Using “The Bundle” for Prevention & Reduction of Pressure Ulcers

2. Using “The Bundle” for Prevention & Reduction of Pressure Ulcers Pressure Ulcer Bundles Judy Frisch, RN, MBA, CPHQ Jody Rothe, RN, WCC Gail Wietor, RN, MS-OLQ January 21, 2010

3. 2010 Data Submission and Reports • Due on or about the 10th of each month • New this year, facility specific data • Benchmark to like size facilities • Tool is posted at MetaStar website • Save to your computer • Some of the cells are locked • We will provide like facility and over all numbers for you to enter monthly

6. Objectives • Learn ways to help leadership commit to the Pressure Ulcer Reduction and Prevention Project • Understand how “The Bundles” can assist in decreasing and preventing pressure ulcers • Learn how to activate quality improvement (QI) activities • See how data drives the QI activities • Sustain successes & learn from the failures

7. Organizational Commitment • Leadership has a good understanding of • Quality of life issues • Cost incurred with a pressure ulcer for both the facility and patient/client/resident • Responsibility & accountability of practice • Community stewardship • Pride in the quality of our work • Business case for preventing & reducing ulcers

8. Leadership Commitment • Involves time & resources for • An interdisciplinary workgroup to • Assess current practice, policy & procedures • Identify the gaps • Establish accountability • Design new steps to address gaps • Educate, educate, educate • Measure & evaluate the changes

9. Bundles • Bundles are • Evidence based healthcare interventions • Combined activities for the greatest effect • Proven to reduce & prevent pressure ulcers • Incorporated into daily practice • Reflected in the facilities policies & procedures

10. The Elements of the Bundles • Conduct a pressure ulcer admission assessment for all patients • Reassess risk for all patients daily • Inspect skin daily • Manage moisture: keep patient dry & moisturize skin • Optimize nutrition and hydration • Minimize pressure

11. The Bundles • Offer • Tools – flow diagrams, checklists & assessments • Rationale • Plans of Action • Assessment checklists for policies & procedures • Guidelines

12. Activate Quality Improvement (QI) Activities • Choose the members of the interdisciplinary team • Secure leadership approval of commitment to project • Refer to Bundles for recommendations – business case etc • Check if you have the right members at the table • Potential members listed in the Bundles

13. Activate QI Activities • Write a team charter to plan • what you want to accomplish (aim) • how are you going to know that you have accomplished your aim (measures) • what are you going to change (QI activities) • Map out the current process • Use process tools to capture current practice • Flow diagrams, top down flowcharts, fishbone diagram, Root Cause Analysis

14. Identify Gaps in your Process • Review the facility’s Pressure Ulcer policies & procedures • Checklist for reviewing policies & procedures • Side by side comparison of the policies & procedures with the current process • Identification of gaps between practice & policy & procedures

15. Project Aim • Based on the gap analysis • Identify what you want to accomplish • Be specific with the accomplishments • Provide a date of when you will accomplish it • Insert into your charter & review at each meeting • Change the aim if it is not working

16. Project Measures • Adopt the project and process measures • Timely risk assessment • Timely skin assessment • Timely preventive strategies • Pressure ulcer prevalence • Facility acquired rate

17. Timely Risk Assessment:Percent of admissions with timely risk assessment performed • Denominator: • Number of admissions for the month to your facility or pilot population • Numerator: • Number of above admissions that have timely assessments with a standardized risk-assessment tool, such as the Braden Scale • Hospitals and Nursing Homes: within 8 hours of admission • Home Health, Hospice and Assisted Living: at time of admission evaluation

19. Timely Skin Assessment:Percent of admissions that have a timely, comprehensive skin assessment performed • Denominator: • Number of admissions for the month to your facility or pilot population • Numerator: • Number of above admissions that have timely, comprehensive skin assessments • Hospitals and Nursing Homes: within 8 hours of admission • Home Health, Hospice and Assisted Living: at time of admission evaluation

21. Timely Preventive Strategies:Percent of patients/residents/clients who receive preventive strategies soon after being identified as at-risk • Denominator: • Number of admissions for the month to your facility or pilot population, who are identified as at-risk • Numerator: • Number of above admissions that receive timely, preventive strategies • Hospitals and Nursing Homes: within 24 hours of admission • Home Health, Hospice and Assisted Living: within 48 hours of admission evaluation

