AHA/HRET HEN: Data and Coaching Webinar: Pressure Ulcers

1. AHA/HRET HEN:Data and Coaching Webinar:Pressure Ulcers Data Review Friday, June 29, 2012 2:00 – 2:30 PM, CDT

2. Welcome and Overview • Welcome, thank you for joining us today! • Housekeeping: • This webinar is being recorded and will be archived. • You will receive a PDF of today’s presentation, as well as a link for the evaluation, a summary of Q&A and the polling questions and a link for the recording. • For additional questions: please reach out to your state lead – or email us: HEN@aha.org. • For additional resources and information: please visit our website: www.hret-hen.org • Agenda: • Content Review • Measurement Review • Hospital Story

3. Objectives • Discuss strategies to identify patients at risk for skin injury…use of subscales • Outline evidence-based strategies to assess and prevent moisture related injury from incontinence • Demonstrate an understanding of the HAPU related measures in the HRET Encyclopedia of Measures • Describe the HAPU measurement and data requirements • Discuss a strategy to promote staff buy-in and ownership

4. Introductions • Jessica Blake, LSW, MA, HRET • Steve Tremain, MD, Cynosure Health  • Cheryl Ruble, RN, MS, CNS, Cynosure Health • Kathleen M. Vollman MSN, RN, CCNS, FCCM, FAAN, Advancing Nursing, LLC • Charisse Coulombe, MS, MBA, HRET • Liz Schulte, CAPM, CHES,BJC HealthCare

5. Polling Question #1 How Many of You are Joining Us From: Hospital type? A. General Medical / Surgical B. Teaching C. Rural D. Children’s

6. Polling Question #2How Many of You are Joining Us From: Hospital size? A. CAH B. Not CAH, <100 beds C. Not CAH, 100-299 beds D. Not CAH, 300+ beds

7. Polling Question #3 What best describes your facility: • We implemented strategies to prevent HAPU and have seen significant reductions • We are just getting started with HAPU prevention • We are struggling to find resources • We are struggling to obtain staff buy-in

8. HAPU: Working Our Way Towards Zero Kathleen M Vollman MSN, RN, CCNS, FCCM, FAAN Clinical Nurse Specialist/Educator/Consultant ADVANCING NURSING LLC Northville, MI kvollman@comcast.net www.vollman.com

9. Disclosures • Sage Products Speaker Bureau & Consultant • Hill-Rom consultant • Eloquest Healthcare 9

10. Identify Patients at High Risk

12. Risk Assessment on Admission, Daily, Change in Patient Condition • Use standard EBP risk assessment tool • Research has shown risk assessment tools are more accurate than RN assessment alone • Braden Scale for Predicting Pressure Sore Risk • Six subscales • Rated 1-4 • Pressure on tissues • Mobility, sensory perception, activity • Tissue tolerance for pressure • Nutrition, moisture, shear/friction • Score 6-23 Available at: www.ihi.org; Macklebust, JA (2009) The Braden Scale reliable assessment to effective interventions.

13. It’s About the Sub-Scales • Retrospective cohort analysis of 12,566 adult patients in progressive & ICU settings for year 2007 • Identifying patients with HAPU Stage 2-4 • Data extracted: Demographic, Braden score, Braden subscales on admission, LOS, ICU LOS, presence of acute respiratory and renal failure • Calculated time to event, # of HAPUs • Results: • 3.3% developed a HAPU • Total Braden score predictive (C=0.71) • Subscales predictive (C=0.83) Tescher AN, et al. J WOCN. 2012;39(3):282-291

14. Braden Score Braden Sub-Scales (C=0.83) Friction Score of 1=126 times the risk Multivariate model included 5 Braden subscales, surgery and acute respiratory failure C=0.91 (mobility, activity and sensory perception more predictive when combined with moisture or shear/friction)

15. Polling Question #4 Are you using Braden sub-scales to target specific prevention strategies? • Yes, we are using the sub-scales • We have started implementation of the sub-scales • No, we do not use the sub-scales • No, we use a different assessment tool

16. Moisture Injury: Incontinence Associated Dermatitis (IAD) • An inflammatory response to the injury of the skin’s water-protein-lipid matrix • Caused by prolonged exposure to urinary and fecal incontinence • Top-down injury • Physical signs on the perineum and buttocks • Erythema, swelling, oozing, vesiculation, crusting and scaling Brown, DS & Sears, M, OWM 1993;39:2-26 Gray M et al. OWN 2007;34(1):45-53 Doughty D, et al. JWOCN. 2012;39315

17. Impact of Moisture • Urinary and fecal incontinence are common in the acute care setting, occurring in more than one-third of hospitalized adults • Humidity/Moisture: • Strain at which the skin breaks is 4x greater with excess moisture than with dry skin • Moisture increases the risk of shear and friction damage Nicolopoulos CS, et al. Arch Dermatol Res. 1998;290:638-640 Bliss DZ, et al. Nurs Res.2000;49:101-108. Gray M, et al. Adv Skin Wound Care. 2002;15(4):170-175.

