Pressure Injury Quality Improvement Strategies...Pressure Injury • With increasing enrollment...
Transcript of Pressure Injury Quality Improvement Strategies...Pressure Injury • With increasing enrollment...
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M A R G A R E T W I L B E R , R N , B S NS H A R O N M O O R E A N P - B C , W O C N
B R I A N L E H M A NO C T O B E R 1 7 , 2 0 1 7
Pressure Injury Quality Improvement Strategies
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Pressure Injury Quality Improvement Strategies
• Catholic Health LIFE opened November 1, 2009
• Occurrence reporting-falls
• Falls Performance Improvement Team
• 2010 fall rate 19.51%
• 2016 fall rate 12.34%
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Pressure Injury
• With increasing enrollment there were increased
reported pressure injuries
• Factors driving LIFE to address this trend:
1. Changes to Level II reporting in 2013, 2014 & 2015
Level II Pressure Injuries
• LIFE Level II reports
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2012 & 2014 CMS Survey Findings
2. CMS audits resulted in findings for SDY04-Participant
Assessment, which also drove the standardization of surveillance
and assessment
• CMS found that the Home Health Assessments were
completed by the clinic nurse. CMS required the Home
Health RN Assessment in the home after enrollment
including a skin check
• The corrective action plan included one assessment to be
completed by the community RN in the home and the
second assessment to be completed by the Center RN
• This is in addition to the RN assessment completed at
enrollment
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Wound Performance Improvement Team
In 2014 a Wound Performance Improvement Team was created
GOALS:• Critically analyze the wound process and wound outcomes
• Review and analyze the rate of SNF vs. Community pressure injuries for 2012 and 2013 to develop a reduction rate for 2014
• Nurse Practitioner to become wound certified
• Develop a process to identify participants at risk upon admission, when there is a decrease in mobility and upon discharge from a hospital or SNF
• Develop interventions to address risk
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Wound Performance Improvement Team
Early Efforts
• Weekly Wound meeting
• Revise Skin Assessment & Pressure Injury Prevention
Policy & Procedure
• 2013 audit determined that the Braden Tool did not
predict risk, for those participants that developed a
pressure injury
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Wound Performance Improvement Team
Systems and Process
The team:• Developed a standardized nursing wound progress note
• Developed standards of wound measurement
• Developed a consent form for wound photography
• Revised the P & P:o All participants have a full RN assessment to include completion of the
Braden Scale and PIPT at enrollment, 6 & 12 months or with a significant change in condition
o Follow up home visits include a full skin examination, education, ensuring a treatment plan is in place including appropriate DME
o Once the participant has reached a 6 month reassessment without a reoccurrence, the plan can be re-evaluated in concurrence with the PCP staff
These assessments enable the IDT to prioritize appropriately and aggressively care plan pressure injury risk and pressure injury relieving interventions
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Wound Performance Improvement Team
Reintroduce Braden
• Risk assessment-validated risk assessment
tool
• Braden tool reintroduced with education
and guidance from the LIFE WOCN NP
• Developed frequency of assessments based
upon Braden score:o A score of 16 or greater-follow up visit every 6 months
o Score of 15 or 14-every 3 months
o Score of 13 or less and/or history of previous pressure injury-every month
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Pressure Injury Prevention Tool
The Team
developed a
Pressure Injury
Prevention Tool
for risk
assessment and
recommendations
for pressure
relief.
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Policy and Procedure Algorithm
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Wound Certification
• Sharon Moore ANP-BC became wound certified, providing education
and leadership
o Educated staff RN’s on pressure injury risk, staging, treatments,
interventions, and education for the participants/caregivers
o Educated and recognized the HHA’s as the front line prevention staff
o Coordinated DME vendors to in-service staff on pressure relieving
devices to include mattresses, wheel chair cushions, Broda chairs
o Urinary/bowel incontinence products, moisture wicking mattress
pads
o Educated surgeons, wound specialists and infectious disease
providers on the PACE model of care
o NP, RN’s and social work often attend appointments
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Continuum of Care Process Improvements
• LIFE RN completes a weekly visit to the SNF to
assess the participant’s pressure injury and to
complete a case communication
• Pressure Injury Prevention Tool
• Utilized for SNF nursing case communications
• Faxed to the hospital for all LIFE admissions
• LIFE supplies DME to the SNF
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Continuum of Care Challenges
• SNF challenges:
• Culture of resistance from the SNF staff
• Nursing staff unavailable to participate in case communications
• Agency staff
• Unavailability of the medical record
• LIFE has:
• Gained access to the Catholic Health SNF EMR
• Developed some trust
• LIFE RN’s have developed some good working relationships in
the SNF
• The SNF’s have become educated about the LIFE program over the
years
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Process Improvements
• Staging and documentation inconsistencies-LIFE & SNF
• LIFE WOCN NP confirms the staging for any reported
Stage III, IV or unstageable pressure injury-Level II
• Upon discharge from the hospital, SAR or a respite stay
longer than 3 days, the participant is brought directly to
the clinic for assessment and a complete skin check is
performed
• Allows clinical staff to address any skin issues that may
not have been known during the hospital, subacute or
respite stay
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Database Development
• Weekly Wound Meeting-Excel spreadsheet
utilized to track the progress of all open wounds
• Access database was developed in 2014
• Track all wounds across the continuum of
care
• By 2015 LIFE was outgrowing Access
• Additional reporting couldn’t be supported
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Database Development
• 2015 LIFE began discussions with Emergencetek Group
• Points for discussion included:
• Capital Expenditure and Cost Approval
• Hosting Solutions
• Licenses for Third Party Components
• Security – Access Rights to Software
• IT Liaison to facilitate access to vendor for development
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Database Development
• Much work was undertaken to create the new database:o Creating standard wound types
o Creating standard anatomical structures & direction
o Creating standard treatments
o Creating standard interventions
• All wounds were mapped from the Access database into
the new database
• LIFE QA staff manually reviewed, verified and edited
any insufficient mapping of 2015 and 2016 wounds into
the database
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Outcomes
• 2016 Quarter 4-the weekly wound report
was operational
• This enabled the ability to determine
pressure injury rates for 2015 and 2016!!!
• Data driven processes
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Pressure Injuries
Results:
• In 2015 pressure injury acquisition rate among community participants was 2.89%; in 2016, 2.12%.
• In the SNFs the 2015 rate was 5.34%; compared to 3.21% in 2016.
• The 2015 hospital rate was 0%; 2.22% in 2016.
• There was no significant difference (P>.05) among care site comparisons but the total reduction from 3.41% in 2015 to 2.45% in 2016 was statistically significant (P <.05).
• The prevalence of pressure injury present at enrollment increased from 0.17% in 2015 to 0.38% in 2016 was statistically significant (P<.05).
0%
1%
2%
3%
4%
5%
6%
2015 2016
LIFE Yearly Acquired Pressure Injury Rate(Includes all locations)
Community SNF Hospital Total
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Weekly Wound Report
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Metrics Report
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Pressure Injury Graphs July 2016-July 2017
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Add Wound
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Add Status
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Add Intervention
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Add Treatment
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Next Steps
Determine if 2017 Wound Performance Improvement Team
Goals have been met:
• Decrease the rate of newly developed pressure injuries by 25%.
• Prevent Stage II pressure injuries from progressing to Stage III,
IV or Unstageable.
• Review and consider implementing Pressure Ulcer Scale for
Healing (PUSH) tool
• Develop Care Plan problem that encompasses all skin
interventions
The Braden Score and Tissue Type have been added to the
database for future reporting and implementation of the PUSH
tool.