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

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%

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

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

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

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

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

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

Pressure Injury Prevention Tool

The Team

developed a

Pressure Injury

Prevention Tool

for risk

assessment and

recommendations

for pressure

relief.

Policy and Procedure Algorithm

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

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

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

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

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

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

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

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

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

Weekly Wound Report

Metrics Report

Pressure Injury Graphs July 2016-July 2017

Add Wound

Add Status

Add Intervention

Add Treatment

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.