18. Assessment, definitions, grading, & evidence-based interventions • Joan Junkin Doughty, D, et al. JWOCN;3,993:303-315

19. IAD Assessment IAD Tool Junkin J, Selek JL. J WOCN 2007;34(3):260-269 Junkin J, Selek JL. J WOCN 2007;34(3):260-269

20. Polling Question #5 Are you familiar with the term “incontinence associated dermatitis,” used to describe incontinence related moisture injury? • Yes • No

21. EBP Recommendations to Reduce Injury From Incontinence & Other Forms of Moisture • Clean the skin as soon as it becomes soiled • Use an incontinence pad and/or briefs to absorb/wick away wetness from the skin • Use a protective cream or ointment on the skin to protect it from wetness • Disposable barrier cloth prevents unprotected episodes (www.ihi.org 5 Million Lives Campaign) • Consideration of pouching device or a bowel management system • Ensure an appropriate microclimate and breathability with < 4 layers of linen National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure ulcer prevention & treatment: Clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009. Williamson, R, et al (2008). Linen Usage Impact on Pressure and Microclimate Management. Hill-Rom www.ihi.org

22. Achieving the Use of the Evidence For Friction & Moisture • Resource & System • Breathable glide sheet/stays • Foam Wedges • Microclimate control • Reduce layers of linen • Wick away moisture body pad Skills & Knowledge Resources & System Factorsimpacting the ability to achieve quality nursing outcomes at the point of care Value Attitude & Accountability Vollman KM. Australian Crit Care, 2009;22(4): 152-154 22

23. Questions? • Let’s pause for questions… ?

24. Pressure Ulcers Data Management Strategy Charisse Coulombe Data Director, HRET

25. Why is Pressure Ulcer Data Needed? • Measures are used to assess the impact of changes • To demonstrate hospitals have reduced their rates of harm over the 2 year period for the HEN project • To monitor that interventions to reduce pressure ulcers are working • Part of the PDSA cycle

26. What Pressure Ulcer Data is Needed? • At a minimum, 1 process measure and 1 outcome measure • Process: Measures interactions between healthcare practitioner and patient; a series of actions, changes, or functions bringing about a result • Outcome: Measures change or the end result of healthcare intervention

27. Encyclopedia of Measures • Technical manual to ensure the hospital's Pressure Ulcer measure definitions align with the comprehensive data system (CDS) • Comprehensive details about measure characteristics • Topic • Measure Name • Definition • Numerator, Denominator • Calculation specifications • Source(s)

28. Pressure Ulcer Process Measures • Patients with Pressure Ulcer Risk Assessment Completed within 24 hours of Admission • Patients with Skin Assessment Documented Within 24 Hours of Admission

29. Pressure Ulcers Process Measure Example • Patients with Pressure Ulcer Risk Assessment Completed within 24 hours of Admission • Assesses the total number of patients that have a pressure ulcer assessment completed within 24 hour of admission • Numerator: Number of inpatients with documentation in medical record of a complete pressure ulcer risk assessment

30. Pressure Ulcer Process Measure Example • Denominator: All inpatients admitted to hospital or unit under surveillance All inpatients admitted to hospital or unit under surveillance [Denominator] Number of inpatients with documentation in medical record of a complete pressure ulcer risk assessment [Numerator]

31. Polling Question #6 6) Has your hospital selected your Pressure Ulcer process measure? • Yes, selected and actively tracking • Yes, the measure has been selected • No, still researching which measure to select

32. Pressure Ulcer Outcome Measures • Patients with at least One Stage II or Greater Nosocomial Pressure Ulcer (NSC 2) • Patients with at least One Stage II Nosocomial Pressure Ulcer (subset NSC 2) • Patients with at least One Stage III or Greater Nosocomial Pressure Ulcer (subset NSC 2) • Decubitus Ulcer - Adult (AHRQ PSI 3) • Pressure Ulcer - Pediatric (AHRQ PDI 2) • Pressure Ulcer (MCR FFS) (CMS HAC)

33. Scenarios • 8 year old Kyle was admitted to a community hospital for orthopedic surgery. During his stay he developed a decubitus ulcer. • For the Pressure Ulcer - Pediatric (AHRQ PDI 2) measure, Kyle would be included in the numerator and in the denominator. • Sara is an inpatient at a local hospital, and has been identified has having a Stage II Pressure Ulcer during a prevalence study on inpatient pressure ulcers. • For the Patients with at least One Stage II Nosocomial Pressure Ulcer (subset NSC 2) measure, Sara would be included in the numerator and the denominator. • If Sara did not have a State II Pressure Ulcer, she would not be included in the numerator, but would be included in the denominator.

