Pressure Ulcers Drew Bystedt Katie Glenn Linda Le Javier Solis Bri Weed
Background ●
A pressure ulcer is an area of skin that breaks down when something keeps rubbing or creating friction against the skin.
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Pressure on the skin reduces blood flow to the area. Without enough blood, the skin can die. An ulcer may form.
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Symptoms A.
Red skin that gets worse over time
B.
The area forms a blister, then an open sore
“If you can’t measure it, you can’t improve it” ●
If we do not measure our pressure ulcer rates than we cannot determine how well we are doing in preventing pressure ulcers.
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Counting skin lesions does not result to pressure ulcers.
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Measuring the incidence and prevalence rates of pressure ulcers in our facility.
Measure & Aim Measure: Percentage of patients developing pressure ulcers after admission to facility. Aim: Reduce the incidence rate of facility acquired pressure ulcers by 6% in the next 4 months.
Skilled Nursing Facility ● Highest level of care for older adults outside of a hospital ● Post-Acute Care ● Best choice for patients who require 24-hour medical care and supervision ● Services include: Assessment, treatment, injections, and administration of medications, rehabilitation ● 93.1% of facilities reported pressure ulcers
Root Cause Analysis ●
Root cause analysis ● An accident investigation technique undertaken to find and fix the fundamental causes of an adverse event ● Used following a sentinel event, an incident in which death or serious harm to a patient occurs ● Also used following a near miss event, an incident that did not result in death or injury but could have, only by chance was the patient not harmed ● Ask and understand what went wrong in the process to result in adverse outcomes ● Follows the same steps as PDSA cycle ● Should evaluate whether risk reduction strategies achieved desired results
Improvement Processes ●
Plan-Do-Study-Act Cycle ○ Plan ■ State objectives: Lower pressure ulcers incidence rate ■ State improvements: Quality of care to patients ■ Process changes: Refine rotation process through a new care plan ■ Data collected: Rate of pressure ulcers before implementation plan ○ Do ■ Implement changes: More specific care plan established for patients ■ Document problems: Record issues that arise from the implementation plan ■ Gather data: Record pressure ulcers prevalence rates after implementation
Improvement Processes ●
PDSA continued ○ Study ■ Analyze data: Determine if implementation reduced pressure ulcer rates by comparing before and after rates ■ Compare results: Contrast data with other SNFs ■ Summarize lessons learned: Team collaboration, importance of rotation and detailed care plan ○ Act ■ If unsuccessful, repeat PDSA ■ If successful, implement them on a wider scale with maintaining change in facility
Pressure Ulcer RCA ●
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Outline the problem ○ Reducing the incidence of pressure ulcers anywhere on the skin of patients ○ Patient safety, organization compliance, reduced reimbursements Analysis of problem: Damage to tissue, muscle, bone ○ death of tissue ■ Poor skin condition, poor environment, inadequate nutrition, contaminants on skin ■ Damage of tissue, shear injury, pressure injury ●
Friction injury from patient being repositioned, patient unable to assist in moving
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Pressure injury from patient staying in same position,
Team Management ●
Team Dynamics ○ Learning the essential elements of a functioning team ○ Learning important aspects of team building and team functioning ○ Working as a group to accomplish a task ■ Productive meetings ■ Team composition and roles ■ Decision-making
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Stages of Team Development ○ Forming ○ Norming ○ Storming ○ Performing
Change Management ● ●
Change management is a systematic approach to dealing with change, both from the perspective of an organization and on the individual level. Kotter’s 8- Step Change Model ○ Step 1: Create a Sense of Urgency- Developing a need to change ○ Step 2: The Guiding Team- creating a trusted group to influence others into accepting change ○ Step 3: A Change Vision and Strategy- developing the right vision and strategy for the change efforts ○ Step 4: Communicate the change vision- Create buy-in ○ Step 5: Fewer Obstacles, More Empowerment-Remove obstacles that stop people from acting on the vision
Change Management Cont. â—‹ â—‹ â—‹
Step 6: Identify and celebrate Short-Term Wins- build momentum and energize others Step 7: Consolidate gains and produce more change- Keep implementing change until the vision is fulfilled Step 8: Anchor new approaches in the culture- Create a support structure which will continue the new-winning behavior
Value & Context ● Can be classified as a facility acquired condition that is preventable 2% - 28% of residents have them 60% are at risk for developing them CMS does not reimburse (cost can add up to $70,000) Nearly 60,000 deaths are attributed from acquired pressure ulcers ○ Pressure Ulcer event reduction falls within CMS’ top HAC reduction priorities ○ ○ ○ ○
Value & Context ● CMS launched National Nursing Home Collaborative ● The National Pressure Ulcer Advisory Panel (NPUAP) ● New York State Gold STAMP Program ○ (Success Through Assessment, Management Prevention) ○ Partnership of hospital, home health, skilled
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nursing, hospice, assisted living provider settin and other healthcare stakeholders and partner across New York State.
References ●
http://www.nlm.nih.gov/medlineplus/ency/article/007071.htm
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http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressureulcers/pressureulcertoolkit/putool5.html
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http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressureulcers/pressureulcers/puqio4.htm
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https://healthy.kaiserpermanente. org/static/health/pdfs/quality_and_safety/multi/multi_pressure_ulcers.pdf
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http://www.npuap.org/resources/educational-and-clinical-resources/pressure-ulcer-root-causeanalysis-rca-template/
References ●
http://www.nmmra.org/providers/nursinghomes_ulcers.php
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http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/CertificationandComplianc/Downloads/2012-Nursing-Home-Action-Plan.pdf
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http://www.cdc.gov/nchs/data/databriefs/db14.pdf
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http://www.health.ny.gov/professionals/nursing_home_administrator/gold_stamp/docs/2013-1217_resource_guide.pdf