August 18, 201611:00 a.m. – 12:00 p.m. CT

AHA/HRET HEN 2.0 PRESSURE ULCER/INJURY WEBINAR

ADVANCING SKIN SAFETY: MANAGING MOISTURE AND PERFECTING PREVALENCE

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WELCOME AND INTRODUCTIONSLauren Kaderabek, Program Manager, HRET | 11:00 – 11:05

HRET/HEN 2.0 Hand Hygiene (Soap UP!) Office HoursAugust 23| 11:00 – 12:00 p.m. CT

HRET/HEN 2.0 Leadership Engagement WebinarAugust 25| 11:00 – 12:00 p.m. CT

HRET/HEN 2.0 Rural/CAH Affinity Group WebinarAugust 29| 11:00 – 12:00 p.m. CT

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UPCOMING WEBINARS

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HRET HEN RESOURCES

• 2016 Change Package• Top 10 Checklist• Resources• HRET HEN Pressure

Ulcer Topic website

ENCYCLOPEDIA OF MEASURES (EOM)• Catalogued measure

information available on the HRET HEN website– HEN Core Topics –

(evaluation measures)– HEN Core Process

Measures– HEN Additional Topics

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• Pressure Ulcers Analytics Listserv® is available for:– Sharing of:

• HRET Resources• Publically Available Resources• Best Practices• Learnings from Subject Matter Experts

– Troubleshooting for Data Reporting and Analysis

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SIGN UP TODAY: PRESSURE ULCERS LISTSERV®

Sign Up Here

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AGENDA FOR TODAY

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HEN DATA UPDATEAnnette Urganus, Data Analyst, HRET | 11:05 – 11:10

Baseline 2015-10 2015-11 2015-12 2016-01 2016-02 2016-03 2016-04 2016-05 2016-06Relative reduction,

baseline to Feb - Apr 2016

Pressure Ulcer Rate, Stages 3+ (per 1,000 patients)

1.44 0.63 0.87 0.63 0.72 0.74 0.85 0.81 0.88 1.02 -44%

Number (%) of hospitals reporting

1078 (83%)

1015 (78%)

1014 (78%)

1022 (79%)

931 (72%)

899 (69%)

875 (67%)

769 (59%)

664 (51%)

368 (28%) --

Pressure Ulcer Prevalence, Hospital-Acquired-Stage 2+

0.34 0.21 0.24 0.23 0.22 0.25 0.25 0.21 0.25 0.35 -30%

Number (%) of hospitals reporting

1033 (80%)

859 (67%)

869 (67%)

958 (74%)

861 (67%)

864 (67%)

880 (68%)

747 (58%)

698 (54%)

458 (36%) --

Results for months in which data submission was less than 50% should be interpreted cautiously, as the data on which the results are based is not yet complete.

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HEN DATA UPDATE

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LOOKING BEYOND PRESSURE TO KEEP SKIN SAFEDot Weir, RN, CWON, CWS, Wound Management, The Wound Healing Center of Osceola Regional Medical Center| 11:10 – 11:30

• Previously referred to as:– Perineal dermatitis– Incontinence associated dermatitis– Irritant dermatitis– Diaper dermatitis / diaper rash

• Regardless of name, very costly and painful skin damage• Must be differentiated from a pressure injury• COMMONLY called “excoriation”

– We’ll put that to rest

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MOISTURE ASSOCIATED SKIN DAMAGE (MASD)

TOP-DOWN INJURIES

• Newer concept to describe superficial cutaneous injuries– Versus “bottom-up” injuries such as pressure injuries

• Injuries resulting from– Mechanical forces– Moisture and/or the effects of inflammation– Friction

• Three most common– Moisture associated skin damage (MASD)– Medical adhesive related skin injury (MARSI)– Skin tears

Thayer DM, Rozenboom B, Baranoski S. Top-down Injuries, Prevention and Management of Moisture-Associated Skin Damage (MASD), Medical Adhesive-Related Skin Injury (MARSI) and Skin Tears. In: Doughty D, McNichol L. WOCN Core Curriculum, Wound Management. Chapter 17, Wolters Kluwer, 2016.