23. Pressure Ulcer Prevalence:Percent of patients/residents/clients with pressure ulcers at one point in time during the month • Denominator: • Number of patients/residents/clients who had their skin assessed on the chosen day • Numerator: • Number of patients/residents/clients with (a) pressure ulcer(s) • Number of patients with at least one pressure ulcer are counted, not the number of pressure ulcers • All patients with at least one pressure ulcer are included, regardless of the stage(s)

25. Facility-Acquired Rate:Percent of patients/residents/clients with facility-acquired pressure ulcers • Denominator: • Number of patients/residents/clients who had their skin assessed on the chosen day • Numerator: • Number of patients/residents/clients with at least one facility-acquired pressure ulcer • Count the number of patients with at least one pressure ulcer, not the number of pressure ulcers • Include all patients with at least one pressure ulcer, regardless of the stage(s)

27. Project QI Activities • Plan Quality Improvement activities • Use evidence based interventions located in the bundles • Seek out existing resources (MetaStar Website @ www.metastar.com) • Ask other participants what they are doing & what is working for them • Educate, educate, educate • Monitor prevention and treatment

28. Key Areas for Staff Education • Pressure ulcer assessment • Monitoring treatment & prevention for patients/residents with pressure ulcers • Treatment options for pressure ulcers • Accurate documentation • Care planning/MDS coordination

29. Pressure Ulcer Prevention • Early Prevention intervention may include: • Protecting skin against effects of pressure, friction, & shear • Protecting skin from moisture • Encouraging optimal nutrition and fluid intake • Positioning for optimal prevention

30. Manage Moisture • Manage moisture • Minimize exposure • Products to absorb moisture • Topical agents • Be proactive • Take advantage of grouping tasks • Be prepared with supplies at hand

31. Optimize Nutrition & Hydration • Use a team approach • Include dietician early • Ask all caretakers to assess & report back • Offer the nutritional plan in the grouping of tasks • Make sure documentation is complete • Engage family • Family Fact Sheet @ www.ihi.org

32. Minimize Pressure • Use cues to turn/reposition patients every two hours • Keep supplies in patient rooms • Assess for use of re-distribution surfaces • Use turning techniques • Prevent friction & shear injury

33. Pressure Ulcer Assessment • On admission, change in condition, each MDS assessment or transfer to another unit • Address using the Braden or Norton tool • Impaired mobility • Incontinence/moisture • Nutritional deficits • Altered Level of Consciousness • Altered sensory perception

34. Monitoring & Treatment • Wound assessment & documentation • Site/location • Size • Pain • Stage • Drainage • Appearance • Physical health • Psychosocial status • Nutrition/ hydration status-nutritional assessment • Pain status-comprehensive pain assessment

35. Treatment Guidelines • Clinical Practice Guidelines provide current principles and protocols for prevention and treatment • 1996 AMDA Pressure Ulcer Clinical Practice Guideline: Pressure Ulcers • 1999 AMDA Clinical Practice Guideline: Pressure Ulcer Therapy Companion • AHCPR Clinical Practice Guideline #3: Pressure Ulcers in Adults: Predication and Prevention • AHCRP Clinical Practice Guideline #15: Pressure Ulcer Treatment

36. Accurate Documentation • Reflect the necessary information to communicate pressure ulcer risk and/or presence • For hospitals the present on admission (POA) documentation • For Nursing homes the MDS

37. Care Planning for Pressure Ulcers • Development of a Care Plan • Interdisciplinary team needs to be involved • Areas of risks and interventions should be addressed in the resident’s care plan as they apply to specific problems • Education of the resident and family

38. Care Plan • Once care plan developed, the process involves: • Implementation of the plan of care • Monitoring the response to the plan of care • Ensuring oversight (person(s) or team) for implementation • Reassessment of the plan of care

39. Tips for Success • Post data for staff to understand the issues • Name the project • Consider a Pressure Ulcer Unit Champion • Determine ownership of documentation • RN, CNA, others • Identify barriers to address • Saying not enough staff is an excuse

40. Contact Information: MetaStar, Inc. 2909 Landmark Place Madison, WI 53713 800-362-2320 www.metastar.com jfrisch@metastar.com; ext. 8216 jrothe@metastar.com; ext. 8271 gwietor@metastar.com; ext. 8227 This material was prepared by MetaStar, the Medicare Quality Improvement Organization for Wisconsin, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 9SOW-WI-PS-09-196