Pressure Ulcer Prevention
Revisited
Linda J. Cowan, PhD, ARNP, FNP-BC, CWS
Research Health Scientist
North Florida / South Georgia Veterans Health System
Gainesville, FL
Clinical Associate Professor, University of Florida College of Nursing
Financial Disclosures
• Research Funding Received:
– VA Office of Nursing Services
– VA QUERI
– Biomonde
– HealthPoint/Smith & Nephew
– Celleration, Medline, Hollister
Clinical
Problem
• Pressure ulcer prevention (PUP) is used
as a quality of care indicator and is a top
priority for all health care facilities.
• Preventable pressure ulcers still occur
– PUs impact 1.6 million Americans each year,
collectively costing $3.6 billion annually in the
United States (US) (Baranowski, 2006).
Objectives
• Describe important evidence from PUP
research
• Identify at least 3 components of successful
PUP programs
• List essential members of PUP teams
• Describe methods of PUP education that
providers may be more inclined to complete
Key Questions to Answer
•
•
•
•
•
•
How is your facility doing?
Who should be involved?
Where do we start with PUP strategies?
Do providers want more PUP education?
How should this education be delivered?
Does recent research or the scientific literature
have anything to contribute to PUP efforts?
• What are some helpful tips to making a
successful PUP program?
PUP Efforts:
HOW IS YOUR FACILITY DOING?
Our Organization: Veterans Health
Administration (VHA)
•
•
•
•
America’s largest integrated health care system
Over 1,700 sites of care
Serves over 8.3 million Veterans each year
Aspirational goal for pressure ulcer reduction set by
VHA: “Getting to zero”
• Target preventing all avoidable pressure ulcers particularly most severe (stage III & stage IV)
• Office of Inspector General (OIG) completed 42 site
visits of VA facilities (July 2013 to April 2014) to
evaluate implementation of VHA Handbook 1180.02
“Prevention of Pressure Ulcers” revised July 1, 2011
OIG: Top 7 areas for VA improvement
1. Consistent documentation of PU location, stage, risk scale score, and date
acquired. (Facilities need the most improvement in this area)
2. Facility-defined requirements for patient & caregiver PU education (for those
at risk or w/PU); staff documentation of how/when this was provided
3. Required activities performed (and documented) for patients determined to
be at risk for pressure ulcers and for patients with pressure ulcers
4. Facility defined requirements for staff pressure ulcer education, and acute care
staff received training on how to administer the pressure ulcer risk scale, conduct
the complete skin assessment, & accurately document findings.
5. Skin inspections & risk scales performed: transfer, change in condition, & D/C
6. If the patient’s PU was not healed at discharge, a wound care follow-up plan
was documented, and patient was provided appropriate dressing supplies.
7. For patients at risk for and with PUs, interprofessional treatment plans were
developed, interventions were recommended, and Electronic Health Record
(EHR) documentation reflected that interventions were provided.
PUP Efforts in VA Facilities
• OIG: two areas needing most attention:
– Education (24 findings)
– Documentation (28 findings)
– These two areas accounted for 35% of all negative
site visit findings
VA Wound Provider Survey 2014
• National VA Survey:
– March 3rd to March 31st, 2014
– online, anonymous
– 1,726 VA wound providers
• ~24% response rate
• Purpose:
– gather current evidence about experiences,
education, preferences, and opinions of
wound care providers related to wound
management and PUP
Cowan, L & Garvan, C. (2014). Online Survey of VA Wound Providers.
Poster presentation at SERWOCN, August 27, 2014, Montgomery, AL.
Characteristics of Respondents and their facilities
Main role (n=303 respondents)
RN
Wound Consultant
ARNP
MD
PT
DPM
Other (OT, CWOCN, SW, PharmD, etc.)
