Tuesday, May 6, 2014

These presenters have

nothing to disclose

IHI Expedition
Preventing Pressure Ulcers

Kathy Duncan, RN
Annette Bartley, RN
Todays Host
2

Sarah Konstantino, Project Assistant, Institute for

Healthcare Improvement (IHI), assists in programming
activities for expeditions, as well as maintaining
Passport memberships, mentor hospital relations and
collaboratives. Sarah is currently in the Co-Operative
Education Program at Northeastern University in
Boston, MA, where she majors in Business
Administration with a concentration in Management
and Health Science. She enjoys cooking, traveling, and
fitness.
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 8

Expedition Director
Kathy D. Duncan, RN, Faculty, Institute for Healthcare Improvement
(IHI), oversees multiple areas of content and is the clinical lead for IHIs
National Learning Network. Ms. Duncan also directs content
development and provides spread expertise for IHIs Project JOINTS as
well as additional content direction for the Hospital Portfolio, directs a
number of virtual learning webinar series, and manages IHIs work in
rural settings. Previously, she co-led the 5 Million Lives Campaign
National Field Team and was faculty for the Improving Outcomes for High
Risk and Critically Ill Patients Innovation Community. In addition to her
leadership on the field team during the Campaign, Ms. Duncan was the
content lead for several interventions in IHIs 100,000 Lives and 5 Million
Lives Campaigns. She also serves as a member of the Scientific
Advisory Board for the American Heart Associations Get with the
Guidelines Resuscitation, NQFs Coordination of Care Advisory Panel
and NDNQIs Pressure Ulcer Advisory Committee. Prior to joining IHI,
Ms. Duncan led initiatives to decrease ICU mortality and morbidity as the
Director of Critical Care for a large community hospital.
 9
Overall Program Aim

The aim of the Expedition is to provide participants

with strategies for preventing pressure ulcers that
have been tried and tested in a variety of different
contexts with great success.
Expedition Objectives
10

At the end of this Expedition, participants will be able

to:
Identify a range of simple tools and methods which
will help you to prevent pressure ulcers
Test strategies for identification of patients at risk for
pressure ulcers
Implement reliable processes for pressure ulcer risk
assessment and pressure ulcer prevention
Implement reliable processes for pressure ulcer
prevention strategiess
Schedule of Calls
11

Session 1: Getting to Zero Strategies for Success

Date: Tuesday, April 22, 12:00 1:30 pm ET

Session 2: Identification and Assessment of Patients at Risk

Date: Tuesday, May 6, 12:00 1:00 pm ET

Session 3: Developing Reliable Care Processes

Date: Tuesday, May 27, 12:00 1:00 pm ET

Session 4: Measurement for Improvement

Date: Tuesday, June 10, 12:00 1:00 pm ET

Session 5: Engaging Patients, Families, and the Community in Pressure Ulcer

Prevention
Date: Tuesday, June 24, 12:00 1:00 pm ET
Session 6: Generating Ideas from Frontline Staff
Date: Tuesday, July 8, 12:00 1:00 pm ET
Todays Agenda
12

Welcome and introduction

Discuss the action period
assignment from call 1
Identification and assessment
of patients at risk
Guest presentations
Action Period Assignment
 13

Faculty
Annette Bartley is a registered nurse with over 30 years
of experience in healthcare. She has held leadership roles
in frontline clinical care, management and at director level.
In 2006 she was awarded a Health Foundation Quality
Improvement Fellowship spent at the US Institute for
Healthcare Improvement (IHI), during which time she also
completed a Masters in Public Health at Harvard
University. Annette is now an Independent Quality
Improvement Consultant responsible for developing,
supporting and leading a number of highly successful
quality improvement and patient safety initiatives across
the UK at regional, and national level. Her work extends
internationally and she is viewed as an authority on the
prevention of avoidable pressure ulcers using quality
improvement methodology. Annettes passion is inspiring
and supporting frontline care teams to reliably deliver high
quality, safe, person centered care.
 14

Faculty
Bevette Griffin, RN, CWON
Graduated from Saint Francis School of
Nursing in Peoria, IL in 1973
Worked from 1973 to 1989 as Staff RN/ Charge
RN at OSF Saint Francis Medical Center
Working since 1989 as Ostomy/ Wound Care
Nurse at OSF Saint Francis Medical Center
Certified Ostomy/ Wound Care Nurse through
Wound Ostomy Continence Certification Board
since 1999
Action Period Assignment
W asked you to test the use of the Safety Calendar.
Review your pilot units current performance. Ask five
members of staff what the units process for preventing
pressure ulcer is and check whether their responses
match. In addition, check if they are consistent with your
local policy/protocol.
Check the charts of five patients and review the
percentage compliance with risk assessment.
We would welcome a couple of volunteers to share their
learning from their pre-work
Please raise your hands?
Identification and Assessment of Patients at Risk 16
Developing a Systems Based Approach

