Pressure Ulcer Reduction and Prevention Project Outcome Congress and Celebration

1. Pressure Ulcer Reduction and Prevention Project Outcome Congress and Celebration Pressure Ulcers: What we all need to know Sharon Baranoski, MSN, RN, CWCN, APN, FAAN

2. Pressure Ulcer Reduction and Prevention Project Congratulations

3. Objectives Recognize the Agency for Healthcare, Research & Quality pilot initiatives Discuss what Preventive Legal Care is Review the new International PU Guidelines from NPUAP & EPUAP

4. Pressure Ulcers: What we all need to know • Significant Problem • Annually 2.5 million patients treated in acute-care facilities for Pressure Ulcers • PU patients are 3 times more likely to be discharged from acute care to LTC

5. Pressure Ulcers: What we all need to know • More likely to occur among those over 65 years of age--By 2030---Potential for 1 out of every 5 American, (72 million people) to be over 65. • Despite guidelines on prevention & treatment PU are becoming increasingly common

6. Pressure Ulcers: What we all need to know • Medicare records from 1993 to 2003 show: PU increased by 63% in hospitalized patients • Mean average LOS of 13 days in acute care —higher than national average for a hospital LOS • Net cost $9.1-11.6 billion per annum

7. Pressure Ulcers: What we all need to know • Medicare Goal: improve quality for beneficiaries while avoiding unnecessary costs • Resulted in review of Medicare payments and new coverage decisions • In FY 2007 there were 257,412 Medicare beneficiaries with PU’s. Average DRG payment $37, 800 to $43,180 • Cost of treating 2.5 times the cost of preventing

8. Pressure Ulcers: What we all need to know • Incidence rates: • 0.4-38% hospitals • 2.2-23.9% skilled nursing facilities • 0-17% in home health agencies • Evidence supports that PU occur relatively early in the admission process • Hospitals within the first week • LTC within the first 4 weeks • No data for home care

9. Pressure Ulcers: What we all need to know • Mortality • Several studies show a 60% mortality for older persons with PU within 1 year of hospital discharge • Most often PU don’t cause death but may be a predictor of mortality • 60,000 patients die each year from PU complications

10. Pressure Ulcers: What we all need to know • Lawsuits—More than 17,000 lawsuits related to pressure ulcers annually • 2nd most common claim after wrongful death and greater than falls and emotional distress

11. PU Projects Guidelines • 2004--LTC regulations Tag F-314 • 2005--PU reportable in some states • 2007--Some states start PU Collaborative • 2007 --Federal Register “PU can reasonably be prevented through application of evidence-based guidelines” • 2008—CMS QIO 9th Scope of work • 2008--POA indicator, HAC • 2009--NPUAP/EPUAP International PU Guidelines

12. Pressure Ulcer Prevention • Prevention should be the goal of all healthcare providers PREVENTION

13. PU Prevention • Are we ready for change? AHRQ pilot project • Assessing Readiness—organizational change • Pressure Ulcer Prevention Initiative • Multiple, simultaneous modifications to work flow • Communication • Decision making • Failure to assess leads to unanticipated difficulties in implementation Do members understand why change is needed? Is there urgency to change? Is senior leadership supportive? Who will take ownership? What resources are needed?

14. PU Prevention • Managing Change • Implementation Team • Members with critical knowledge of care processes • Consider existing procedures and practices • Re-design depends on assessment of current practice and knowledge • Plan for change based on the needs identified specific to your organization

15. PU Prevention • Best Practice • What “bundles” of best practices do we use • How should a comprehensive skin assessment be done? • How should a standardized PU risk assessment be conducted? • What can be done at the unit level to enhance prevention practices • What additional resources are available?