Main clinical setting (n=302)
Inpatient acute care (not intensive care)
Inpatient acute care (intensive care)
Outpatient care
Rehabilitation care
Long term care
Spinal cord injury care
Other
N
%
98
77
49
31
16
13
19
32%
25%
16%
10%
5%
4%
6%
53
41
107
8
35
54
4
18%
14%
35%
3%
12%
18%
1%
Cowan, L & Garvan, C. (2014). Online Survey of VA Wound Providers.
Poster presentation at SERWOCN, August 27, 2014, Montgomery, AL.
Board certification (n=303)
N
%
Currently board certified (wound)
Was (wound) board certified in the past
Never (wound) board certified
157
8
138
52%
3%
46%
(SCI Providers: 12 BC / 0 BC in past / 38 never BC)
Nature of wound management training (n=303)
None
Only informal
Some formal
Years’ experience in wound care field (n = 271)
7
2%
98
32%
198
65%
Mean = 14.2
SD = 9.8
Cowan, L & Garvan, C. (2014). Online Survey of VA Wound Providers.
Poster presentation at SERWOCN, August 27, 2014, Montgomery, AL.
VA Wound Provider Survey 2014
Active inter-professional skin or PUP
task force at your facility? (n=303)
Yes
No
Not sure
SCI Setting
Yes
No
Not sure
N
%
229
31
28
80%
11%
8%
67%
2%
10%
Cowan, L & Garvan, C. (2014). Online Survey of VA Wound Providers.
Poster presentation at SERWOCN, August 27, 2014, Montgomery, AL.
PUP Efforts:
WHO SHOULD BE INVOLVED?
TEAM: Together Everyone Aims for More
Interprofessional Approaches to Pressure
Ulcer Prevention (PUP)
VeHU Presentation September 18, 2014
Charlene Demers, ARNP, CWOCN
Aimée D. Garcia, MD, CWS, FACCWS
Team
“ A number of people with
complementary skills who are committed
to a common purpose, performance
goals, and approach for which they are
mutually accountable.”
Katzenbach J & Smith D. 1993. The Wisdom of Teams: Creating the High-performance
Organization. Harvard Business School Press.
Teams for PUP
Pressure ulcer assessment, prevention, and
monitoring are an interprofessional (not solely
WOC nurse) responsibility that includes:
– Systematic application of risk assessment
– Implementation of preventive and therapeutic
measures
– Monitoring outcomes
– Education
– Documentation
Team members
•
•
•
•
•
•
•
•
•
Physicians- Surgeon and Medicine (PAs)
Nursing (NP, RN, LPN, CNA)
Physical Therapy (PT, PTA)
Occupational Therapy
Nutrition
Pharmacy
Prosthetics
Social worker(s) / Case Managers
Administration
Interprofessional Approach
• Physicians
–
–
–
–
Early surgical intervention to improve mobility
Ordering of pressure redistribution surface after surgery
Supervision of overall clinical care
Collaborate in prevention plan
• Nursing
– Nursing assumes the primary role by identifying those at
risk, initiating and coordinating the plan of care for
prevention
– Risk assessment and prevention strategies
• Implementation of standing order sets
– Turning and repositioning / Offloading
– Identifying and entering necessary consults
• PT/OT, dietician, social worker, etc.
• Rehabilitative and/or SCI staff
– recommend strategies to improve mobility and
use of protective & pressure redistributing devices
• Physical Therapy
– improve mobility, function and activity levels
– Evaluate safety of ambulation
– Ordering appropriate durable medical equipment
to improve patient’s functional status
• Occupational Therapy
– Seating evaluations
• Pharmacists
– assist with analysis of medication profile, product
availability, and parenteral nutrition formulation
• Social Workers
– assure prevention is priority across continuum of care
– evaluate and address special needs and discharge
planning
• Informatics
– facilitate documentation and accurate communication
among team
• Quality Management
– assists with monitoring incidence and evaluating
program outcomes
• Education Department
– assists with ongoing education for staff and patients
and/or the patient’s designated family members,
surrogates, or authorized decision makers
• Logistics and Prosthetics
– assist with availability of products and devices for
prevention
PUP Efforts:
WHERE DO HEALTH CARE FACILITIES
START WITH PUP STRATEGIES?
