Intermountain-led
CMS Hospital Engagement Network
Pressure Ulcer Prevention
September 23, 2014
Affinity Call
Marlyn Conti , BSN, MM, CPHQ
Patient Safety Initiatives Manager
Intermountain Healthcare
Outline for Discussion
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Review of the HEN Pressure Ulcer work
Q1 2014 Data review
“Just-one-thing” Recommendations
2012 Participant survey
2014 Participant survey
Next steps
Overall Progress Through Q1 2014
Intermountain HEN 2012-Q1 2014
Pressure Ulcer PSI 3
Patients with Stage III, Stage IV or unstageable pressure ulcers
Intermountain HEN 2012-Q1 2014
Pressure Ulcer PSI 3
Patients with Stage III, Stage IV or un-stageable pressure ulcers
Intermountain HEN 2012-Q1 2014
Pressure Ulcer >= Stage 3
Stage 3 or greater from the prevalence survey
Intermountain HEN 2012-Q1 2014
Pressure Ulcer >= Stage 3
Stage 3 or greater from the prevalence survey
Decline in denominator in Q1 2014 is due to anomalous data
Intermountain HEN 2012-Q1 2014
Pressure Ulcer >= Stage 2
=> Stage 2 added in 2014
Intermountain HEN 2012-Q1 2014
Pressure Ulcer >= Stage 2
=> Stage 2 added in 2014
Intermountain HEN 2012-Q1 2014
Pressure Ulcer Prevalence
All stages from the prevalence survey
Intermountain HEN 2012-Q1 2014
Pressure Ulcer Prevalence
All stages from the prevalence survey
Decline in denominator in Q1 2014 is due to anomalous data
High Performing Hospital Highlight…
Pressure Ulcers Prevalence
Most Improvement
Lowest Rates
BAYLOR HEART AND VASCULAR HOSPITAL
THE HEART HOSPITAL BAYLOR PLANO
BAYLOR MEDICAL CENTER AT WAXAHACHIE
BAYLOR MEDICAL CENTER AT WAXAHACHIE
THE HEART HOSPITAL BAYLOR PLANO
ST PATRICK HOSPITAL
DENVER HEALTH MEDICAL CENTER
UPPER CONNECTICUT VALLEY HOSPITAL
CASSIA REGIONAL MEDICAL CENTER
SCOTT & WHITE HOSPITAL-ROUND ROCK
DELTA COMMUNITY MEDICAL CENTER
BAYLOR HEART AND VASCULAR HOSPITAL
SANPETE VALLEY HOSPITAL - CAH
SCOTT & WHITE CONTINUING CARE HOSPITAL
BAYLOR MEDICAL CENTER AT IRVING
THE ORTHOPEDIC SPECIALTY HOSPITAL
LDS HOSPITAL
HEBER VALLEY MEDICAL CENTER
BAYLOR REGIONAL MEDICAL CENTER AT PLANO
DELTA COMMUNITY MEDICAL CENTER
Just One Thing Matrix
Recommendations
Getting Started
Working Harder
Ahead of the Curve
Appoint a leadership
supported team or work
groupto drive
improvement &
education SWAT (or
champion) teams that
includes unit nurse.
(moderate-high level of
evidence)
Adopt decision
algorithms for nursing
staff to select
appropriate surfaces ,
physical therapy and
dietary referrals
(moderate-high level of
evidence)
Establish monthly
prevalence studies or
collect incidence data
from electronic medical
records, then feed that
data back to the SWAT
teams.
(moderate-high level of
evidence)
Intermountain
SKIN Bundle
Participant Survey 2012
38% sites at Improvement stage, 26% challenges, 24% sustaining
Participant Survey 2012
IH HEN HAC Ranking
9.00
7.87
8.00
7.00
6.26
6.00
5.00
4.58
4.88
4.87
5.13
4.73
4.00
3.27
3.27
Falls
Readmit
3.00
2.00
1.00
0.00
SSI
VTE
ADE
CAUTI
CLABSI
VAP
PU
Pressure Ulcers ranked at 3rd at 5.13 for priority by the participating hospital
2014 Pressure Ulcer
Survey Report
Carlos Barbagelata
Intermountain Institute for
Healthcare Delivery Research
9/23/14
1. Do you have a team assigned to work on
Pressure Ulcer prevention?
Answer
Response
%
Yes
15
79%
No
4
21%
Total
19
100%
1a. Is your pressure ulcer prevention team
multidisciplinary? (if yes, which disciplines are
included)
Answer
Response
%
Yes
Yes
7
50%
Bedside RN, Dietician, Infection Control
No
7
50%
RN Manager
Total
14
100%
Nursing, Physical Therapy, dietary
Wound Care/Ostomy
RN, RRT, PT
WOC/RRT/HCI/PT/Transport/Nutrition
Administration, Nursing, RT, WOC
1b. How frequently does your Ulcer Prevention
team meet? (Check all that apply)
Answer
Response
%
Other (e.g. for RCA, as-needed,
etc.)