MOISTURE-ASSOCIATED SKIN DAMAGE

• Inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture– Urine or stool– Perspiration– Wound exudate– Mucous or saliva

• Includes intertriginous skin related issues

Thayer DM, Rozenboom B, Baranoski S. Top-down Injuries, Prevention and Management of Moisture-Associated Skin Damage (MASD), Medical Adhesive-Related Skin Injury (MARSI) and Skin Tears. In: Doughty D, McNichol L. WOCN Core Curriculum, Wound Management. Chapter 17, Wolters Kluwer 2016.

• Increases permeability and decreases barrier function• Stratum corneum normally slightly acidic and protects the

skin from pathogens when intact• Moisture, or moisture with friction can allow pathogens to

enter– Commonly Candida albicans and Staphylococcus

• Alkaline nature of urine changes pH of skin may enhance erosion by proteases and lipases found in fecal incontinence when present further eroding skin surface

• When skin is moist, effects of friction are more damaging

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EFFECTS OF MOISTURE ON SKIN

Zulkowski K. Diagnosing and Treating Moisture-Associated Skin Damage, ADV SKIN WOUND CARE 2012;25:231-6;

INCONTINENCE IRRITANTS

• Urine– Water: saturates skin, reduces

hardness, increases risk of friction and erosion

– Ammonia: raises pH, promotes pathogenic growth, disrupts acid mantle, activates fecal enzymes

– Damage can occur within 48 hours

Gray M. Journal of WOC Nursing 2004; 31(1 Suppl):S2-9 .

• Stool– Fecal enzymes: damage stratum

corneum, promotes erosion, worse in high volume diarrhea

– Gastrointestinal Bacteria: may be pathogenic

– Damage in 8 hours (possibly less) with high volume diarrhea

INCONTINENCE IRRITANTS

Gray M. Journal of WOC Nursing 2004; 31(1 Suppl):S2-9.

INCONTINENCE IRRITANTS

• Incontinence containment devices1,2, 3

– ↑ skin permeability– ↑ CO2 emissions & skin pH,

effect cumulative over time– Frictional trauma– Alteration to microflora of skin– Skin response varies based on

type & brand of device

1. Grove GL et al. Clinical Problems in Dermatology 1998; 26:1832. Zimmerer RE et al. Pediatric Dermatology 1986; 3: 95.3. Zhai H et al. Skin Research & Technology 2002; 8:13.

DIAGNOSIS CRITICAL

• Present on admission policy in hospitals• Incorrect diagnosis at admission can have far

reaching implications• Education to staff (medical and nursing)

MOISTURE-ASSOCIATED SKIN DAMAGE

• Must differentiate between pressure, diabetic, arterial, venous, moisture-associated skin damage and “other” type wounds?

ASSURE THAT WOUNDS ARE CLASSIFIED AND IDENTIFIED APPROPRIATELY

NPUAP 2016 CONSENSUSSTAGE 2 PRESSURE INJURY DEFINITION

• Partial-thickness loss of skin with exposed dermis. – The wound bed is viable, pink or red, moist, and may also

present as an intact or ruptured serum-filled blister. – Adipose (fat) is not visible and deeper tissues are not visible.

Granulation tissue, slough and eschar are not present. – These injuries commonly result from adverse microclimate

and shear in the skin over the pelvis and shear in the heel. • This stage should not be used to describe moisture associated skin

damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).

