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Larry Kula, MBA Consultant, Performance Excellence Fairview Medical Group Fairview Health Services

december
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Larry Kula, MBA Consultant, Performance Excellence Fairview Medical Group Fairview Health Services

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    2. No Disclosures

    3. Objectives Review and understand pressure ulcer incidence from respiratory devices in Minnesota Describe strategies for preventing and managing pressure ulcers from respiratory devices

    4. Last year (October 2009 October 2010), 30% of reportable pressure ulcers were device-related Majority of devices involved were cervical collars and respiratory devices Device-related Pressure Ulcers

    5. Reported AHE Example #1 Stage III pressure ulcer behind the ear from oxygen tubing Root Causes Skin inspection behind ears not completed Early redness not communicated when seen

    6. Reported AHE Example #2 Stage IV pressure ulcer Root Cause Skin under tracheostomy flange not inspected on a regular basis

    7. Reported AHE Example #3 Suspected Deep Tissue Injury developed into Unstageable Root Cause unable to visual skin for inspection under ETT holder

    8. Reported AHE Example #4 Stage III pressure ulcer on bridge of nose from BiPAP/CPAP mask Root Cause Staff not aware of mask alternatives for high-risk patients Staff not aware of most effective strategies for reducing pressure under BiPAP/CPAP masks.

    9. How did we get here? Spring 2010 Advisory Group assembled Summer 2010 Review / analysis of Adverse Health Events Literature search Focus Groups Identified Best Practices Beginning December 2010 Disseminated recommendations

    10. Includes Gap Analysis to assist with embedding the recommendations Implement plan developed to address relevant gaps Achieve at least 90% of the recommended practices

    11. MHA Recommendations Establish Respiratory Therapy Skin Safety champions All hands on deck Each relevant inpatient area Emergency Department Operating Room Radiology Respiratory Therapy Dietary Physician/provider Certified Nursing Assistant staff Physical Therapy/Occupational Therapy Risk Management / Process Improvement / Quality Improvement Nursing Administration Define clear roles and expectations Attend designated Skin Safety Committee meetings (adhoc?)

    12. Types of involvement: Facilitate integration of Best Practice pressure ulcer prevention in respiratory therapy policies and procedures.

    13. Types of involvement: Facilitate education of respiratory therapy staff in Best Practice respiratory device-related pressure ulcer prevention Partner with wound care staff for training / education Show the Data!!! 1 out of 10 reportable pressure ulcers involved respiratory devices, thus, involve Respiratory Therapists. Paradigm shift : Respiratory therapists play a part in Pressure Ulcers This may include causing or preventing. Give them the choice.

    14. Types of involvement: Auditing for compliance with Best Practice respiratory-device related pressure ulcer prevention

    15. Effects of Training Percent that Adopt New Practice Presentation of new practice 5% Present and demo new practice 10% Participants practice at workshop 15% Continue Feedback and Coaching 80% Source: Power in Staff Development Through Research on Training by Bruce Joyce and Beverly Showers

    16. Funny Math We do each step about 90% of the time, but our overall numbers are not very good. 90% compliance with Daily Skin Inspections 90% compliance with Daily Braden Risk Assessment 90% compliance with repositioning every 2 hours Overall compliance with Best Practice is not 90%, rather: 90% x 90% x 90% = 72% Need to run the Gauntlet Daily Skin Inspection AND Braden AND repositioning Q2H =90%

    17. Types of involvement: Consideration of skin safety care in review of respiratory device purchases #1 consideration in purchases..Price

    18. Types of involvement Participation in Root Cause Analyses respiratory device-related pressure ulcers Chronology development Issue Identification / Wish Bone / Root Causes Action planning Disciplines assume other disciplines know what they know

    19. Specific Respiratory Device Recommendations

    21. Secure straps with least amount of tension/pressure to obtain adequate placement/seal Minimal leak or minimal seal techniques (CPAP/BiPAP/NPPV) Consult with respiratory therapy for proper re-fitting at first sign of skin damage Consider utilizing alternative products for high risk patients Full face masks or nasal masks that incorporate gel or silicone based cushions Consider rotation of devicescleaning in-between

    22. Visually inspect all types of masks and tubing on a regular basis. Replace if straps lose elasticity, become soiled, or defective. Do not tie knots in straps to tighten.

    23. Commercially available ear protectors to attach to oxygen tubing Oxygen tubing with protectors pre-attached

    24. Foam tracheostomy straps designed to hold oxygen cannula away from the ears. Commercially available foam/collar type adjustable straps are preferable to traditional methods (tape/twill ties) of securing trachs and ETT (AHA Guidelines)

    25. Silicone stoma pad (cushion between the flange and the tracheostomy site) for pressure redistribution Utilize a ventilator arm or rolled towel on the chest to offload pressure and drag of ventilator tubing

    26. Tips to Minimize Friction / Pressure Gel pads sold separately or incorporated into masks Note: actual gel pad is clear / transparent Application of wound dressings over vulnerable or affected area

    27. AHE Root Causes revealed that tracheostomy sutures Had been forgotten about Assumption that someone else was responsible Goal - begin dialog / communication Create standard procedure and timeline for management of tracheostomy sutures If standard timeline is not in place, contact the surgeon/provider after 7-10 days or sooner if skin irritation near the sutures occurs. During hand-off to next level of care, include instructions for converting from suture stabilization to other means for securing and stabilizing flange.

    28. Neonatal/Pediatric: Greater than 50% of all pediatric pressure ulcers are related to equipment and devices Pediatric pressure ulcers occur primarily on the head/occipital region

    29. Neonatal/Pediatric: Special populations require special needs / special products Use commercially available pediatric products when available rather than adapting standard equipment. Specific interventions intended for adults may NOT be safe for neonatal and pediatric patients (i.e. rotating ETT); always follow pediatric specific recommendations and manufacturers instructions when available

    30. Bariatric: Pressure ulcers from respiratory equipment can result from pressure within skin folds. Consider use a of silver textile product to wick away moisture from skin folds

    31. Bariatric: Special populations require special needs / special products Instead of adapting standard equipment, use commercially available bariatric products Longer tracheostomy tubes Bariatric tracheostomy collars

    32. Acknowledgements DeeDee Nix, RN, MS, CWOCN Vicki Haugen, RN, MS, CWOCN Julie Powell, RN, BSN, CWOCN Julie Kula, RN, BSN, CWOCN

    33. Questions?

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