34. Polling Question #7 7) Has your hospital selected your Pressure Ulcers outcome measure(s)? • Yes, selected and actively tracking • Yes, the measure has been selected • No, still researching which measure to select

35. What Happens if the Hospital Collects a Pressure Ulcer Measure that isn’t in the Encyclopedia of Measures? • Data system allows the hospital to create an organization-defined measure • Hospital specifies the numerator and denominator definitions in addition to entering their data

36. Example of Pressure Ulcer Organization Defined Measures • Measure Definition: Patients with high risk score for Braden Scale (>18) • Numerator: Number of patients with high risk score for Braden Scale • Denominator: Number of patients eligible for Braden Scale screen

37. Polling Question #8 8) Who is currently reviewing Pressure Ulcer data on a monthly basis? • Board of Directors/Quality Committee of Board • Senior Leadership of your hospital/system (e.g. CEO, VPs) • Nursing only • Interdisciplinary Team that includes Nursing, Wound Care, Infection Control, Dietary, Physical Therapy, Medical Staff • All of the above • Combination of A, B, C, D

38. What Pressure Ulcer data is Submitted? • Baseline • Timeframe flexible • Can submit 1 year, 6 months, 1 month, etc. • Data set that will be used for comparison to the measurement period(s) • Measurement (2 years) • Submitted in monthly increments • Data set that will be compared to the baseline to determine if improvement is occurring

39. Pressure UlcerData Collection & Submission • Current: • Hospital directly enters all Pressure Ulcer data into CDS • In Progress: • If your state has a state-level data warehouse that collects Pressure Ulcer data, working to get the data uploaded to CDS by HRET • Notes: • Only collecting aggregate hospital-level data (not unit level, or patient level)

40. Questions? • Let’s pause for questions… ?

41. Next Up! Coaching • Thank you for joining us for the Data session of the webinar. • We will now transition into the Coaching session of the webinar.

42. AHA/HRET HEN:Data and Coaching Webinar: Pressure Ulcers Coaching Review Friday, June 29 2:30 – 3:00 PM, CDT

43. When the right solution is not enough: Emphasizing methods in pressure ulcer prevention improvement Liz Schulte, CAPM, CHES, Project Manager, BJC HealthCare, St. Louis, MO

44. About Us • BJC Healthcare is one of the largest nonprofit health care organizations in the United States. Through our 13 hospitals and multiple community health locations, we deliver services to urban, suburban and rural residents primarily in the greater St. Louis, southern Illinois and mid-Missouri regions. 2011 BJC Statistics: • Employees 27,984 • Physicians 4,269 • Staffed Beds 3,508 • Hospital Admissions 150,602 • ED Visits 481,385 • Net Revenue $3.6 billion • Charity Care $252.3 million

45. What Did We Test? • Process improvement of the hospital acquired pressure ulcer prevention process in three high event volume units • Pilot process focused on three standard criteria: • Turning at risk patients every two hours • Daily event tracking and immediate analysis • Standard prevention education for staff, patients and families • Implementation method: Provide all three pilot units with the same “what,” but gave each the freedom to develop the “how”

46. What Have We Learned So Far? • Implementing with standard criteria and a custom process increased staff buy-in and process ownership • Sustained attention to event analysis can proliferate benefits of process improvement

47. What Barriers Did We Encounter? • Competing priorities at hospital and unit level • Numerous initiatives and internal infancy of portfolio management • Nursing management turnover • For this project, unit managers were the primary drivers for process compliance and accountability

48. How Did We Overcome These Barriers? • Detailed process documentation and standard work • Acceptance/Change management tools • Finding the “what’s in it for me” (WIIFM) during each stakeholder engagement • Unit and hospital champions • Strong subject matter experts and mid-level leadership

49. What Can Others Learn From Our Journey? • Application of the Pareto principle in pilot site selection • Three pilot sites showed a combined 58% decrease in hospital acquired pressure ulcers; equated to a 30% decrease system wide in the same time period • Most powerful tools for success: • Collaboration • Project plan/schedule • Issue tracking and elevation

50. Do Not Try This At Home (Suggestions for What Not to Do…) • Stick to the plan or allow for wiggle room? Sometimes it’s hard to tell… • Even when the right path is clear or easy, don’t forget to ask why (and write down the answer)