Pressure Ulcers: The Goal is Zero

1. Pressure Ulcers: The Goal is Zero Colorado 5 Million Lives Campaign Launch November 15, 2007

2. Prevent Pressure Ulcers The Goal: Reduce the incidence of hospital-acquired pressure ulcers by December 2008. Focus on �getting to zero.�

3. What Do we know? Whitfield MD, Kaltenthaler EC, Akehurst RL, Walters SJ, Paisley S. How effective are prevention strategies in reducing the prevalence of pressure ulcers?J Wound Care. 2000;9:261-266. The prevalence of pressure ulcers has remained constant at about 7% over the past 20 years, even though considerable time and money has been invested in various prevention strategies.

4. What Do we know? Lyder CH. Pressure ulcer prevention and management. JAMA. 2003;289:223-226. 1.3 million to 3 million adults have a pressure ulcer Estimated cost of $500 to $40�000 to heal each ulcer. The incidence of pressure ulcers varies greatly by clinical setting. Incidence rates of 0.4% to 38.0% for hospitals, 2.2% to 23.9% for long-term care, and 0% to 17% for home care have been reported. Pressure ulcers in elderly persons have also been associated with increased mortality rates.

5. What Do we know? Courtney BA, Ruppman JB, Cooper HM. Save our skin: Initiative cuts pressure ulcer incidence in half. Nursing Management. 2006;37(4):35-46. OSF Saint Francis Medical Center initiated the implementation of the Six Sigma methodology which led to the development of the Save Our Skin (SOS) project, an effort that boasted an ambitious goal of reducing the number of hospital-acquired pressure ulcers in adult patients by 50% within one fiscal year.

6. What Do we know? Breslow RA, Hallfrisch J, Guy DC, Crauwly D, Goldberg AP. The importance of dietary protein in healing pressure ulcers. J Am Geriatr Soc. 1993;41(4):357-362. A study designed to determine the effect of dietary protein on healing of pressure ulcers in malnourished patients. The authors conclude that high protein diets may improve the healing of pressure ulcers in malnourished nursing home patients.

7. What Do we know? Ferrell BA, Osterweil D, Christenson P. A randomized trial of low-air-loss beds for treatment of pressure ulcers. JAMA. 1993;269(4):494-497. Low-air-loss beds provide substantial improvement compared with foam mattresses.

8. What Do we know? Risk is predictable. Risk factors include age, immobility, incontinence, poor nutrition, sensory problems, circulation problems, dehydration, and poor nutrition. Skin integrity can deteriorate in hours. Frequent assessment prevents minor problems from becoming major ulcers. Wet skin is more vulnerable to skin disruption and ulceration. Dry skin is a risk factor as well. Continual pressure, especially over bony prominences, increases risk. Pressure-relieving surfaces may help.

9. Burden of Pressure Ulcers Prevalence in acute care = 15 % Incidence in acute care = 7 % 5-7% of all acute hospital admissions 2.5 million patients treated each year Nearly 60,000 die each year from complications $11 billion dollars per year

10. An Example of What Is Possible�  St. Vincent�s Medical Center Jacksonville, FLSt. Vincent�s Medical Center Jacksonville, FL

11. OSF DataOSF Data

12. Owensboro Medical CenterOwensboro Medical Center

13. Statewide Collaborative for PUPStatewide Collaborative for PUP

14. Same statewide collaborative different level of careSame statewide collaborative different level of care

15. Reducing Pressure Ulcers Conduct a pressure ulcer admission assessment for all patients Reassess risk for all patients daily Inspect skin daily Manage moisture � keep the patient dry and moisturize skin Optimize nutrition and hydration Minimize pressure

16. Conduct a Pressure Ulcer Admission Risk Assessment; Reassess Daily Use visual cues in admission documentation for completion of skin and risk assessment. Standardize risk assessment tool/checklist across the institution. Incorporate action steps linked to risk. Use multiple methods to visually identify patients at risk. Place stickers on chart, use visual cues on door and bed. Post compliance rates to motivate staff. Improve processes to ensure risk assessment is conducted within four hours of admission and reassess daily. Assess surgical patients.

17. Inspect Skin Daily Daily skin inspection is required for high-risk patients. Skin integrity can deteriorate in a matter of hours. Always look at sacrum, back, buttocks, heels, and elbows every time the patient is assessed.

18. Manage Moisture Cleanse skin at time of soiling and at routine intervals. Watch for excessive moisture due to perspiration and wounds. Use gentle cleansing agent. Use moisturizers for dry, fragile skin. Provide under-pads that wick moisture away from skin. Keep kit of needed supplies at bedside for at-risk incontinent patients.

19. Optimize Nutrition/Hydration Respect patient�s dietary preferences. Involve dietician, use supplements as needed. Monitor hydration. Offer water (when appropriate) whenever patient is turned.