16. PU Prevention • Implementing Best Practice • Implementing the new prevention practices at the front-line level • Customized to your organization & integrated to ongoing work processes • Not a special project, it is a new required practice • As you progress, additional interim changes may be needed • Roles, responsibilities, engaging staff

17. PU Prevention Checklist for implementing best practice • Roles & responsibilities of staff: • specific roles have been assigned • Members of wound care team • Members of the unit-based team • The unit champion • Organizing the prevention work: • Paths of ongoing communication & reporting identified • Mechanisms to address accountability have been developed • Strategies for building new practices into daily routine identified

18. PU Prevention • Putting practices into operations: • An implementation plan has been developed • Support from key stakeholders has been assured • A plan to pilot test new practices has been initiated • A strategy for engaging staff has been established • Education plans have been devised to help staff learn new practices

19. PU Prevention • Measuring PU rates & practices • “If you can’t measure it, you can’t improve it.” • QI program—tracking performance--Care is improving, staying the same, or even getting worse • Monitor outcome ( P & I rates); at least one or two care processes (skin assmts, risk assmts) • Monitor the staff compliance with their roles

20. PU Prevention • Sustaining prevention practices • Most difficult part of a change process • Keeping new practices in place • How successful have we been in supporting new practices? • Reinforcing the desired prevention practices Essential that changes become integrated into existing organizational structure and routines, and that management goals and reporting mechanism are in alignment with the new standards and practices.

21. PU Prevention No matter how well you are doing you can always do better! Perfection in pressure ulcer preventive care is NEVER achieved. All you can do is take steps to reach the ideal of no avoidable pressure ulcers.

22. Preventive Legal Care • Federal Register (May 2007) states that PU’s can be “reasonably be prevented through the application of evidence-based guidelines”. • Reasonably preventable DOES NOT MEAN “always preventable” • Legal Uncertainty about the impact of this new Federal Register statement in the medical liability context

23. Preventive Legal Care • It is more important now than ever for healthcare providers to fully understand, appreciate and adapt to the legal issues that arise from the care of patients with pressure ulcers. • The interrelationship between medical-decision-making, reimbursement and legal issues has never been greater

24. Preventive Legal Care Lawsuits Judgments $312 million in one single case Unlike other medical complications, they NEVER go unnoticed Visuals that PU’s create add to the financial potential of even the most meritless claims • Common in acute and LTC

25. Preventive Legal Care Areas of Vulnerability Guidelines Assist with care recommendations, rather than specifically regulate care Review yearly—check clinical currency, legal & healthcare implications Review wording carefully : always, never, must, shall, or immediately should be rigorously avoided • P & P are guidelines not rules or regulations • “policy” used interchangeably with rules and regulations • “Words” used in P & P’s • Mandatory & exact compliance in the minds of our patients and lay persons

26. Preventive Legal Care Compliance Dilemma Standing Orders: Must comply with prescribing law P & P Can’t overrule the law ie: Ordering a enzymatic debrider; a pharmaceutical Need an Order/signature • Institutional practices need to be evaluated to ensure compliance with prescribing regulations. • Prescriptive privileges: • MD’s, Do’s, NP’s, PA’s • Must sign orders

27. Preventive Legal Care Scope of Practice Nursing Staff delegation LVN, LPN—assessment cannot be performed independently • Ensure that all caregivers are practicing within their scope of practice with regard to PU assessment & documentation • CMS billing policy: advanced practitioners and other CMS-defined providers can make medical diagnoses.

28. Preventive Legal Care Clinical Documentation Legal Perspective The chart should note every time the patient was turned, his wound cleaned, the patient instructed on wound care, and so on. The notion that every event can be accurately and fully documented removes the focus from the patient care and puts it on creating a perfect paperwork”. • “What was not documented, was not done” Plaintiff’s arguments • Unreasonably high standard for clinicians • Documentation must be balanced with patient care • Comprehensive, consistent, concise, chronological, continuing and also reasonably complete.