Risk Identification What will success

look like?
Risk Assessment

Communication of
Partnership Risk status
with patient Appropriate preventative
strategy implemented

Evaluation of outcome
Who is at Risk?
18
High Risk Groups
19

The presence of pressure ulcers has been

associated with an increased risk of secondary
infection and a two to four fold increase of risk of
death in older people in intensive care units
(Bo M, Massaia M et al, 2003).
Pressure ulcers can occur in any patient but are
more likely in certain high risk groups such as:
The elderly, obese, malnourished and those
with certain underlying conditions.
Anyone can get a pressure sore whether they are aged 10 or aged 80. But the people who are most at risk are: 20

1. People who have trouble moving and cannot change position

themselves
2. People who cannot feel pain over part or all of their body
3. People who are incontinent
4. People who are seriously ill, or have had surgery
5. People who have a poor diet and dont drink enough water
6. People who are very young or very old
7. People who have damaged their spinal cord and can neither
move nor feel their bottom and legs
8. Older people who are ill or have suffered an injury like a broken
hip
http://your-turn.org.uk/patients/what_is_PS.htm
Patient Stories
21

Sarah aged 9 got a pressure sore on her heal after having an

operation on her broken leg.

Josie aged 28 had a pressure sore after giving birth to her first child
and having an epidural.

James, aged 35 suffered a pressure sore on the back of his leg after
changing to a new wheelchair.

Stan, age 73 got a pressure sore on his bottom after a bad chest
infection kept him housebound for 2 months.

http://your-turn.org.uk/patients/what_is_PS.htm
Risk Factors

Limited Mobility Poor Nutritional Status

Impaired Mental Status Obesity
Recent weight loss
Exposure to moisture
Feeding assistance
Urinary incontinence
needed
Bowel incontinence
Wound exudate Skin condition
Excessive Perspiration + Pressure ulcer history
++
Risk of Pressure Ulcer by Number of
Risk Factors

Number of risk factors present

Mor, V et al Canadian J of Quality of Care
Risk Identification (Individual)
Consider risk factors that are present
-Shortness of breath, weight loss, inability to eat,
orthopedic surgery (hip, knee) diabetes
Consider if patient cannot move voluntarily
-Bedridden, chair ridden, coma, restrained, desaturation
with movement, traction, pain
Consider the history/ pattern of ulcer development
-High risk? Or acquired, trapped in one place for
extended time?
Risk Identification (unit/facility)
25

Patient Population Urinary Catheters

Specialty Nasogastric Tubes
Surgery, Gastrointestinal, Oxygen cannula
ICU, Pediatric)
Oxygen masks
Age
Resources
Pain Staffing
Equipment
 Risk Assessment (NPUAP 2014) 26

Consider all bed-bound and chair-bound persons, or those whose

ability to reposition is impaired, to be at risk for pressure ulcers.
Use a valid, reliable and age appropriate method of risk
assessment that ensures systematic evaluation of individual risk
factors.
Assess all at-risk patients/residents at the time of admission to
health care facilities, at regular intervals thereafter and with a
change in condition. A schedule is helpful and should be based on
individual acuity and the patient care setting.
Acute care: assess on admission, reassess at least every 24 hours
or sooner if the patients condition changes
Long-term care: assess on admission, weekly for four weeks,
then quarterly and whenever the residents condition changes
Home care: assess on admission and at every nurse visit.

Identify all individual risk factors (decreased mental status,

exposure to moisture, incontinence, device related pressure,
friction, shear, immobility, inactivity, nutritional deficits) to guide
specific preventive treatments. Modify care according to the
Risk Assessment Tools 27

It is not what you use its the way that you use it
Braden Risk Scale was developed in 1987 by Barbara Braden and
Nancy Bergstrom.
Tested for reliability and validity with results published in Nursing
Research in 1987.
A larger multi-site study was conducted to determine the reliability
and validity of the tool in a variety of settings. Results were
published in Nursing Research in 1998.
A follow-up report in Nursing Research in 2002 demonstrated that
the tool could be used in Black and White subjects with similar
validity.
The Braden Scale offers the best balance between sensitivity and
specificity and highest prediction capacity
Risk Assessment
28

Assess pressure ulcer risk on admission for ALL patients

within 2 hours (as soon as possible!)
Re-assess skin at least daily (depending on individual
risk) or when patients needs changes.
Initiate and maintain correct and suitable preventative
measures.
Need to Reduce Complexity
29

Gut Instinct- Is the patient at risk?

