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Pressure is On to Reduce Pressure Ulcers

 |  By cclark@healthleadersmedia.com  
   November 21, 2013

No longer accepted as "normal complications," pressure ulcers are the target of healthcare leaders who are investing in prevention strategies and seeing results.

This article appears in the November issue of HealthLeaders magazine.

Just a few years back, hospital-acquired pressure ulcers at 506-licensed-bed Crouse Hospital in Syracuse, N.Y., and other organizations, were "accepted as normal complications" that sick patients are just likely to get, says Chief Quality Officer Derrick Suehs.

"That's the way it was. We'd say, 'Patient Bob has just had surgery and will be lying in bed for five days, and we should watch to see if he gets an ulcer.' We identified these ulcers when they occurred, and then we took care of them."

That attitude is now gone at Crouse, where stage 3 and 4 pressure ulcer rates for the two-year period ending June 30, 2011, were higher than all but 105 other acute care hospitals reporting data, according to spreadsheets prepared by the Centers for Medicare & Medicaid Services and displayed on Hospital Compare. With 0.671 per 1,000 eligible discharges, Crouse was much worse than the national average of 0.136.

"Today the conversation has changed," Suehs says. "Now it's, 'How do we prevent them in the first place?' It's a different mental framework. We get physicians, nurses, and hospitals to move away from the idea that these are normal complications, so they're okay."

Crouse launched numerous initiatives to reduce all of its preventable hospital-acquired conditions, or HACs, including a control chart that has tracked pressure ulcers at all severity stages by quarter since 2006.

Teams with physician and nurse champions educate frontline staff to be on the lookout for the earliest signs of skin redness at stage 1 or 2. They work with a team of wound ostomy nurses to evaluate patients who might be at higher risk because of the immobility necessitated by their condition or disease or when pain makes movement intolerable.

Patient skin assessments are taken on a daily basis, and a special budget was approved to buy new beds designed to prevent pressure ulcers for the entire hospital. The beds are equipped with mechanisms to relieve pressure on heels and elbows. Crouse also rents special mattresses embedded with air and water that staff use to easily shift patients' positions to relieve pressure.

One important action is to make sure that nursing and admitting staff correctly code patients who arrive at the hospital with an existing pressure ulcer; coding the pressure ulcer as present on admission will help ensure that Crouse is not blamed for causing it, says Jennifer Watkins, Crouse's director of quality improvement.

"Especially with patients coming from a nursing home, for example, if we don't take the opportunity to do a full assessment in the beginning, a pressure ulcer may appear to be a hospital-acquired condition, when in fact the patient came in with skin already starting to break down," Watkins, says.

And Crouse's rates of severe decubitus ulcers are dropping. Hospital officials say the latest update shows Crouse's rates of pressure ulcers at 0.447. It's not zero yet because the rolling evaluation period still captures the time frame when Crouse's pressure ulcer rates were higher.

At Adventist Sonora (Calif.) Regional Medical Center, which has 72 acute care beds, pressure ulcer rates were almost as high those at Crouse for that period, at 0.645 per 1,000 eligible discharges. Sonora Regional had the distinction of having the 114th highest number of pressure ulcers on Hospital Compare.

"We recognized we had a problem," says Dixie Hukari, Sonora's executive director of quality management. "But with a number of interventions, we haven't had a patient with a hospital-acquired stage 3 or stage 4 pressure ulcer since May 2011."

They initiated turning schedules, began using moisture barriers for vulnerable parts of patients' skin surfaces, and initiated a campaign called the PUP, or Pressure Ulcer Prevention, program.

How hospitals deal with severe bedsores and seven other HACs from the Agency for Healthcare Research and Quality PSI-90 list is increasingly important. They're now folded into two pay-for-performance programs under the Patient Protection and Affordable Care Act. The AHRQ PSI-90 counts for 35% of the 1% Medicare base DRG hospital-acquired condition penalty, and counts for about 6% of the value-based purchasing incentive program, provided that the hospital has a minimum number of cases for all measures in the equation. Poorly performing hospitals will see downward adjustments to their reimbursements starting Oct. 1, 2014.

To be sure, it's a bad thing for a hospital like Sonora, which serves a large retirement community, if there's a penalty for having too many pressure ulcers and other preventable HACs. It means a loss of important revenue, Hukari says.

But the financial penalties aren't the reason for increased efforts, she says.

Rather, it was "public reporting of these conditions that really got our attention. It's not like we didn't know we had them, but we didn't have rates we could compare with other hospitals. And ours was a pretty high rate."