29. Preventive Legal Care Documentation Avoidable/Unavoidable Long Term Care: CMS language: determination of compliance with Medicare law Tag F-314 Evaluate resident’s clinical condition and risk factors Define & implement interventions Monitor & evaluate impact of interventions • Skin Assessment • Risk Assessment • Pressure Ulcer Assessment Staging & Wound Description • Electronic Medical Record/Manual • Photography • Support Surface use

30. Preventive Legal Care Acute care Acute care Skin and Risk Assessment Pressure Ulcer Assessment Staging & Wound Description Documentation in the EMR or Narrative chart Interventions and impact Photography—follow facility policy Turn/Reposition/Support Surface use • CMS list four conditions that are never events, PU’s is not one of them • Hospital Acquired Condition applies to acute care, remember “reasonably preventable”

31. Preventive Legal Care Home Care Home Care Skin and Risk Assessment Pressure Ulcer Assessment Staging & Wound Description Documentation in the EMR or Narrative chart Interventions and impact Photography—follow facility policy Turn/Reposition/Support Surface use • New OASIS C coming 2010 • 13 elements addressing Pressure ulcers • Important to document POA also with a full assessment • Focus: Appropriate wound care with improved outcomes; risk of developing wounds; care planning & prevention

32. Home Care Success will be measured by: • Reported outcomes-quality & adverse events • Supply cost containment • OASIS accuracy • Visit utilization • Appropriate wound care interventions based on evidence based protocols

33. Preventive Legal Care Education Education Basics of skin & pressure ulcer care Importance of turning & repositioning Support surfaces What interventions you are doing for prevention Risk factors Notify them when you see a problem occurring • Professional Education— • Education based on skill level • In-house training • Annual reviews • Include CNAs role • Patient & Family Education • Lack of knowledge can fuel unrealistic expectation

34. Preventive Legal Care Expectations Communications Physician should explain PU’s and document risk factors Document education on PU with patient and family members • Patient & Family expectations • PU risk • PU development • Prevention measures

35. EPUAP & NPUAP International Pressure Ulcer Guidelines PU’s Lit. review Beds Lit. review Nutrition Research International P. U. Guidelines, EPUAP/NPUAP Draft 2009

36. Pressure Ulcers Guidelines Purpose of the Guidelines • Prevention: Aim of these recommendations is to prevent the development of PU’s. The recommendations apply to all patient and vulnerable people of all age groups in all healthcare settings • Treatment: Aim is to recommend evidence-based care for patients with existing PU’s. The recommendations apply to all patient and vulnerable people of all age groups in all healthcare settings International P. U. Guidelines, EPUAP/NPUAP Draft 2009

37. Stage/Category STAGE I Stage Intact skin with non-blanchable erythema of a localized area usually over a bony prominence. Discoloration of the skin, warmth, edema, hardness or pain may also be present. Darkly pigmented skin may not have visible blanching. Further description—no change Definitions: slight changes International P. U. Guidelines, EPUAP/NPUAP Draft 2009

38. Stage/Category II STAGE II Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguineous filled blister. Further description –no change International P. U. Guidelines, EPUAP/NPUAP Draft 2009

39. Stage/Category • Stage III • NO CHANGE • Stage IV • NO CHANGE International P. U. Guidelines, EPUAP/NPUAP Draft 2009

40. Stage/Category • Unstageable or UNCLASSIFIED • Added will be either a Stage III or IV • NO CHANGE • sDTI/ DEEP TISSUE INJURY—NO CHANGE International P. U. Guidelines, EPUAP/NPUAP Draft 2009

41. Risk Assessment • Risk assessment all settings’ • Educate health care professional on how to achieve accurate & reliable risk assessment • Structured approach---use a scale • Includes a skin assessment • Conduct on admission and repeat as determined by patient acuity • Prevention plan International P. U. Guidelines, EPUAP/NPUAP Draft 2009