Start with ABCDE…
• ABCDEs of PUP Initiatives (Lyder & Ayello, 2009).
– Administrative support backed by support at patient
care level is vital
– Bundling care practices + having an identifiable theme
– Creating culture of change, commitment, and
communication
– Documentation of pressure ulcer prevention practices
must be visible
– Education is essential (I would also add: all initiatived
should be Evidence-based)
Administrative Support
• Top – Down approach (National, Regional, Facility)
– Create positive culture, support staff, provide accurate &
consistent policies and tools (outcome tracking & reporting)
• Ways to approach Administration
– Focus on Improving Quality and Cost Savings
• Demonstrate how efforts (investment of people, resources, time) will
improve delivery of safe & effective patient care & patient outcomes
• Numbers talk: Know your potential ROI (Return on Investment)
– Conference, Workgroup, Lean Project, Systems Redesign
• PU prevention and management must be identified as priority with
resources allocated to develop & sustain effective program
• Support for interprofessional approaches
• Support for certified wound specialists & their continuing education
(CWOCN, CWCN, CWS, WCC, etc.)
• Support for equipment & devices such as OR table pads, specialty
beds, mattresses & seat cushions, heel floatation devices, etc.
Bundling Practices
• Agency for Healthcare Research and Quality (AHRQ)
evidence-based best practices (EBBP) for pressure
ulcer prevention in “Toolkit for Improving Quality of
Care” (2011)
– “Bundle” concept was developed by Institute for
Healthcare Improvement (IHI)
– Concept of skin care “bundle”
• Groups together specific care practices to achieve desired outcome
– Three critical components (evidence-based):
• Standardize pressure ulcer risk assessment
• Comprehensive skin assessment
• Care planning and implementation to address areas of risk
SKIN Bundles
• VA Skin Bundle (VASKIN): a concerted effort to
disseminate EBBP into clinical setting(s)
• VA SKIN bundle exceeds three critical
components
– by incorporating specific (evidence-based)
interventions based on recommendations published
by National Pressure Ulcer Advisory Panel and Wound
Ostomy, Continence Nurses Society
• VA SKIN bundle is evidence-based framework
– but will allow for innovation for special population(s)
Great Example: VISN16 Success
• “VA Skin Bundle” concept approved by 21 subject
matter experts from VISN 16 Skin Integrity Workgroup
– At VISN 16 Skin Integrity Summit II held September, 2012
in Ridgeland, MS
– Additional edits/revisions provided by members of VHA
National “HAPU” Prevention Initiative supported by Office
of Nursing Services (ONS)
• Skin Bundle example in next slide presented nationally
on Virtual Learning University (VeHU) in 2013
– Special recognition goes to Suzy Scott-Williams, RN, MSN,
CWOCN & Mona Baharestani, PhD, APN, CWON, FACCWS
• Over 300 clinicians attended virtually
V
A
Veteran’s Skin Bundle
S
K
I
N
Select Surfaces and Devices to Redistribute/Relieve
Pressure
Assess Skin and Risk Status
Risk Assessment on Admission (Braden, SCI, Surgery, medical device)
Inspect skin (head to toe) during care activities (e.g. turning, bathing)
Keep Turning and Repositioning
Incontinence Management
Nutrition and Hydration Assessment and Intervention
Suzy Scott-Williams, RN, MSN, CWOCN, 2013
Using Quality Improvement
• Process Improvement / Quality Improvement
and Continuous Quality Improvement
methods to implement Bundles:
– Plan – Do – Check - Act
– Lean
– Six Sigma
– Systems Redesign
– VA TAMMCS
VA-TAMMCS
Framework
VISN16
Workgroup
Reduce HAPU stage III & IV by
30% from FY12 to FY13
Interprofessional Team, Nurse
Managers, Staff Nurses
Nursing Process
VANOD data, Internal assessment
Mini RCA on each incidence
Action Plan, Education,
compliance, equipment,
devices resources
Communication plan, feedback,
Executive leader involvement
Comparison of other Skin Bundles
• VHA: VA SKIN
– VA: Assess risk & skin, Select surfaces/devices, Keep
turning/repositioning, Incontinence management,
Nutrition & hydration (assess & address)
• AHRQ: AHRQ Pressure Ulcer Bundle