The hospital already had a wound care nurse who was part time but decided to increase that to full time, and gave the nursing support staff additional education so they have wound care certification. Sonora's expanded efforts include working with Premier healthcare alliance's Hospital Engagement Network and looking at where its patients were getting pressure ulcers, such as around the ear due to oxygen tubing friction.

And it turned out that a lot of the ulcers occurring were associated with nasal cannulas used to deliver oxygen. Leaders realized that they could purchase different products that reduced the risk, such as a cannula that had a padded part that fit over the ear.

Elastic stockings, special cold pads, and skin inspections of patients every 12 hours or at the start of every shift change were also implemented, "so we can catch problems early and implement these tools to keep any redness from developing into a pressure ulcer," Hukari says.

Sonora has also given more attention to patient nutrition, to beef up calories and the amount of protein to speed wound healing.

At 382-bed WellStar Cobb Hospital in Austell, Ga., the two-year preventable pressure ulcer rate for the period that ended June 30, 2011, was 0.239, higher than the national average of 0.136 per 1,000 eligible discharges.

Marcia Delk, MD, WellStar Cobb's senior vice president for safety, quality, and credentialing and chief quality officer, says that failure to document patients who came in with pressure ulcers was one reason the hospital might have looked worse than it was.

"Previously, nurses would recognize a pressure ulcer and start interventions, but they didn't document it. It took a little time for the team to understand what those needs were and make sure they reflected [them] in the record."

Other practices include the use of what Delk calls a "turn and assist" product to protect the sacrum, a common site of pressure ulcers. The product is made from parachute-like material that reduces friction and slipping, absorbs moisture, and helps staff reposition patients.

With a new Epic electronic health record system to be installed at WellStar Cobb soon, there will be an embedded alert mechanism for nurses and doctors to signal the beginnings of skin breakdown, Delk says. The alert prompts review and documentation, as well as two-way communication.

Until then, the hospital uses a "pink sheet," with a diagram of the patient showing the areas of concern.

"That allows the physician to go right to that area with the nursing team and make sure they're dealing with the correct area of the body," Delk says.

Other strategies include spending $5 million across the five-hospital WellStar system to purchase special beds, including about 30 beds that use alternating air pulsations to reduce pressure on certain areas and shift the patient's weight around on a schedule that nursing staff can customize.

But one effort the hospital is excited about, Delk says, is a still somewhat experimental Early Mobility Program for all patients in the intensive care unit, including those on ventilators. Launched by Johns Hopkins researchers, the program requires staff to devote time with ICU patients to get them up and moving, actually walking, even while on ventilators, she says.

So far, the program has not only reduced pressure ulcer formations in the ICU, but also seems to have increased muscle strength, reduced pulmonary complications in this high-risk population, and increased their alertness because sedation is decreased during the process.

"Patients who can get up and participate seem to enjoy it. Even though they don't enjoy being sick, it gives them a very positive attitude that they are making progress," Delk says.

Delk adds that there have been no pressure ulcers, according Johns Hopkins' most recent report covering 2010 to 2012.

Other efforts include expanding nutritional assessments and using a silicon-based foam dressing on certain parts of the body prophylactically, regardless of whether skin breakdown has begun, to act as a moisture barrier that protects the skin.

"We're now thinking of expanding the use of this product beyond the ICU to other patients in the hospital because we've had such good results," she says.

Delk emphasizes that the WellStar system has been traveling on its quality improvement journey at a faster pace in recent years to improve care for its patients.

"But if there was a turning point, it was the review of the data [on HACs] that focused our efforts on where we need to prioritize and improve. We're not perfect, but we are first to say we are on a journey that involves constantly looking at our data to tell us where we should focus," Delk says.

At Crouse and other hospitals, strategies are not piecemeal, with different teams or individuals addressing each of the HACs. It isn't like one group assesses fall risk and another makes sure there isn't a central line bloodstream infection and another group worries about urinary catheter use.

Rounding with physicians and staff includes assessments of all these risks at the same time, says Watkins. "Our efforts are encompassing to get staff to pay attention to what's going on with the patient at all levels so we reduce all hospital-acquired conditions."

And it's important not to let efforts stop once a hospital starts to see success, Suehs adds.

"A lot of places will say, 'Good, for the past three months we've been able to do this.' They declare victory.

"I think one of our successes is that we don't declare victory, even after nine months. We're waiting for a year and a half before we actually say we've made a difference. We want to make sure that our changed habits and technology are embedded in our care."

Reprint HLR1113-9


This article appears in the November issue of HealthLeaders magazine.

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