42. Nutrition Both poor nutritional intake and poor nutritional status have been shown to correlate with the development of PU’s as well as protracted healing of wounds. • Malnutrition –status of nutrition in which a deficiency or excess, or imbalance of energy, protein and other nutrients causes measurable adverse effects on tissue, body structure, body function and clinical outcome. In the guideline, malnutrition refers to a status of under-nutrition or undernourishment. • Dehydration—common and under-recognized problem • The Exact causal relationship between PU’s and nutrition still remains unclear International P. U. Guidelines, EPUAP/NPUAP Draft 2009

43. Nutrition Recommendations: ESPEN and ASPEN • Nutritional screen in every individual at risk of PU’s • Use a valid, reliable and practical screening tool • Nutritional screening policy in place • Nutritional risk and PU risk, refer to a dietician or other; consider enteral nutrition • Nutritional support-assess, monitor, evaluate, and reassess • Minimum of 35 kcal per kg body weight per day, with 1.5 g/kg/day protein and 1 ml per kcal /day of fluid intake • Palliative care: Prognostic profile and wishes of the individual International P. U. Guidelines, EPUAP/NPUAP Draft 2009

44. Repositioning for the Prevention of Pressure Ulcers Component of Prevention • All at risk individual • Repositioning must take into consideration the condition of the patient and the support surface in use • Repositioning frequency—influenced by the pt’s condition and support surface in use • DeFloor (2005) study: turning every 4 hours on a visco-elastic foam mattresses resulted in statically less pressure ulcers compared to turning 2 or 3 hours on a standard hospital mattress. • Use a foot stool or foot rest when pt in chair and feet do not reach the floor International P. U. Guidelines, EPUAP/NPUAP Draft 2009

45. Repositioning for the Prevention of Pressure Ulcers • Avoid sloughed position • Limit the time sitting in a chair & use pressure relief • Select position that is acceptable to the individual and minimizes pressure and shear exerted on skin and soft tissue • Documentation should include, frequency, position adopted and evaluation of outcome of repositioning regime • Education & Training of all caregivers International P. U. Guidelines, EPUAP/NPUAP Draft 2009

46. Support Surfaces • Prevention in individuals at risk should be provided on a continuous basis during the time that they are at risk • Do not base the selection of a SS solely on the perceived level of risk or category/stage of pressure ulcer • Choose a support surface compatible with the care setting • Examine the appropriateness and functionality on every encounter. Verify that the SS is within its functional life span • Use high specification of foam mattresses rather than standard hospital foam mattress. • Use an active SS (overlay or mattress) for pts at higher risk when frequent turning is not possible or condition prevents International P. U. Guidelines, EPUAP/NPUAP Draft 2009

47. Support Surfaces • Continue to turn & reposition • Use a pillow under the calf to elevate the heels • Heel protecting devices should elevate the heel completely so to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon • Seating surface need more repositioning than when in a lying position • No synthetic sheepskin, donuts or cut-out ring type devices International P. U. Guidelines, EPUAP/NPUAP Draft 2009

48. Operating Room • Refine risk assessment of individuals undergoing surgery by examining other factors which increase risk of PU development including: • Surgery greater than 4 hours • Increased hypotensive episodes intra-operatively • Low core temperature during surgery • Reduced mobility on Day 1 Post-op • Use a pressure redistributing mattress on the operating table for all individuals identified as being at risk • Position to avoid pressure during surgery and on heels, elevate • Use a pressure redistributing mattress pre and post op • Change the pts position pre & post operatively differently then when in surgery (if possible) International P. U. Guidelines, EPUAP/NPUAP Draft 2009

49. Pain Management • New section on Pain Management: • Prevent, Reduce, manage • Assess all individuals for pain related to a pressure ulcer or its treatment.  • Assess for pressure-ulcer-related pain in adults using a validated scale. International P. U. Guidelines, EPUAP/NPUAP Draft 2009

50. So in the End, the new Guidelines are • More Comprehensive • More Detail • More Evidence Based • ACCOUNTABLE International P. U. Guidelines, EPUAP/NPUAP Draft 2009