– Comprehensive skin assessment, standardized risk
assessment, evidence-based care planning &
implementation to address areas of risk, defining staff
roles, educate staff, clinical pathway
• SIGN & Ascension Health: SSKIN
– Skin inspection, Surface selection, Keep turning/keep
moving, Nutrition
• Common to all: Documentation, Education, Evidence
Authors:
Roger Resar, MD: Senior Fellow, IHI;
Assistant Professor of Medicine, Mayo
Clinic School of Medicine
Frances A. Griffin, RRT, MPA: Faculty, IHI
Carol Haraden, PhD: Vice President, IHI
Thomas W. Nolan, PhD: Senior Fellow, IHI
Berlowitz et al.(2011) AHRQ
Acute Care Skin Bundle
Build
Your
Own
“Bundle”
Risk Assessment
Skin Inspection
Keep Moving / Repositioning
Prevent Shearing Forces
Float / Elevate Heels
Incontinent Care: Moisture Management
Pressure Redistribution: Support Surfaces
Patient / Caregiver / Staff Education
Perioperative Skin Bundle (Scott-Williams, 2012)
Skin Assessment : Pre-op, post-op, recovery, transfer (educate professionals)
Scott-Triggers: Tool developed by Suzy Scott-Williams to identify surgical
patients needing specific interventions to prevent perioperative PU (>2 = risk)
Braden Scale: Common risk assessment tools may not be valid in O.R. setting
(score <20 = risk)
Transfer Devices: Appropriate transfer devices protects staff from injury and
reduces risk of friction and shear injury to patient
Table Pads: Pressure reducing/redistributing pads for O.R. tables
(recommended for any surgical procedure over __ hours)
Positioning Equipment: Stirrups, arm boards, heel devices, ulnar padding
(based on evidence); heels should always be off-loaded in supine position.
Padding: Use padding and padding practices that are evidence-based
Hand-off Communication: Use effective and consistent communication
tools/practices
SCI Specific Skin Bundle
• Kathleen Dunn and Susan Thomason 9-6-2013
– Risk – Assessment – Interventions – Annual Evaluation – Patient Education
• Pressure Ulcer Risk Factors (Significant in evidence-based literature)
–
–
–
–
–
•
Complete SCI
History of at least 1 previous ulcer
Pressure Ulcer (PU) Recurrence
Number of years since injury
Injury duration >30 years…
Per VHA Handbook 1180.02 (2011) “Prevention of Pressure Ulcers”
– Document risk upon admission, discharge, transfer, or change in condition
using Braden, or a pressure ulcer risk scale that has been validated in people
with SCI …
• Per VHA Handbook 1176.01 (2011) “Spinal Cord Injury/Disorders (SCI/D)
System of Care”
– All Veterans with impaired sensation or mobility must have an annual
comprehensive assessment of risk factors, a review of prevention strategies,
a thorough inspection of skin/body wall, and recommendations for pressure
ulcer prevention shared with the Veteran (i.e., a pressure ulcer prevention
plan)…
Bundling care practices is only one part:
Don’t Forget the whole ABCDE Approach
• Administrative support backed by support at the
patient care level is vital
• Bundling care practices
– have an identifiable “theme”
• Creating a culture of change, commitment, and
communication
• Documentation of pressure ulcer prevention
practices must be visible
• Education is essential
Creating a Culture…
• Change
– Never easy but necessary for improvement
– Embrace the concept of a JUST culture
• Avoiding blaming people for failure
• Critically examine processes which result in failure
• Commitment
– Patient Safety First
• Communication
– Most process failures result from lack of
communication
– Documentation
Documentation of PUP Practices
• Must be visible – readily available and easily
found (patient’s medical records & unit tracking)
• Must be accurate – date, time, patient
assessment, skin & wound assessment, patient
needs (including education), plan to meet these
needs, exactly what was done, and follow up
• Must be consistent
• “Tending of data on HAPU rates, severity, and
documentation compliance must be integrated
into the culture of the unit” (Susie Scott-Williams,
2012)
Education is Essential
• Administration
• Clinical staff
• All settings
– inpatient, outpatient, ICU, LTC, Rehab, home, etc.
