Perfecting Pressure Ulcer Care: Working towards zero Karen Cole, RN, BSN, CWOCN, CDE Jennifer Shaver, RN, BSN, NM

1. Perfecting Pressure Ulcer Care: Working towards zero Karen Cole, RN, BSN, CWOCN, CDE Jennifer Shaver, RN, BSN, NM/ ICU Claxton-Hepburn Medical Center Ogdensburg, NY 13669

2. Ogdensburg, New York

3. Claxton-Hepburn Medical Center (CHMC)

4. ICU Pressure Ulcer Prevention Program (PUPP) In 2003 � 2004 concerns arose over pressure ulcer prevalence in ICU ranging from 33% - 50% We developed and implemented practice changes; quickly and easily! Introduced onto Medical Surgical Units and our hospital-based skilled nursing facility

5. How�. Complete skin assessment, with Braden score, documented on admission and every shift Escalating intervention according to assessment (pressure relief, turn assist, off-loading, etc) Included in interdisciplinary needs assessment, addressed at team meetings Education and training on a �no-lift� policy, with purchase of appropriate equipment (pursued and received grant funding for)

6. Spring 2005 Staff confusion: What does it all mean???? �VAP, BSRCLI, RRT, IHI, 100K, PUPP � (etc) TMI (too much information) ! ICU Performance Improvement Team sought to demystify the clinical initiatives being implemented, as well as focus on intent (positive patient outcomes)

7. Developed �The ICU Promise�; modified to include ALL of our ongoing initiatives Posted in ICU, and all staff welcome to sign on: 94% did! * Received a small token of appreciation when signed on: author-signed critical care handbook * Handwritten thank you notes, personalized and signed by PIT members, CEO, ICU Med Director, VP PCS

8. ICU� and I care! The ICU Promise Prevents pressure ulcers, peptic ulcer disease, and deep vein thrombosis Raises the head of the bed Oral care is done; thoroughly and frequently Manages pain Includes the patient and their family in education and decision making Sedates and weans ventilator patients appropriately Evaluates and treats blood glucose values Sepsis is managed, and prevented To provide excellent care, to every patient and family, everyday!

9. When it all came together� 64 yo fe with a BMI of 98% for AMI, complicated by CHF, Pneumonia * Intubated on admission. Trach on day 7, ventilated for 5.5 weeks 2 minor staff injuries first hour of admission Implemented Vent Bundle, Pressure Ulcer Prevention Program, and Glycemic Management Staff RNs empowered to obtain appropriate bariatric equipment, including lift-free devices Strong administrative support received for patient and staff safety

11. Staying on target� Educate, educate, educate! * Implications of CMS regulations, 10/08 * Annual nursing skills fair for professional and non-professional staff on staging and interventions; captured �what�s working/what�s not working� at each session * Pressure ulcer staging cards at physician dictation areas

12. Staying on target� Tracking and sharing the data * Inclusion in organizational Strategic Plan * Hospital-wide prevalence and incidence surveys * ICU Scoreboard; includes documentation metrics * Documentation and practice supporting purchase and use of special equipment * Electronic notification trigger to WOCN and Dietician of pre-existing PU Updated and reorganized �Skin Care Team� *Uncovered �hidden players� with identification of ED wait times as potential challenge

13. Staying on target� Capturing teachable moments * �Time wounds all heels� Avoiding complacency/encouraging ownership *The power of anecdotes: sharing �the story�, developing the new story

14. Camden, S., Shaver, J., and Cole, K. Promoting the patient's dignity and preventing caregiver injury: caring for a morbidly obese woman with skin tears and a pressure ulcer. Bariatric Nursing and Surgical Patient Care March, 2007, Vol. 2, No. 1: 77-82. Cole, K. & Shaver, J. Ideas for organizational policy changes to improve incidence of pressure ulcer incidence in an ICU. 4/2006. Presented at the Symposium on Advanced Wound Care and Medical Research Forum, San Antonio, TX. Shaver, J. Promoting dignity and preventing caregiver injury. 11/2005. Presented at the National Association of Bariatric Nurses Conference, Ashville, NC.