
_______
______
_______
______
_______
______
Pre Albumin:
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Facility-Acquired PU Investigation Tool
Privileged Confidential Work Product of the QAA Committee
Page 1, Fourth Quarter
PU Risk Assessment Scores: (Braden, etc.)
Date: 3/9/11 Score: 14
YES
Date:12/9/10
Score: 14
Date:____ Score:___
NO
Were risk assessment scores accurate?
Has resident been refusing PU prevention interventions?
YES
NO
Other
treatments?
Has incontinence (bowel or bladder) or moisture been a problem unaddressed prior to ulcer?
Has pain been a problem unaddressed prior to ulcer?
Family
notified of
ulcer:
YES
NO
Physician
notified of
ulcer:
YES
NO
CNA comm.
tool/care plan
updated:
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Care plan
updated:
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Facility-Acquired PU Investigation Tool
Privileged Confidential Work Product of the QAA Committee
Page 2, First Third
Resident name:
(Insert names of staff
actually working with the
resident)
Date:
Shift:
Nurse:
CNA:
CNA:
CMA:
Shift ulcer
found:
1 shift prior:
2 shifts
prior:
3 shifts
prior:
4 shifts
prior:
5 shifts
prior:
6 shifts
prior:
7 shifts
prior:
8 shifts
prior:
4/14
4/13
4/13
4/13
4/12
4/12
4/12
4/11
4/11
days
nights
eve
days
nights
eve
days
nights
eve
Millie
Shirley
Holley
Millie
Becca
Ralph
Anne
Becca
Ralph
Jeanine
Chris
Dawn
Jeanine
Stella
Julie
Dolores
Chris
Dawn
Ethel
Sue
Ethel
Sue
Mike
Dolores
Ilise
Mark
Ilise
Fred
Ilise
Mark
OTHER:
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Shift ulcer
found:
1 shift
prior:
2 shifts
prior:
3 shifts
prior:
4 shifts
prior:
5 shifts
prior:
6 shifts
prior:
7 shifts
prior:
8 shifts
prior:
4/14
4/13
4/13
4/13
4/12
4/12
4/12
4/11
4/11
In the same 72 hour period as above, note the changes of condition the resident had PRIOR to the ulcer being found.
Mark: YES or Y if present. If NO changes of condition have occurred, check this box:
Cognition level
Physical activity level
Urinary incontinence
Bowel incontinence
Mobility – ability to change
and control body position
Usual food intake pattern
Usual water/liquid intake
pattern
Pain
Started new medication(s)
Developed multi-system
organ failure
Become a hospice
candidate or recipient
Started refusing care
Other: fever, difficulty
breathing, shear factor with
HOB up, if any new devices
were used, etc. (Note
issues.)
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Facility-Acquired PU Investigation Tool
Privileged Confidential Work Product of the QAA Committee
Page 2, Last Third
Determination of root cause for PU development, both resident and system level:
Resident sitting up in the chair all the time
Action plan for resident and system improvements:
Resident to bed after meals
4/15/2011
Signature of Investigator
Date investigation completed
4/15/2011
DON signature
Date reviewed
4/15/2011
Administrator signature
Date reviewed
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Determination of Root Cause and
Quality Improvement Plan
 Usual findings:
 Superficial causes
 Not systems issues
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NH’s Root Causes Included:
 Resident on hospice
 Refuses care
 Resident has
increased pain
 Resident leans to side
 Resident does not eat
well
 Constant motion
 Resident has loose
stool episode before
skin breakdown
 Heels pressing against
geri-chair while up
during the day
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What were the REAL root causes?
Findings from compiling the 65 FA PU Inv. Tools:
 43% did not have a validated risk assessment
timely prior to the FA PU
 42% mattress/bed was not appropriate to
the level of risk prior to the FA PU
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REAL Root Causes, continued
 38% gap between last full body skin
assessment
 20% care plan not updated with risk changes
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REAL Root Causes, continued
 31% did not have nutritional interventions
prior to the FA PU
 34% abnormal lab values identified to the FA
PU were unaddressed
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Training on the Tool is Available
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Action Items
 Share the FA PU Investigation Tool with your
QI team.
 View the training webinar.
 Have someone use it, review it and learn.
 Implement a test of change.
 Celebrate your successes.
 Count your days between FA PUs!
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Q&A (during a polling question)
Will you try
using the FA PU
Investigation
Tool?
 Yes
 No
 Doesn’t apply
in my setting
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References
 Department of Health & Human Services, Centers for
Medicare & Medicaid Services Appendix
PP/483.25(c)/Pressure Sores/Tag F314. Guidance to
Surveyors for Long Term Care Facilities
 Facility Quality Measure Report. (2011 Quarter 4).
 Partnership for Patients. U.S. Department of Health &
Human Services. April 2011. Retrieved from:
http://www.healthcare.gov/news/factsheets/2011/04/p
artnership04122011a.html
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References, continued
 Regulatory Services Fiscal Year 2011 Annual Report
January 2012. Texas Department of Aging and Disability
Services.
 Tschannen, D., Bates, O., Talsma, A. and Guo, Y. Patientspecific and Surgical Characteristics in the Development
of Pressure Ulcers. American Journal of Critical Care.
2012;21:116-125 doi: 10.4037/ajcc2012716
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Additional information can be found at:
http://qmweb.dads.state.tx.us
Agency for Healthcare Research and
Quality (AHRQ). www.ahcpr.gov
www.npuap.org
http://TexasQIO.tmf.org
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Contact
Melody Malone, PT, CPHQ
Quality Improvement Consultant
TMF Health Quality Institute
214-632-2238
[email protected]
http://TexasQIO.tmf.org
This material was prepared by TMF Health Quality Institute, the Medicare Quality Improvement
Organization for Texas, under contract with the Centers for Medicare & Medicaid Services
(CMS), an agency of the U.S. Department of Health and Human Services. The contents do not
necessarily reflect CMS policy. 10SOW-TX-C7-12-81
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