Innovations to Stop Pressure Ulcers among Patients at Critically

High Risk for Pressure Ulcer Development – a Multidisciplinary

Approach

October 14 2016

Disclosures

The speakers have nothing to disclose.

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Amy Bratta, PT, DPTJulie Rece, MSN, RN, CRRN, CWOCN

Marci Ruediger, PT, M.S.Holly Stevens, RD, LDN, CNSC

Acknowledgements

The Pressure Ulcer Prevention Leadership Team

• Amy Bratta, PT, DPT

• Christopher Formal, M.D.

• Robert Kautzman, BSN, Ph.D.

• Deborah Long, MSN, RN, CRRN

• Julie Rece, MSN, RN, CRRN, CWOCN

• Marci Ruediger, PT, MS

Other Key Players

• Patricia Barker, RHIT, CDIP

• Paul Buttner, RN, BSN, CWON

• Naoko Otsuji-Miwa, RN, BSN, CRRN, CWOCN

• Evelyn Phillips, MS, RD, LDN, CDE

• Pamela Thompson, IT Clinical Systems Manager

• Skin Champions

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Objectives

Participants will be able to:

• describe a bundle of best practices to prevent pressure ulcers in rehab patients at highest risk.

• describe methods for safely mobilizing and feeding patients who are at highest risk for pressure ulcers

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96 Bed Inpatient Acute Rehab Hospital

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About Magee

How we got started

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Baseline efforts

• Strong collaboration -wound care and nutrition

• High quality tube-feeding supplements

• Advanced seating capabilities

• Everyone turned and shifted

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Nursing-Specific Actions

• Head to toe assessment by RN, WOCN, MD

• Head of bed

• Weekly full body assessment with photos

• Shift of WOCN hours8

WOC Team

Barriers for Skin Protection

• Foam

• Ointments

• pH balanced skin cleanser

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Supplies

• Liberal use of barriers - protect intact skin exposed to stool

• Elimination of plastic from bed pads and briefs

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Nursing-Specific Communication

• Staff education

• Wound care formulary

• Supply guidelines 11

Equipment

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Poop in a Group

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Physician

WOCN

Front-line nurse –BI/stroke

Therapy Seating Specialist

Pharmacy Director

Nurse manager -SCI

NutritionNursing supervisor General Rehab

Physician-Specific Actions

• Physician champion

• Assess skin at admission

• Engage nursing assistants

• Work with WOCN to identify and stage ulcers

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What is malnutrition?• Consensus statement by the Academy of Nutrition and Dietetics &

American Society of Enteral and Parenteral Nutrition in 2012

Risk Factors• Insufficient energy intake• Weight loss• Loss of muscle mass• Loss of subcutaneous fat• Localized or general fluid accumulation • Decreased functional status

Starvation-Related

Malnutrition(anorexia nervosa)

No

Acute Disease or Injury- Related

Malnutrition (trauma, burn,

major infection, TBI)

Yes

Chronic Disease-Related

Malnutrition (renal disease, cancer,

Sarcopenic obesity)

Jensen GL, Bistrian B, Roubenoff R, Heimburger DC. Malnutrition syndromes: A conundrum vs. continuum. JPEN J Parenter Enteral Nutr. 2009; 33 (6):710-716.

Inflammation present?

Statistics on Malnutrition

• Approximately 30-50% of patients admitted to acute hospitals are malnourished

• If left untreated, ~2/3 of these malnourished patients will experience a further decline in their nutrition status

• Malnutrition is associated with a 200–500% higher risk for developing a pressure ulcer among other conditions

Coats KG, Morgan SL, Bartolucci AA, Weinsier RL. Hospital-associated malnutrition: a reevaluation. J Am Diet Assoc. 1992:93:27-33. Giner M et al. In 1995 a correlation between malnutrition and poor outcome in critically ill patients still exists. Nutrition. 1996:12:23-29. Braunschweig C, Gomez S, Sheean PM. Impact of declines in nutritional status on outcomes in adult patients hospitalized for more than 7 days. J Am Diet Assoc. 2000; 100:1316-1322; quiz 1323-1324. IHI.org . Whittington K, et al. J WOCN. 2000;27:209–215. Banks M, Bauer J, Graves N, et al. Nutrition. 2010;26:896-901. Thomas DR, et al. Am J Clin Nutr. 2002;75:308-13. Schneider SM et al, Br J Nutr 2004; 92: 105-111.