• Ancillary staff
– housekeeping, engineering, volunteers, etc.
• Patient
• Caregivers / family members
• Community
All Initiatives should be
Evidence-Based
Sources of Evidence:
• External Evidence
– Robust research
– Strength of evidence
• Quality – Quantity – Validity - Reliability
• Internal Evidence
– PI/QI methods
– Applicable to your situation?
Having Evidence Based Protocols
Taken from AAWC presentation “Developing a Comprehensive Content Validated
Pressure Ulcer Guideline” (2012) on www.aawconline.org - Susan Girolami &
Laura Bolton (Co-Chairs).
PUP
Guidelines
AAWC Wound Care Specialty Council
• Significant Findings of Mean Content Validity for PU
Prevention Guidelines (Sandwich)
–
–
–
–
Documentation
Interdisciplinary Approach
Risk Assessment
Nutritional Assessment
• Hydration & Nutrition plan of care
–
–
–
–
–
–
–
Medical/surgical history
Psychosocial/quality of life
Environmental factors (fall risk)
Rehabilitation & restorative programs
Position to manage pressure, shear, friction
Off-loading beds, chairs, OR equipment
Physical Exam
• Skin inspection & Maintenance
– Education
PUP Efforts:
DO PROVIDERS WANT MORE PUP
EDUCATION? IF SO, HOW SHOULD THIS
EDUCATION BE DELIVERED?
2014 VA Wound Provider’s Survey
Wound education
adequate? (n=289)
Yes
No
I don't know
11%
33
PUP education
adequate? (n=286)
Yes
No
I don't know
13%
29%
36
83
38%
110
60%
49%
173
140
Almost 50% said NO
Which types of wound are you most
confident caring for?
VERY confident
caring for this
wound type
% respondents
81%
See this
wound type
weekly
% respondents
66%
Pressure ulcers
Moisture related dermatitis and
incontinence associated dermatitis
72%
65%
73%
53%
Acute wounds
Chronic wounds
Surgical wounds
Venous leg ulcers
Traumatic wounds
Diabetic foot ulcers
Arterial ulcers/Peripheral Arterial Disease
(PAD)
62%
61%
60%
52%
44%
41%
38%
55%
79%
51%
55%
21%
51%
43%
Minor injuries (abrasions, skin tears)
Top 10 Topics of Interest for Clinical Education
1
2
3
VA Wound Provider’s Survey
Current research findings regarding chronic wounds and wound care
Identifying and treating unusual wounds
7
New products available for dressings and topical treatments
Biological wound therapies (e.g., stem cell, personalized wound
treatments, skin substitutes, wound matrices)
Infection and reducing bioburden/biofilm
Overview of advanced wound therapies (negative pressure, hyperbaric
oxygen therapy, electrical stimulation, ultrasound, etc.)
How to achieve a multi-disciplinary approach to wound management
8
Legal issues with chronic, non-healing wounds or pressure ulcers
4
5
6
9
Pressure ulcer prevention, treatment or management
Vascular issues: Treatment (surgical and non-surgical interventions for
10
venous and/or arterial insufficiency)
Cowan, L & Garvan, C. (2014). Online Survey of VA Wound Providers. Poster
presentation at SERWOCN, August 27, 2014, Montgomery, AL.
