Preventing Pressure Ulcers Tuesday, May 6, 2014

Tuesday, May 6, 2014
These presenters have
nothing to disclose
IHI Expedition
Preventing Pressure Ulcers
Kathy Duncan, RN
Annette Bartley, RN
Today’s 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
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Expedition Director
Kathy D. Duncan, RN, Faculty, Institute for Healthcare
Improvement (IHI), oversees multiple areas of content and is the
clinical lead for IHI’s National Learning Network. Ms. Duncan also
directs content development and provides spread expertise for
IHI’s Project JOINTS as well as additional content direction for
the Hospital Portfolio, directs a number of virtual learning webinar
series, and manages IHI’s 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 IHI’s 100,000 Lives and 5 Million
Lives Campaigns. She also serves as a member of the Scientific
Advisory Board for the American Heart Association’s Get with the
Guidelines Resuscitation, NQF’s Coordination of Care Advisory
Panel and NDNQI’s 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.
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 strategies​s
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
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
Today’s Agenda
Welcome and introduction
Discuss the action period
assignment from call 1
Identification and assessment
of patients at risk
Guest presentations
Action Period Assignment
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. Annette’s
passion is inspiring and supporting frontline care teams to
reliably deliver high quality, safe, person centered care.
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 unit’s current performance. Ask five
members of staff what the unit’s 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
Developing a System’s Based Approach
What will success look
Risk Identification
Risk Assessment
with patient
Communication of
Risk status
Appropriate preventative
strategy implemented
Evaluation of outcome
Who is at Risk?
High Risk Groups
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:
People who have trouble moving and cannot change position
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 don’t 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
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.
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
Skin condition
Pressure ulcer history
Risk of Pressure Ulcer by Number of Risk
% with PU
Number of risk factors present
Mor, V et al Canadian J of Quality of Care
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
Surgery, Gastrointestinal,
ICU, Pediatric)
Urinary Catheters
Nasogastric Tubes
Oxygen cannula
Oxygen masks
– Staffing
– Equipment
Risk Assessment (NPUAP 2014)
 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
patient’s condition changes
 Long-term care: assess on admission, weekly for four weeks, then quarterly
and whenever the resident’s 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.
Risk Assessment Tools
It is not what you use… it’s 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
The Braden Scale offers the best balance between sensitivity and
specificity and highest prediction capacity
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
Need to Reduce Complexity
Gut Instinct- Is the patient at risk?
YES or NO?
Pre-Pressure Ulcer Risk Assessment (PPURA) - NHS Scotland
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
Predictable Risk
Utilize patient ‘At risk’ cards to quickly identify those at
increased risk
Making the Connection
Risk assessment
Preventative action
Measure impact
PDSA Changes
Patient risk cards
Patient and family contracts
Visual cues
Safety briefing/huddles
Movement /activity sessions
100 days free campaign….
Raise your hand
Use the Chat
Guest Presentations
Bevette Griffin RN,CWON
OSF Saint Francis Medical Center
Children’s 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
• Decreasing HAPU’s was one of the first 6Sigma 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
HAPU’s by 50%.
• 3 root causes were identified: accountability,
knowledge deficit and communication
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
• Gradual decrease in HAPU’s to below 2%
quarterly since June 2011,reported to NDNQI.
• Constant challenges: Making skin a priority
and creating a culture of prevention
• All HAPU’s are assessed by the WOCN nurses
for accuracy ( with the staging and IF they are
really from pressure)
• All HAPU’s 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?
• 2 RN’s will assess every pt upon admission and
• Unit “huddles” list patients with low Braden
• 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
• Device related HAPU’s ( NG tubes, FMV,
• Correct staging and documentation of
pressure ulcers on admission by Physicians
and nursing staff
• Transitioning the use of the sacral dressing to
all the ICU’s
• Keeping the SOS initiative live and well
• 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
Identify a local strategy for promoting pressure ulcer
prevention awareness across the multi-disciplinary team
and with patients and families
Expedition Communications
Listserv for session communications:
[email protected]
To add colleagues, email us at [email protected]
Pose questions, share resources, discuss barriers or
Next Session
Annette Bartley, RN
Kathy Duncan, RN
Karen Cole: Claxton-Hepburn Medical Center
Stephanie Calcasola: Baystate Medical Center

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