8
57%
Once a Month
7
50%
2–3 Times a Month
0
0%
Once a Week
0
0%
Other (e.g. for RCA, as-needed, etc.)
Quarterly meetings prior to quarterly prevalence studies
RCA done, as well as monthly meetings
As-Needed
1c. Does your pressure ulcer prevention team
have resources to collect/interpret/review data?
(If yes, please explain below)
Answer
Response
%
Yes
13
93%
No
1
7%
Total
14
100%
Yes
Online education using NDNQI tool, survey review, quarterly data collection, analysis by
quality lead and team
P&I, floor staff are assigned to be on the committee and help with survey results.
Pressure Ulcer Tracking Sheet, Weekly skin assessments
Wound Care/Ostomy
Provided with corporate data. Collect and evaluate internal data
Prevalence Study
WOC, RN Mgr/Supv, HCI
incident reports and NDNQI
2. Do you provide hospital-acquired pressure ulcer
reports foruse by hospital staff and teams? (If yes,
please describe how reports are distributed or made
available)
Answer
Response
%
Yes
15
83%
No
3
17%
Total
18
100%
Yes
Available on system report center, can be accessed by unit
staff, taken to governing board, patient safety council and
medical staff quality councils
Intermountain generated, Reports portal
We have used P&I results each quarter and send to the
managers of each floor and reported in hospital quality
reports.
Standard Corp Reports
Discussed with staff in staff meetings
WOC to RN Mgr to Unit Staff
They are placed on our swat team space and sent to
managers, and reviewed in our PCC meeting
Reports are available upon request or via email
HAPU team to RN Mgr to Unit Staff
RCA and unit-based outcome graphs
2a. Do your reports include prevalence, incidence,
or both?
Answer
Response
%
Both
11
73%
Prevalence
3
20%
Incidence
1
7%
Total
15
100%
2b. How are reports updated or made available?
Answer
Response
%
Other (please specify)
Other (please specify)
11
73%
Unit boards updated weekly
Once a Month
5
33%
Quarterly surveys
2-3 Times a Month
0
0%
Quarterly e-mailed report
Once a Week
0
0%
As-needed
Quarterly after P&I survey
2c. Could you share an example of how the
reports are used by hospital staff/teams?
Text Response
Used for Quality Assurance and Performance Improvement. Nursing Manager shares with unit staff
Track and trend unit performance. Recommend more follow up with Wound Care specialists if units
seeing an increase in ulcers
Continuing education to discuss what preventions may have been done sooner (HAPU identified
earlier).
Discuss at staff/unit meetings
Reviewed by the hospital managers and quality team for process improvement. It could be improved
to be reported more frequently. We also use the hospital event reporting system for all 3 & 4
pressure ulcers and DTI. The manager will have to comment on the patient immediately.
When a pressure ulcer is found the team discusses the best approach to care for the p.u.. Also each
staff member is to be on alert for possible breakdown and take action before a pressure ulcer starts.
All pateints have some form of pressure ulcer prevention.
It shows what hospital acquired ulcers were found, which units and what the ulcer was. The
managers are then able to review the documentation and find ways to prevent it in the future. It is
also used as quality improvement throughout our hospital.
Incident reports are completed on all pressure ulcers (hospital-acquired and present on admission).
Hospital acquired ulcers are sent to each unit's manager for review and a RCA is completed. A
meeting is held to discuss significant occurences, the RCA is reviewed by the multidisciplinary team,
and a remedial plan is determined to prevent reoccurence.
3. What tools do you use to educate staff about
assessment and properly staging pressure ulcers?
(check all that apply)
Answer
Response
%
Posters
10
59%
Fact Sheets
13
76%
Assigned Computer-Based Training
13
76%
EMR Reminders
9
53%
Care Process Models
7
41%
Other
2
12%
Other
Braden scale in EHR for PrU documentation
Swat meeting education, swat members take education back to floor nurses
4. Do you have skin and/or pressure ulcer
assessment prompts embedded in your Electronic
Medical Record (EMR)?
Answer
Response
%
Yes
16
94%
No
1
6%
Total
17
100%
4a. How often are the staff prompted to repeat
the assessment?
Answer
Response
%
Every 12 hours
11
69%
Every 24 hours
3
19%
Other
2
13%
Every 8 hours
0
0%
Total
16
100%
Other
On admisson and then criteria based
Shift assessment
4b. What EMR vendor is being used?
Text Response
Internal
Internally developed system. Transistioning to Cerner over next 18
months
Currently Tandem (Intermountain EMR) soon to change to
Cerner/Intermountain EMR (iCentra)
We use Tandem at this time and transitioning to iCentra
Currently a home grown EMR. Changing to a Cerner Hybrid
program within the next year.
Tandem/ Help1
Allscripts
Cerner
4c. What type of assessment is being used?
Text Response
Braden, "naked man" on admissions to document any non HAPU,
Braden Score, Overall wound/skin assessment
Braden, BradenQ
Head-to-toe
5. What is the one intervention that has had the
most impact in reducing pressure ulcers at your site
in the past two years?