Educational Preferences: Setting
• Preference of when and where you would like
to receive wound management training, CEUs,
CMEs, updates or in-services (n=299):
– Anything I can do during work hours - having
“protected time” to complete it = 86% (n=257)
– Anything I can do at home or on my own time =
14% (n=42)
Preferred method for receiving training,
updates, CEUs, CME, or in-services (n=303)
# of
respondents
Face-to-face trainings or workshops
Attending professional conferences
Simulation learning in-person
Interactive computer modules with case
scenarios
Self-study online
Self-study written materials
Online gaming modules where you can play
a game while you are learning
245
225
152
133
73
65
51
PUP Efforts:
WHAT DOES RECENT RESEARCH
EVIDENCE (SCIENTIFIC LITERATURE)
CONTRIBUTE TO PUP EFFORTS?
Clinical Pearls about Evaluating
Research Evidence
• Know where to look in articles
– Abstract: Research question same as yours?
– Methods: Appropriate type of study? Large enough
sample? Sampling techniques? Robust methods?
Valid tools and outcome measures?
– Results: Believable and can be applied to your
situation?
Looking for Evidence
• Evidence Syntheses versus Evidence Summaries
• Meta-Analyses and Systematic Reviews
• Decision Support Tools online
– Best Practices versus Evidence-Based Guidelines
• Evidence-Based Guidelines
• Primary Studies
• Evidence-based text-books, professional
organizations, expert opinion
• PI/QI
Evidence Tables:
• Association for Advancement of Wound Care
Guideline Department
– Pressure Ulcer Care Initiative
– References Updated August 16, 2011.
– PU Evidence Table 8.1 derived from 13 PU
Guidelines (56 pages): http://aawconline.org/wpcontent/uploads/2011/03/AAWCPressureUlcerGui
delineEvidenceTableAug11.pdf
– AAWC PU Guidelines:
• http://www.ncbi.nlm.nih.gov/pubmed/23985608
Example from Evidence Table
PUP Research Evidence
Fogerty et al. 2008
• Used 2003 National Inpatient Sample (NIS) dataset of 7,977,728
inpatient discharges.
– Included 37 states (representing 90.3% of US population)
– 944 hospitals
• Total sample with PU was 94,758; without PU was 6,610,787
• Identified top 45 risk factors in acute care which included 25 medical
diagnoses
– at top of list: Age >75, race, paralysis, infection/sepsis, and nutritional
deficiency (see next slide for top 11 diagnoses)
– majority of risk factors identified were not accounted for by Braden
Scale
Fogerty M, Abumrad N, Nanney L, Arbogast P, Poulose B, Barbul A. (2008). Risk factors for
pressure ulcers in acute care hospitals. Wound Repair and Regeneration, 16: 11-18.
Fogerty et al. Risk factors
1. Age > 75 years
OR 12.63*
*(as AA age, risk goes higher than Cauc as they age)
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Gangrene diagnosis
OR 10.94 (95% CI 10.43, 11.48)
Paralysis
OR 10.3 (95%CI 9.69, 10.69)
Septicemia
OR 9.78 (95%CI 9.33, 10.26)
Osteomyelitis
OR 9.38 (95% CI 8.81, 9.99)
Malnutrition
OR 9.18 (95% CI 8.81, 9.99)
Pneumonitis/Pneumonia OR 8.7 (95% CI 8.33, 9.09)
UTI
OR 7.17 (95% CI 6.96, 7.38)
Bacterial infection
OR 5.71 (95% CI 5.49, 5.93)
Senility
OR 4.84 (95% CI 4.62, 5.07)
Mycoses
OR 4.47 (95% CI 4.41, 4.86)
PUP Research Evidence
• Cowan et al. 2012 – Veteran Sample
– Sample of 213 Veterans. Compared Braden Risk Score to other Medical
factors; found 2 Braden sub-scores more predictive of PU than total scores; 4
medical factors (pneumonia, surgery, candidiasis, malnutrition) more
predictive than Braden total scores
• Niederhauser et al. 2012 – Systematic Review of 12 studies
– Comprehensive PUP programs can be effective but sites need to rigorously
evaluate their programs and publish their results
• Sullivan & Schoelles 2013 – Systematic Review of 26 implementation
studies
– Key components, “simplification & standardization of PUP interventions &
documentation; interdisciplinary teams, leadership, designated skin
champions, ongoing staff education, sustained audit & feedback”
• Soban et al. 2011 – Systematic Review of nurse-focused QI interventions
– SR of 39 studies: Interventions combined with educational and/or QI
strategies are effective at reducing PU incidence: assembling a team,
performance monitoring and FEEDBACK are very important
• Falise et al. 2014 PHHP Honor’s Thesis (in press)
– Looked at nutrition; ADL impairment; relationship between BMI and PU using
MDS 3.0 dataset: ADL impairment more predictive than BMI, but very low
BMI (undernourished) strongly associated with PU
Pieper & Kirsner 2013
Pieper, B. & Kirsner, R. (2013). Pressure Ulcers: Even the Grading of
Facilities Fails. Ann Internal Med. 159(8): 571-572.