20. Minimize Pressure Turn/reposition patient at least every two hours. Use alerts and cues to remind staff to turn patient. Protect skin when turning patient (use lift devices or �drawsheets,� heel and elbow protectors, sleeves and stockings; do not �drag�). Use pillows and cushions strategically. Use static and/or dynamic pressure-relieving support surfaces. Static surfaces include well-designed mattresses, mattress overlays filled with water, air, gel, foam, or a combination of these. Dynamic surfaces include devices that vary pressure beneath the patient, reducing duration of pressure at any given skin site.

21. Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) Infection

22. Reduce MRSA Infection The Goal: Reduce methicillin-resistant Staphylococcus aureus (MRSA) infection by December 2008.

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24. Mention country and hospital variabilityMention country and hospital variability

25. This Can Be Done!

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27. What Does the Evidence Tell Us? Target Modes of MRSA Transmission Person-person via hands of health care providers Personal equipment (e.g., stethoscopes, PDAs) and clothing Environmental contamination Airborne transmission Carriers on the hospital staff Rare common-source outbreaks

28. Prevent Infection and Colonization Colonized patients Reservoir for transmission Nearly 1/3 develop infection, often after discharge Long-lasting and can transmit MRSA to patients in other health care settings (e.g., nursing homes) and family members High rates of MRSA colonization complicate empiric antibiotic therapy (e.g., vancomycin) Mention C. diff as effect of antibioticsMention C. diff as effect of antibiotics

29. Human and Financial Impact Over 126,000 hospitalized persons infected annually 3.95 MRSA infections per 1,000 hospital discharges Over 5,000 patients die as a result of these infections Over $2.5 billion excess health care costs attributable to MRSA infections On average, each patient with MRSA infection has: 9.1 days excess length of stay (LOS) Over $20,000 excess cost per case (range $7,000 � $32,000) 4% excess in-hospital mortality

30. Expert Input Association for Professionals in Infection Control and Epidemiology (APIC) Centers for Disease Control and Prevention (CDC) Society for Healthcare Epidemiology of America (SHEA) Experts published in literature Other Campaign partners

31. Five Key Interventions Hand hygiene Decontamination of the environment and equipment Active surveillance cultures (ASCs) Contact precautions for infected and colonized patients Compliance with Central Venous Catheter and Ventilator Bundles

32. Hand Hygiene Single most important intervention before and after patient contact Compliance rates of 40-50% no longer are acceptable Hold staff accountable Encourage patients and families to remind caregivers Alcohol hand rubs make hand hygiene easier Rapidly kill bacteria (except Clostridium difficile spores) Surprisingly gentle on hands Not a substitute for soap and water when hands are grossly soiled

33. TIPS: Hand Hygiene Count the steps! Check placement. Provide the supplies. Provide real-time feedback. Send and post department-level data.

34. Decontamination of Environment and Equipment Use dedicated equipment for colonized/infected patients. Clean patient care and personal equipment when leaving the bedside. � Put environmental services personnel on the team Clean and disinfect the environment carefully. Focus on �high-touch� areas.

35. TIPS: Decontamination Use a checklist for cleaning. Educate staff. Verify competence. Schedule cleaning times for rooms of patients in isolation or on contact precautions. Use immediate feedback mechanisms to assess cleaning and reinforce proper technique.

36. Active Surveillance Use cultures (ASCs) to detect colonized patients. Necessity of ASCs per se in controlling MRSA is controversial. �Knowledge is power.� � Clinical cultures miss many colonized patients. Successful programs combine ASCs with reliable implementation of other interventions. Flag colonized patients when discharged.

37. TIPS: Active Surveillance Begin with admission cultures only. Measure compliance; add the second culture when high (> 90%). Provide real-time notification of positive admission culture. Schedule consistent day of week for second culture. Include culture in routine discharge order sets. Measure transmission. Number or rate of patients who convert from negative to positive Flag colonized patients when discharged.

38. Contact Precautions Use for infected and colonized patients per CDC/HICPAC guidelines Gloves, gowns, and hand hygiene Single rooms preferred Reinforces need for reliable barrier practices Facilitates cleaning during stay and post-discharge If necessary, cohort patients with MRSA

39. TIPS: Contact Precautions Train staff on importance Ensure adequate supplies Check and replenish supplies regularly Consider scheduled times for checking supplies Educate patients and families/visitors Encourage them to question personnel Use �visual cue� especially if single rooms or cohorting not possible Ensure patients on precautions have same standard of care as others frequency of entering the room monitoring vital signs Plan & notify for patient leaving room

40. Device Bundles Critically ill patients at high risk May be colonized or acquire in hospital Bundles Central Line: prevent BSLI Ventilator: prevent VAP Minimize device days!

41. Additional Resources Ihi.org Campaign Materials Getting Started Kit Annotated Bibliography Tools National Calls Mentor Network Hospitals Discussion Groups kathydduncan@comcast.net