MOISTURE-ASSOCIATED SKIN DAMAGE

• Moisture alone causes maceration– Acute inflammation and skin loss are usually due to a combination of

maceration and some other source of injury (chemical irritant, friction or pathogenic invasion)

• Treatment begins with identifying and removing cause– Clostridium difficile or tube feeding–related diarrhea– Type of urinary incontinence– Use of containment devices

• Foley catheter (not ideal)• Condom catheter• Fecal containment system

• Topical management is a structured skin protocol – Cleansing, moisturizing and protecting

• Use of topical antifungals and steroids only when indicated

Gray M, Black J, Baharestani M. et al. Moisture-associated skin damage: Overview and Pathophysiology. Journal Wound Ostomy & Continence Nursing, 2011, 38(3), 233-241.

MOISTURE ASSOCIATED SKIN DAMAGE

• Promote skin health with adequate protection

• Eliminate or minimize exposure to irritants

• Treat infection if present– Fungal or bacterial

• Formulations to protect skin from mechanical injury and stripping

• Most are a polymer with a solvent and when the solvent evaporates there is a film left on the skin

• Available with or without alcohol

• Available as a long wearing cyanoacrylate

PROTECT SURROUNDING SKIN

RE-ASSESS EFFECTIVENESS

EXCORIATION: ANY SUPERFICIAL LOSS OF SUBSTANCE, AS THAT PRODUCED ON THE SKIN BY SCRATCHING.

INTERTRIGINOUS DERMATITIS (INTERTRIGO)

• Thought to be caused by a combination of two factors– Overhydration of skin due to trapped moisture – Friction between two opposing skin folds

• Begins as mild erythema and progresses to severe inflammation with mirrored areas of skin erosion; can erode to full thickness

• Common areas of involvement– Axillae – Intergluteal cleft– Inguinal region– Under breasts– Abdominal or pubic pannus– Neck folds (infants and obese) with drool or sputum

Thayer DM, Rozenboom B, Baranoski S. Top-down Injuries, Prevention and Management of Moisture-Associated Skin Damage (MASD), Medical Adhesive-Related Skin Injury (MARSI) and Skin Tears. In: Doughty D, McNichol L. WOCN Core Curriculum, Wound Management. Chapter 17, Wolters Kluwer, 2016.

INTERTRIGO• Patients complain of pain, itching, burning and odor• Can develop secondary infection (candidiasis, staph, pseudomonas)• Prevention

– Keep clean and dry• Improve airflow

– Wear loose clothing– Utilize moisture wicking products

• Treatment– Air circulation– Use of textile products to wick away moisture– Foam dressings, peripads or socks– Light dusting of antifungal powders

Voegeli D. Moisture-Associated Skin Damage: An overview for community nurses. British Journal of Community Nursing. 2013, 18(1), 6,8,10-12.

INTERTRIGO

• Consensus panel brought forward underappreciated problem in 2012– Defined as an occurrence in which erythema and/or other manifestation of

cutaneous abnormality including, but not limited to, vesicle, bulla, erosion or tear

• Common skin damage due to use of adhesive products particularly (but not exclusively) in institutional healthcare

• Includes:– Irritant contact dermatitis– Allergic contact dermatitis– Maceration– Mechanical trauma– Tension blisters– Folliculitis

MEDICAL ADHESIVE RELATED SKIN INJURY (MARSI)

McNichol L, Lund C, Rosen T, Gray M. Medical adhesives and patient safety: state of the science: consensus statements for the assessment, prevention, and treatment of adhesive-related skin injuries. J Wound Ostomy Continence Nurs. 2013 Jul-Aug;40(4):365-80

MARSI

• Prevention and treatment dependent on cause– Assess for high risk:

• Elderly • Frail • Thin skin

• Minimize use of adhesives on skin• Assess for allergies• Bevel edges of thick foam products• Silicone adhesion• Roll gauze, net and tubular bandage support

MARSI

• Recognize causative factors of any alteration in the skin’s integrity– Treatment driven by cause– Present on admission

• Continuously reassess for improvement– Watch for bacterial or fungal overgrowth – Change treatment plan

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SUMMARY

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Thank You!