Rate of Malnutrition on Admission to Magee

Approximately 52% of all Magee patients present with malnutrition & 51% of those

patients have at least 1 pressure ulcer reported on admission.

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- Assess for malnutrition on admission and initiate support

- Use tube feeding formulas with liquid modular proteins

- Meet at least 80% of protein at admission

- Review medications

- Other risk factors

Clinical Nutrition Innovations

Nutrition Take-Aways

• Consult registered dietitian

• Initiate enteral feeding within first 24-48 hours

• Consider PEG tube if unsafe swallow or unable to meet nutrient needs as per dietitian’s assessment

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Skin Peers

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Therapy Innovations

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Therapy Innovations

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Interdisciplinary Innovations

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Collaboration with other providers

• Bracelets for transported patients

• Brain-storming with providers from a cardio-thoracic ICU

• PA Hospital Engagement Network 3 -year collaborative

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Leadership

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Culture Change

• Moisture dermatitis as “stage 0”

• Sense of urgency related to prevention of skin breakdown

• Principles of Just Culture applied

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Results to Date

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

FY 12 FY 13 FY 14 FY 15

Serious Pressure Ulcers per 1000 Patient Days

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Why did it take so long?

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The Challenge of Wicked Problems

• New challenges with devices

• Staff turn-over

• New patient challenges

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Replication of Process

• Interdisciplinary work

• Iterative process

• Innovation –creating solutions

• Not accepting failure

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Lessons We Learn Again and Again

• Leadership and accountability matter.

• Without these - > much work and no improvement

• Things get “unfixed” without constant vigilance.

• “Over-communication” is a necessity.

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Having Fun While Raising Awareness

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References• Carson, D, Emmons K, Falone W, and Preston AM. Development

of Pressure Ulcer Program across a University Health System. J Nurs Care Qual. 2011; Vol. 00, No. 00, pp. 1-8.

• Coleman S, Nixon J, Keen J, et al. A New Pressure Ulcer Conceptual Framework. Journal of Advanced Nursing. 2014; 70(10), 2222-2234.

• Cox, J., and L. Rasmussen. "Enteral Nutrition in the Prevention and Treatment of Pressure Ulcers in Adult Critical Care Patients." Critical Care Nurse 34.6 (2014): 15-27. Web.

• DeJong G, Hsieh CJ, et al. Factors Associated with Pressure Ulcer Risk in Spinal Cord Injury Rehabilitation. Am J Phys Med Rehabil2014; 00:1-16.

• Edsberg LE, Langemo D, Baharestani MM, et al. Unavoidable Pressure Injury: State of the Science and Consensus Outcomes. J Wound Ostomy Continence Nurs. 2014; 41 (4): 313-334.

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References (continued)• Hoffer, L. J., and B. R. Bistrian. "Appropriate Protein Provision in

Critical Illness: A Systematic and Narrative Review." American Journal of Clinical Nutrition 96.3 (2012): 591-600. Web.

• McClave SA, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society Critical Care Medicine (SCCM) and American Society of Parenteral and Enteral Nutrition (ASPEN). JPEN 2016;40(2):159-211.

• National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014.

• Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals: SECOND EDITION: Administrative and financial support provided by Paralyzed Veterans of America

• Tappenden, K. A., B. Quatrara, M. L. Parkhurst, A. M. Malone, G. Fanjiang, and T. R. Ziegler. "Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition." Journal of Parenteral and Enteral Nutrition 37.4 (2013): 482-97. Web.

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BELIEVE if there’s a willthere’s a way backMAGEE Rehabilitation Hospital

THANK YOU!

Marci Ruediger, PT, M.S.mruediger@mageerehab.org215.587.3454

Julie Rece, MSN, RN, CRRN, CWOCNjrece@mageerehab.org215.587.3432

Holly Stevens RD, LDN, CNSChstevens@mageerehab.org215.587.3092

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