• Estimate 7.5 million persons annually w/PU (worldwide)
• Problems with PU data and research evidence:
– Coders interpretations of documentation in medical record
– Terminology about PU is confusing: PU, pressure sore,
decubiti, decubitus, decub, bedsore, etc.
– Correct identification of PU pics by expert clinicians was
only 57%, with lowest scores for identification of stages III
and IV, suspected deep-tissue injury, and unstageable ulcers
– Levine and colleagues report mean total PU knowledge
score of 69% for physicians, PU knowledge score of nurses
was 79%.
– Lowest scores were in knowledge of risk factors.
Risk Assessment
Pancorbo-Hidalgo, P (2006). Risk assessment scales for pressure ulcer
prevention: a systematic review (Meta Analysis), Journal of Advanced
Nursing 54(1), 94–110. (Cited by 278 journals)
– 14 databases, 1966-2003, 49179 33 studies met criteria
Table 5 Accumulated analysis of indicators of validity
*Weighted average.
Scale
n
studies
Sensitivity Specificity PPV(%)*
(%)*
(%)*
NPV(%)* Efficacy
(%)*
20
N
total
Patients
6443
Braden (1987)
US
Norton
(1962) UK
Waterlow
(1985) UK
Clinical
Judgment
57.1
67.5
22.9
91.0
66.7
5
2008
46.8
61.8
18.4
87.0
60.2
6
2246
82.4
27.4
16.0
89.0
34.4
3
302
50.6
60.1
32.9
75.9
58.0
Pancorbo-Hidalgo Conclusions
• Lack of evidence that use of risk assessment scales
decreases pressure ulcer incidence
• Braden Scale has best validity and reliability indicators, and
has been used in a large number of studies in a wide
variety of settings (though application across settings
should be validated)
• Braden and Norton Scales predict pressure ulcer
development risk better than nurses’ clinical judgement
• Waterlow Scale has good sensitivity but low specificity
Take home message:
Something is better than nothing
Other Difficulties with PUP Documentation
and Research Evidence
• Cowan et al. 2012 – Veteran Sample
– Key diagnoses not added to diagnosis list or active problem list;
inconsistent Braden scores from one day to next (and sometimes one
nurse to the next during same 24 hours); key risk factors and PUP
interventions not documented; inaccurate Braden scores and PU
identification (staging)
• Niederhauser et al. 2012 – Systematic Review
– Only 15% older adults at risk for PU had supportive device doc by day 3
– Study of 2,425 MCR pts in acute care: only 23% of immobile patients
were documented “at risk” of PU
– Medical record review of 834 VA LTC pts: overall adherence to 6 critical
best PUP practices (such as standardized risk assessment and regular
repositioning) was 50%
• Kent, Cowan & Garvan 2014 (unpublished) – Veteran sample
– Poor agreement between RD assessment of nutritional risk and RN
documentation of nutritional risk (Braden Scale nutrition sub-score); RD
nutritional assessment of severe nutritional compromise strongly
associated with PU (low nutritional sub-score of Braden was not)
Discerning PUP “Best Practices”
• Evidence should be readily available for
documented “best practices”
• Best Practices for Prevention of Medical
Device-Related Pressure Ulcers (NPUAP
poster):
– http://www.npuap.org/resources/educationaland-clinical-resources/best-practices-forprevention-of-medical-device-related-pressureulcers/ (evidence cited on poster?)