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HOW LEADERSHIP CAN FIX PRESSURE ULCERS/INJURIESKerry Johnson, BSN, RN, Assistant CNO, Palm Beach Garden Medical CenterNekisha Hyman, BSN, RN, Wound Care Coordinator, Palm Beach Garden Medical CenterTammy Levasseur, RN, PI Specialist, Palm Beach Garden Medical CenterMaria Mezquita, MBA, BS, MT, DCQI ,Palm Beach Garden Medical Center | 11:30 – 11:45

• 199 Bed hospital• 44 ICU beds, includes 12 CVICU beds• 125 Telemetry beds• Primary Service Line-Cardiovascular• Average open heart surgeries per month: 27• Average cardiac caths (diagnostic & PCI per month) 200-220

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MEET OUR TEAM

• David O’Brien, MSN, MHA, RN, CNO• Kerry Johnson, RN, BSN, ACNO• Nekisha Hyman BSN, RN Wound Care Coordinator• Melissa Dacunha, Director of Telemetry• John Secreto, BSN, MHSA, RN, Critical Care Director• Andrew Silverman, RN, BS, MSN, Director• Maria Mezquita MBA, BS, MT, Director Quality

Improvement• Tammy Levasseur, RN, P.I. Specialist

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OUR TEAM

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HOSPITAL ACQUIRED PRESSURE ULCER RATES

0.88

0.64

1.66

0.26 0.26

0.80

1.02

1.861.73

1.97

1.78

0.90

1.91

1.22 1.25

1.87 1.87 1.87 1.87

2.65

0.00

0.50

1.00

1.50

2.00

2.50

3.00

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

Hospital Acquired Pressure Ulcer Rates

2016 HA Rate

2015 HA Rate

HA Threshold

Key principles in our success:

• Leadership Engagement• Teamwork – Materials, Nursing, Quality, Administration, Front Line

Staff• Front Line Staff Engagement• Transparency is Trust• Learning Culture• High Reliability Organization• Celebrate the Win

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SETTING THE STAGE….

• Executive Visibility• Leadership Creating the Culture of Rounding• Breaking Down Silos• Transformational Leadership Style• Transparency of Data

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CULTURE OF ENGAGEMENT - LEADERS

• Interdisciplinary Rounding• Weekly SPAE Meetings• Monthly Wound Care Meeting

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LEADERSHIP INFRASTRUCTURE

• All Hands on Deck• Culture of Trust• Early Reporting & Recognition

– Pressure Ulcer Incident Reporting– Increased Level of Comfort– Increased Incident Report Compliance

• Education• Transformational Leadership Style

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CULTURE OF ENGAGEMENT - STAFF

• Used data to determine area of focus – Anatomical Locations – Medical Device Related – Present on Admission – Early Recognition

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WHERE WE STARTED OUR JOURNEY

• POA Documentation Improvements• ER & Ambulatory Surgery are the First Line in POA Wound

Documentation. • MDPRU Prevention Improvements• Targeted PUP

• ET Tubes & Holders • Bi-Pap• Tracheotomy Faceplate• O2 Tubing

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TESTS OF CHANGE & WHAT WE LEARNED

• Recognition• Reporting• Staging• Education

SOLUTION• Ongoing Education with Staff • Education of New Staff • Moisture Management Protocol• Skin Tear Treatment Protocol

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BARRIERS AND HOW WE RESOLVED

Decrease in Pressure Ulcer Rate in the ICU Units From 6% to 0% in June 2016!!!! What Measures Did We Use?

• Prevalence Data Collected Annually• Incidence Data Collected Monthly

Where Did We Find The Data?• Data Collected Through Our Incident Reporting System and Correlated With Wound Care Data Collected on Wound Rounds

How Did We Share Data With Our Team?• Transparency Across All Disciplines

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MEASURES

• Celebrate the positive– Daily support and encouragement through rounding – Give real-time feedback to staff– Effective & consistent communication

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CELEBRATE THE WIN!