YES or NO?
Pre-Pressure Ulcer Risk Assessment (PPURA) - NHS Scotland

http://
www.healthcareimprovementscotland.org/programmes/patient_safety/tissue_
viability_resources/pura_pressure_ulcer_assessment.aspx
Engage Patients and Family
30

Involve patients and families in pressure ulcer

prevention at the earliest opportunities
Develop a contract of care
What can we do together to help prevent
pressure ulcers
Patient Information leaflets
Predictable Risk
31

Utilize patient At risk cards to quickly identify those at

increased risk

http://www.your-turn.org.uk/index.php/the-your-turn-campaign/what-is-it/

http://www.youtube.com/watch?v=rqpN7YKTlUw
Making the Connection
32

Risk assessment
Communicate
Preventative action
Measure impact
Communication
33

Verbal

Written

Visual
PDSA Changes
34

Patient risk cards

Patient and family contracts
Visual cues
Safety briefing/huddles
Movement /activity sessions
100 days free campaign.
Questions?
35

Raise your hand

Use the Chat

Guest Presentations
36
THE JOURNEY TO DECREASE HOSPITAL
ACQUIRED PRESSURE ULCERS

Bevette Griffin RN,CWON

OSF SAINT FRANCIS MEDICAL
CENTER, PEORIA, ILLINOIS
 OSF Saint Francis Medical Center
And
Childrens Hospital of Illinois
Peoria, IL
600+ Bed Level 1 Trauma Center

Bevette Griffin, RN, CWON

Graduated from Saint Francis School of
Nursing in Peoria, IL in 1973
Worked from 1973 to 1989 as Staff RN/
Charge RN at OSF Saint Francis Medical
Center
Working since 1989 as Ostomy/ Wound
Care Nurse at OSF Saint Francis Medical
Center
Certified Ostomy/ Wound Care Nurse
through Wound Ostomy Continence
Certification Board since 1999
 HISTORY
Decreasing HAPUs was one of the first 6-
Sigma projects adopted by OSF Saint
Francis Medical Center in 2002.
Pressure ulcer incidence was 9.4% when
the project started.
Initial goal was to decrease the incidence
of HAPUs by 50%.
3 root causes were identified:
accountability, knowledge deficit and
communication
 IMPROVEMENTS
Accountability: Ultimate ownership to the staff
RN, NCM as the process owner, chart audits with
action plans and collaborative turning effort
Knowledge Deficits: Revised the skin breakdown
prevention protocol, educated staff housewide,
SOS team established
Communication Deficits: SOS champion became
the skin expert on their units, SOS signs
posted outside the door, overhead music and
pages for turn reminders, pt and family
education booklets
 2002-present
Gradual decrease in HAPUs to below
2% quarterly since June
2011,reported to NDNQI.
Constant challenges: Making skin a
priority and creating a culture of
prevention
 PRESENT QUALITY IMPROVEMENT
PROCESS
All HAPUs are assessed by the WOCN
nurses for accuracy ( with the staging
and IF they are really from pressure)
All HAPUs are reviewed on the unit level ,
by the unit council and an action plan is
made. Then reviewed by the Evidence
Based Practice council and the question is
asked:
Was the HAPU avoidable or unavoidable?
 RECENT ADDITIONS

2 RNs will assess every pt upon admission

and transfer
Unit huddles list patients with low Braden
scores
Report sheets have Braden score on them
Trial on sacral dressings to decrease shear
EICU-another pair of eyes for assessment
Bedpan pages
Continue no-lift culture and promoting early
activity
 PRESENT CHALLENGES
Device related HAPUs ( NG tubes,
FMV, catheters)
Correct staging and documentation
of pressure ulcers on admission by
Physicians and nursing staff
Transitioning the use of the sacral
dressing to all the ICUs
Keeping the SOS initiative live and
well
 QUESTIONS?
Please feel free to contact me at :
Bevette.e.griffin@osfhealthcare.org
 46

Action Period Assignment

Undertake at least one small test of change (PDSA)
taking one or more of the ideas /changes you have
heard presented on to-days call
Test it in your area on a small scale
Identify what you learnt and how you will build upon this
learning
Identify a local strategy for promoting pressure ulcer
prevention awareness across the multi-disciplinary team
and with patients and families
Expedition Communications
47

Listserv for session communications:

PressureUlcersExpedition@ls.ihi.org
To add colleagues, email us at info@ihi.org
Pose questions, share resources, discuss barriers or
successes
Next Session
48

Annette Bartley, RN
Kathy Duncan, RN
Karen Cole: Claxton-Hepburn Medical
Center
Stephanie Calcasola: Baystate Medical
Center