Transcript Eliminating Pressure Ulcers In ECMO Patients

“Saving The Skin: pressure ulcer
prevention in the ICU”
Barbara Logue RN, BSN, CCRN
Cynthia Copeland RN, BSN, CCRN
Cardiothoracic ICU (56ICU)
Barnes-Jewish Hospital
October 2014
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Cynthia and I have been bedside nurses in the Cardiothoracic ICU at Barnes
Jewish Hospital for over 10 years. We also function in the role of unit-bases
wound liaison nurses to assist staff with the long standing challenge of
pressure prevention.
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Starting in 2008 the Centers for Medicare and Medicaid
Services specified they would no longer cover additional
costs for hospital acquired pressure ulcers resulting in
transformational change in hospital
payment/reimbursement practices.
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STATISTICS
• Estimated 60,000 hospitalized patients die each
year from complications due to hospital
acquired pressure ulcers.
• Estimated cost of managing a single full-thickness pressure ulcer
averages $70,000
• Total cost for treatment of pressure ulcers in the United States is
estimated at $11 BILLION a year.
• The prevalence of pressure ulcers in heath care facilities in increasing.
• Rates vary considerably by clinical setting with acute care leading the
list.
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ANALYSIS OF BARRIERS
• Current practices not standardized but guided by primary
nurse
• Nurse’s belief that pressure ulcers could not be prevented in
certain patients
• Reluctance to identify and document
• Unawareness of available products
• EDUCATION, EDUCATION, EDUCATION
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EVALUATION OF OUR CURRENT
PRACTICES
• Turning schedule
• Braden scale assessment tool
• Skin assessment
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DEVELOPING AN INTERDISCIPLINARY
TEAM
• Wound/skin liaison
• Staff RNs
• Bed providers
• Physical therapist
• Dietitian
•Unit manager
• Wound/ostomy team
•Skin product suppliers
•OR involvement
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DEVELOPING
OUR
STRUCTURED
PERFORMANCE
IMPROVEMENT
PROCESS
• Use of Braden Score q12 hours
• Redefining role of skin liaison nurses
• Better utilization of wound/ostomy
nurses
• Use of support surfaces for all patients
• Improvement of documentation
• Team approach for performance
improvement
• Education for all clinical staff
• Change thinking from inevitable to
preventable
• Evaluation of products and availalbility
• Consistent data collection to evaluate
outcomes
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DEVELOPING
OUR PRESSURE
ULCER
PROTOCOL
-Nursing and medical leadership
involvement
-Renewed emphasis on bedside shift
report
-Evaluation of units’s pressure ulcer
therapy supplies
-Aggressive use of prevention tools
-Better communication of suspected
pressure ulcers
-Real-time pressure ulcer identification
-Care tailored to problem
-Weekly posting of pressure ulcer rates
so everyone could see results of our
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efforts
TEACHING TOOLS
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RESULTS
• Excellent clinical care that has resulted
in observable improvement
• Continuous performance improvement
• Team-building
• Changing, adapting, building
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Purpose
• ECMO is a therapy that provides support of
the heart and lungs when patients have severe
cardiopulmonary failure
– They are at extreme risk of developing pressure ulcers
• We did this evidence-based project to see if
implementing a change in the therapeutic bed
would reduce the occurrence of pressure ulcers
in this high-risk population
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Pressure Ulcers in ECMO Patients
Pre-Implementation
35%
31.0%
30%
Unit-Acquired PrU
25%
Hospital Acquired PrU
20%
16.6%
15%
10%
Hospital target
5%
Unit target
0%
Pre-implementation
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ECMO Support
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Multisystem Failure
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High Risk Patients Require
Intensive Interventions
• This patient is on
ECMO with an open
chest, IABP,
ventilator, multiple
vasopressors,
inotropes, blood
transfusions and is
receiving CLRT at 20
degrees every 30
minutes.
Total Care Sport with Continuous
Lateral Rotation Therapy ( CLRT)
• Comparable
hospitals use
low air loss
mattress with
CLRT with
success
ECMO
patients
on Total
Care
Sport
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Implementing Guidelines Specific to
ECMO Population
• Operating room support
• New roles for secretaries, ICU technicians and charge
nurses
• ECMO patients placed on Total Care Sport with (CLRT)
• In-services provided for all 56ICU staff by Hill-Rom
staff and by skin care liaisons
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ICU Technician prepares, delivers and
signs in Total Care Sport bed with OR
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ECMO Patient Arriving from OR
on Total Care Sport Bed
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ECMO patients on CLRT Therapy
Depending on patient tolerance, beds are programmed
to rotate every 30 minutes 10-30 degrees
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Pressure Ulcers in ECMO Patients
Pre- and Post-Implementation
35%
31.0%
30%
Unit-Acquired PrU
25%
Hospital Acquired PrU
20%
16.6%
15%
11.5%
10%
Hospital target
5%
Unit target
0.0%
0%
Pre-implementation
Post-implementation
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Pressure Ulcer Prevention
OR Staff
Management
Nurses
Physicians
Ancillary
Staff
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Acknowledgments
• We thank the OR and 56ICU staff for their tremendous
efforts which led to our positive results.
• We would also like to thank the Greater St Louis Chapter
of the AACN, especially Dawn Held who made this all
possible.
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Questions?
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