PUP Efforts:
SUMMARY: HELPFUL TIPS TO MAKING
A SUCCESSFUL PUP PROGRAM
Implementing Successful PUP Initiative
AHRQ Toolkit says to address six questions:
1. Are we ready for this change?
2. How will we manage change?
3. What are the best practices in pressure ulcer
prevention that we want to use?
4. How should those practices be organized in our
hospital?
5. How do we measure our pressure ulcer rates and
practices?
6. How do we sustain the redesigned prevention
practices?
Remember ABCDE
• Administrative support
• Bundling care practices
• Creating culture of change, commitment, and
communication
• Documentation
• Education and Evidence-Based
References
• Baranoski S. (2006). Raising awareness of pressure ulcer prevention and
treatment. Adv Skin & Wound Care. 19, 398-407.
• Lyder CH, Ayello EA (2009). Annual checkup: the CMS pressure ulcer
present-on-admission indicator. Adv Skin & Wound Care. 22 (10), 476-84.
• Office of Inspector General (OIG) CAP Report evaluating implementation
of VHA Handbook 1180.02 “Prevention of Pressure Ulcers” in VHA
facilities
• Cowan, L & Garvan, C. (2014). Online Survey of VA Wound Providers.
Poster presentation at SERWOCN, August 27, 2014, Montgomery, AL.
• Garcia, A & Demers, C (VeHU Presentation September 18, 2014). TEAM:
Together Everyone Aims for More: Interprofessional Approaches to
Pressure Ulcer Prevention (PUP)
• Agency for Healthcare Research and Quality (AHRQ) evidence-based best
practices (EBBP) for pressure ulcer prevention in “Toolkit for Improving
Quality of Care” (2011)
• Katzenbach J & Smith D. 1993. The Wisdom of Teams: Creating the Highperformance Organization. Harvard Business School Press.
• Fogerty, M., Abumrad, N., Nanney, L., Arbogast, P., Poulose, B., &
Barbul, A. (2008). Risk factors for pressure ulcers in acute care
hospitals. Wound Repair and Regeneration, 16, 11-18.
• Cowan, L., Stechmiller, J., Rowe, M., & Kairalla, J. (2012). Enhancing
Braden pressure ulcer risk assessment in acutely ill adult Veterans.
Wound Repair and Regeneration, 20, 137-148.
• Soban, L., Hempel, S., Munjas, B., Miles, J. & Rubenstein, L. (2011).
Preventing pressure ulcers in hospitals: A systematic review of
nurse-focused quality improvement interventions. Joint
Commission Journal on Quality and Patient Safety, 37 (6), 245-265.
• Berlowitz et al. (2011). Preventing Pressure Ulcers in Hospitals: A
Toolkit for Improving Quality of Care. Retrieved from AHRQ website
at: http://www.ahrq.gov/pressureulcertoolkit
• Sullivan, N. & Schoelles, K. (2013). Preventing in-facility pressure
ulcers as a patient safety strategy. Annals of Internal Medicine,
158(5), 410—W186.
• Cowan, L. & Garvan, C. (2014). Online Survey of VA Wound
Providers. Poster Presentation at NF/SG VHS Research Day, May 16,
2014.
• Niederhauser et al. 2012 – Systematic Review
of 12 studies
• Sullivan & Schoelles 2013
• Falise et al. 2014 PHHP Honor’s Thesis (in
press)