Tuesday, May 6, 2014 These presenters have nothing

Tuesday, May 6, 2014 These presenters have nothing

Tuesday, May 6, 2014 These presenters have nothing to disclose IHI Expedition Preventing Pressure Ulcers Kathy Duncan, RN Annette Bartley, RN Todays Host 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. 2 Audio Broadcast You will see a box in the top left hand

corner labeled Audio broadcast. If you are able to listen to the program using the speakers on your computer, you have connected successfully. 3 Phone Connection (Preferred)

To join by phone: 1) Click the button on the right hand side of the screen. 2) A pop-up box will appear with call in information. 3) Please dial the phone number, the event number and your attendee ID to connect correctly .

4 Audio Broadcast vs. Phone Connection If you are using the audio broadcast (through your computer) you will not be able to speak during the WebEx to ask question. All questions will need to come through the chat. If you are using the phone connection (through your telephone) you will be able to raise your hand, be unmuted, and ask questions during the session. Phone connection is preferred if you have access to a phone.

5 WebEx Quick Reference Welcome to todays Raise your hand session! Please use chat to All

Participants for questions For technology issues only, please chat to Host WebEx Technical Support: 866-569-3239 Dial-in Info: Communicate / Join Teleconference (in Select Chat recipient menu) Enter Text 6 When Chatting

Please send your message to All Participants 7 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.

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. 9 Expedition Objectives 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 10 Schedule of Calls 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 11

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

What will success look like? Risk Identification Risk Assessment Partnership with patient Communication of Risk status 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: 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 20

Patient Stories 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 21

Risk Factors Limited Mobility Impaired Mental Status Exposure to moisture Urinary incontinence Bowel incontinence Wound exudate Excessive Perspiration +++ Poor Nutritional Status Obesity Recent weight loss

Feeding assistance needed Skin condition Pressure ulcer history Risk of Pressure Ulcer by Number of Risk Factors 25 % with PU 20 15

10 5 0 0 1 2 3 4

5 Number of risk factors present Mor, V et al Canadian J of Quality of Care 6 7 8 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) Patient Population Specialty

Surgery, Gastrointestinal, ICU, Pediatric) Age Pain Urinary Catheters Nasogastric Tubes Oxygen cannula Oxygen masks Resources Staffing Equipment

25 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 individual factors. Document risk assessment subscale scores and total scores and implement a riskbased prevention plan. https://www.npuap.org/resources/educational-and-clinical-resources/pressure-ulcer-prevention-points/ Risk Assessment Tools

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

27 Risk Assessment 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. 28

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 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 30 Predictable Risk 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 31 Making the Connection Risk assessment Communicate Preventative action Measure impact 32 Communication

Verbal Written Visual 33 PDSA Changes Patient risk cards Patient and family contracts Visual cues Safety briefing/huddles Movement /activity sessions 100 days free campaign.

34 Questions? Raise your hand Use the Chat 35 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 : [email protected]

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 46

Expedition Communications Listserv for session communications: [email protected] To add colleagues, email us at [email protected] Pose questions, share resources, discuss barriers or successes 47 Next Session Annette Bartley, RN

Kathy Duncan, RN Karen Cole: Claxton-Hepburn Medical Center Stephanie Calcasola: Baystate Medical Center 48

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