actual hospital acquired pressure ulcers Empower the SMARTeam

VHA Georgia: 2009 Clinical Excellence
Reduction of
Hospital Acquired Pressure Ulcers
(Incidence)
Fran Perren, RN CWOCN

Motivation for Change
Incidence rate as of March 2008 – 15% percent
National Average - 7%
New CMS guidelines: no higher DRG
reimbursement for hospital acquired pressure
ulcers.
Areas responsible for the majority of admissions
were not performing skin assessments
SMARTeam already in place, ready for challenge

S kin
M anagement
A nd
R esource
Team

SMARTeam
Originally developed in 1995
Membership:
Nurse representatives from all Med/Surg and ICU units
from different shifts
Physical Therapist
Training:
Attend 8-hour Train the Trainer
Responsibilities:
Maintain Educational Board on each unit
Attend monthly educational meetings
Provide staff in-services on their unit
Teach at Biannual Workshops –Voluntary Attendance
Participate in Annual Prevalence and Incidence Study

Ultimate Goal: Zero Incidence
Include skin assessment/documentation in all areas
Determine if unacceptable rate was due to:
poor documentation, OR/AND
actual hospital acquired pressure ulcers
Empower the SMARTeam
to take ownership of unit staff education and practice
related to skin care
to routinely measure compliance with standards
Institute additional hospital wide education and
preventative measures.

Organizational Advantages
SMARTeam supported since 1995
Leadership culture supporting quality and
safety
– Board of Directors
– Sr. Leadership
– recognition of the importance of the bedside
care provider

Challenges
Most of our patients are admitted via the
Emergency Room or the Surgical Admitting
Center.
Engaging these staff nurses with skin
assessments was essential to reduce
incidence.

Emergency Department:
Engaged and Ready for Skin Care!
wound and ostomy supplies readily
available on unit
pillows and underpads made
available
unsatisfactory mattress pads
replaced
people awaiting inpatient bed
moved from stretcher to bed within
4 hours

ED: Documentation Simplified
Breakdown No/Yes, If yes:
Location_______________
Stage I (redness)
Stage II (broken)
Stage III (sq tissue)
Stage IV (tendon/bone)
Necrosis (black or yellow)
DTI (deep tissue injury)
(purple)

Surgical Admitting Center (SAC):
Skin Assessment Process Initiated
During preop visit
all patients screened using Braden Risk
Assessment
scores < 16 have notation which prompts a
skin assessment on day of surgery
On day of surgery:
patient with preop score of < 16, skin
assessment done
wounds are treated per protocol if not a part
of the surgical site
.

ED and SAC
Integrated on
SMARTeam
Completed education
of all staff

Engaging the SMARTeam to make a
greater impact 2008
Added representatives
Surgery
Emergency Department
Clinical Dietician
Increased workshops to quarterly with
mandatory attendance for patient care staff
Increased Prevalence and Incidence Studies to
quarterly

Engaging the SMARTeam to make a
greater impact 2008
Began performing monthly
audits
Conducted group analysis of
audits
Developed and implemented
corrective measures

Measuring Our Performance
Audit tool developed
Nurse/MD documentation
Tech/Assistant documentation
Physical assessment of patient
Environment of care
Focus on heel and sacral areas

Physician Documentation
CMS guidelines require physician
documentation of pressure ulcers
We needed better Present on Admission
(POA) documentation

The POA Sticker:
Improving Documentation!
Collaboratively developed by:
Quality Institute team
lead WOC nurse
Nursing implemented the process

Serious/Preventable Events Present on Admission
Date: _______________________
Time: _______________
Condition: Present On Admission:
Pressure Ulcer
Location__________________ stage__________________________
Urinary Catheter (Foley) present
Injury associated with a fall
infection
Vascular access present. (Attending physician, pleas evaluate for blood stream
Surgical procedure within the last 30 days. Specify type: _________________
Comments/description of condition POA:
_________________________________________________________________
_________________________________________________________________
Admitting Nurse (Name): ____________________________________________
Physician Notified of POA requiring immediate attention (Physician name):_____________________________
Physician Phone#: _________________________ Time: ____________________
Actions/New Orders: ______________________________________________
No Action Needed. Reason: _________________________________________
Physician Signature (I agree with the assessment findings above):
_______________________________________________________________

Audit Finding:
POA Sticker not
Completed by MD
Solution:
The nurses tag the progress
note to remind the doctor to
sign.
The SMARTeam places
information on their
educational board to focus
the emphasis on POA
identification.

Compliance with POA Documentation
100%
90%
80%
70%
60%
50%
40%
30%
July Aug Sept Oct Nov Jan Feb April
POA Nurse
POA Physician

Audit Finding:
Oral Intake Not Recorded
Solution:
developed Oral Intake Guide
laminated and placed in each patient room

Audit Finding:
Oral Intake Not Recorded
Solution:
engaged hospital volunteers to assist with
patient feeding

Oral Intake Recorded
95%
90%
85%
80%
75%
70%
July Aug Sept Oct Nov Jan Feb April

Audit Finding:
Foley Catheters Not Secured
Solution:
Foley securement device
implemented housewide
device added to all foley
insertion kits

Foley catheters secured
90%
80%
70%
60%
50%
40%
30%
20%
July Aug Sept Oct Nov Jan Feb April

Developed Checklist for Staff Laminated &
Placed on each unit.
Complete Skin Breakdown Form
Complete Oral Assessment Section
Initiate Prevention Protocol
Initiate Heel Protocol
Appropriate Wound Products in Room
Incontinent Products in Room
Proper Positioning with Pillows
No excessive Bed Protection
Document Ted Hose/Compression Device Removal
Document Turning on Activity Sheet
Document Adequate Nutrition on Activity Sheet
Foley Secure
Document Skin Risk Assessment on Activity Sheet

Hospital Wide Education and Prevention
Measures
Hospital Wide Protocols for 20
years
Workshops mandatory for
patient care staff
Enhanced workshops to focus on
prevention and documentation
Hospital mattresses replaced
2008
2008
November
2007
Staging Card created January 2008
“No Diaper in Bed” campaign February 2008

Workshop Stations
Risk Assessment Station
Prevention Protocol Initiation
Wound Staging and Assessment
Topical Therapy Protocol Implementation
Wound Documentation Check- Off
Incontinence
Ostomy
Positioning and Heel Prevention
Wound Vac
Specialty Beds

Wound Staging and
Assessment
K.I.S.S.
Staging Card Developed
Staff get intimidated and lost in verbal
descriptions
Standardized communication and
documentation

Other Practice Changes
Changed to a pH balanced non irritating
bath wash that provides moisture
Implemented absorbent incontinence pad
that wicks moisture away from the patient
(only 1 pad required)

Secrets to our Success
all patient care staff take ownership of
pressure ulcer prevention
frequent audits of skin care and feedback
to the staff
nurse-driven protocols
appropriate products
house-wide staff education

How have we done?
Hospital Acquired Pressure Ulcers
DeKalb Medical at North Decatur
25.0%
20.0%
15.0%
10.0%
22.0% 22.0%
19.0%
15.0% 15.0%
9.0%
5.0%
1.7% 0.74%
0.0%
March 2004
March 2005
March 2006
March 2007
March 2008
December 2008
March 2009
June 2009

Our Award-Winning SMARTeam!

Questions?
Contact information:
Fran Perren , RN CWOCN
fran.perren@dekalbmedical.org