• Engaged & Supportive Leadership Team Drive Service Excellence• Data Analysis is a Critical Component to System Improvements &

Positive Outcomes• Go to the Gemba- Daily Multidisciplinary Wound Care/Prevention

Walking Rounds • Front-Line Staff Engagement• Collaborative Effort with an Evidence Based Medicine Focus• Daily Accountability measures in place to sustain performance• Patient and Family Centered Care• Celebrate the Win !!

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OUR PEARLS

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PERFECTING PREVALENCE: MOVING FROM “DO WE HAVE TO?” TO “LET’S HAVE A PARTY!”Jackie Conrad, RN, MBA, Improvement Advisor, Cynosure Health | 11:45 – 11:55

Incidence Prevalence

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TERMINOLOGY

MOISTURE ASSOCIATED SKIN DAMAGE IS NOT INCLUDED IN PRESSURE INJURY / ULCER INCIDENCE AND PREVALENCE REPORTING

• Prevalence describes the number or percent of patients having a pressure ulcer at a single point in time. – N= # of patients with stage II or greater (POA excluded)– D = # of patients assessed on the day of the study

• NDNQI Training Modules (free to non-members) https://members.nursingquality.org/NDNQIPressureUlcerTraining/Default.aspx

– Module 1 – Pressure Ulcer Staging– Module 2 – Other Wound Types –tears, MASD– Module 3 – Pressure Ulcer Survey Guide – How to Conduct a

Prevalence Study– Module 4 – Community vs. Hospital Acquired PrU

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PREVALENCE

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• Team based activity• Promotes professionalism• Just in time teaching on staging,

assessment, preventative care– Auditors– Front line staff

• Positive patient perception• Real time observations

– PrU prevention measures– Fall prevention measures– CAUTI prevention measures– CLABSI prevention measures

• Staffing challenges• Time commitment• NDNQI is quarterly, isn’t that

enough?• No skin team to champion

Do We Have To? Let’s Have a Party!

THE POWER OF PREVALENCE

Gerald Champion Cross Cutting Prevalence Tool• Excel spread sheet• Data collected during

prevalence study– CAUTI– CLABSI– Falls– Hygiene– Infection Control

http://www.hret-hen.org/resources/display/cross-cutting-prevalence-data-collection-tool

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TOOLS

http://www.hret-hen.org/resources/display/hospital-acquired-pressure-ulcer-prevalence-study-data-collection-tool-

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TURNING THE BURDEN INTO JOY

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BRING IT HOMELauren Kaderabek, Program Manager, HRET| 11:55 – 12:00

What are you going to do by next Tuesday? Find out how your hospital measures pressure ulcer incidence. What

is the current incidence or prevalence rate compared to baseline?

What are you going to do in the next month? Meet with your organization's skin champion to review MASD

protocols

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PHYSICIAN LEADER ACTION ITEMS

What are you going to do by next Tuesday? Review supplies and materials available to managing skin moisture Preview the NDNQI training modules and consider spreading to all

direct care staff.

What are you going to do in the next month? Work with materials to obtain the right equipment and products to

keep patients skin dry Evaluate staff knowledge in recognizing and treating MASD Plan educational activities to increase staff knowledge in early

recognition and treatment of MASD.

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UNIT-BASED TEAM ACTION ITEMS

What are you going to do by next Tuesday? Assess the organization’s plan to recognize and treat MASD Inquire what barriers exist in conducting monthly prevalence studies

What are you going to do in the next month? Meet with the skin care champion to develop a plan to initiate

monthly prevalence studies Support the skin team’s choices in product selections for managing

MASD

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HOSPITAL LEADERS ACTION ITEMS

What are you going to do by next Tuesday? Review patient education materials for pressure ulcer / injury

prevention

What are you going to do in the next month? Engage a patient to patient family advisor in the selection process for

moisture management supplies and materials

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PFE LEADS ACTION ITEMS

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QUESTIONS?

Find more information on our website: www.hret-hen.org

Questions/Comments: hen@aha.org

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THANK YOU!