Text Response
Upgraded mattresses
Hourly rounding on patients
Standardized pressure reduction surface mattresses with an option for an air pump is the
standard for all beds.
New bed surfaces
Nursing Staff Education TAPS or PUP
Repositioning of patients and the use of specialty mattresses.
Pressure reducing mattresses for all patients
Wound Care/Ostomy rounds on all ICU patients daily and teaches "real" patient turning. Also,
implementing the use of foam wedges
Education regarding use of skin care creams and lotion for prevention. We did a big initiative
to stock each unit with the correct products in a way that it is easy for staff to access and use.
Then we did a big education on how to use the products in a way that will prevent skin issues.
It has really helped to reduce our hospital acquired ulcers.
Turning Q 2 hrs when patient does not or is unable to reposition themselves.
A heightened focus on pressure ulcer prevention from the top down with admin support
across the full spectrum of care.
6. What is the most innovative approach that you
feel has contributed to reducing pressure ulcers?
Text Response
Pressure reducing mattresses, pumps, and increased education with staff.
Not "innovated", but continued education, wound care nurses, implementation of "SWAT" teams
TAPS-Turn & positioning systems
I think that the continual education to nursing staff about the importance of it and outcomes has
been the most beneficial. We have sent the wound nurses to the ICU rounds for the patients on
the specialty beds to assess wounds at the time of the unit assessment and that has helped.
Our organization created a standard for using the PUP dressing and that has assisted as well in
the OR cases and ICU cases from what we can tell so far.
Waffle (EHOB) mattressess and seals
Setting up our clean utility rooms so that the skin care products are all in the same area, easy to
grab all of them at one time without searching forever to find them.
Assessment-based intervention and monitoring
Skin care assessment at shift change (both AM & PM) for low Braden scored patients
Partnering with respiratory therapy to address respiratory device related pressure ulcers
7. To help us measure progress, please indicate
your facility's program status since starting the HEN
collaboration to reduce pressure ulcers. What level
do you feel your facility is at?
Answer
Response
%
Working Harder
9
53%
Getting Started
4
24%
Ahead of the Curve
4
24%
Total
17
100%
A. "Getting Started": This level consists of identifying areas that need the most attention and appointing a leader that will help drive improvement
and education SWAT (or champion) teams.
B. "Working Harder": This level focuses on adopting decision algorithms for RNs to select appropriate surfaces and independently make decisions.
C. "Ahead of the Curve": This level focuses on establishing monthly prevalence studies or incidence rates from Electronic Medical Records (EMR),
then feed that data back to the SWAT teams.
8. What barriers are you experiencing that are
preventing you from achieving your goals to
reduce pressure ulcers.
Text Response
Resources - both people and time - to do more frequent prevalence studies and to add incidence.
Many competing priorities with change in EMR.
Not a "barrier" - time for continued education & stressing the importance
Lack of resources to continually turn and reposition patients. Nutrition support (although we now
have a clinical dietician that is advancing our nutrition care), lack of RN wound specialist
Staff turnover, supply cost, compromised patients in ICU that lose perfusion
Acurate reporting of weekly skin assessment findings. Failure to recognize the beginning of skin
breakdown.
Up until approx 1.5y ago - did not have a FT Wound/Ostomy RN
Rate of turnover of staff. In the last 2 years we have had a large amount of new nurses hired and it is
difficult to educate them on proper prevention measures, especially if they are on the night shift.
We used to be a part of the nurse residency educaion program, but were cut because of not enough
time in their program. I see a difference in the nurses coming from the program, they dont know
essential info to prevent pressure ulcers as they did in the past.
Resources both time and money
Acuity and staffing issues
It is difficult to get time with nurses for education.
9. What is your role at your facility?
Text Response
Member of pressure ulcer prevention team.
Patient Safety Coordinator/Quality Consultant
Clinical Effectiveness - Operations for Baylor Scott & White Health, NTX HAPU Council
ICU manager
Wound Care Nurse Manager
Quality Lead
Med/Surg coordinator
Certified Wound, Ostomy and Continence nurse. I lead the SWAT team and perform P&I studies
quarterly and coordinate education throughout the facility regarding new skin and wound care
products.
Manager
Staff RN and wound champion
Data Collector
Wound Specialty Nurse
Wound Care Specialist.
Operations - Clinical Effectiveness
WOCN
10. What is the size of your facility?
Answer
Response
%
>200 people
10
59%
50 - 99 people
3
18%
100 - 200 people
3
18%
20 - 49 people
1
6%
Total
17
100%
There’s still time to complete the
survey!
If the survey has not been completed for you
hospital or organization, please go to:
https://csbsutah.co1.qualtrics.com/SE/?SID=SV_1XD83SpQdlnNw9f
We follow up and develop a resource guide
based on the survey responses to be shared
across the HEN
2014 plans for improvement
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Quarterly Affinity Calls
2015 CMS HEN contract renewals - unknown
Sustainability?
Collect and share best practices across our network
hospitals & system in a single document