level 2 pressure ulcers are a pain in the @&%! part 2 2 pressure...level 2 pressure ulcers are a...

Level 2 Pressure Ulcers are a Pain in the @&%!

Part 2

NPA Annual Conference

October 19-21, 2015

Presenters:

Verna Sellers, MD, MPH, AGSF, CMD

Kimberly Woodley, ASQ-CQE

Objectives

With information from this session attendees

should be able to:

• Learn how to develop a risk assessment tool that

addresses the needs of the population they serve.

• Learn from Level 2 events

• Learn to implement IDT interventions based on the risk

score

“Being ignorant is not so much a shame, as being unwilling to learn.”

- Benjamin Franklin

Centra - A regional not for profit integrated health

system serving communities in central Virginia

Acute Care

• 4 acute care

facilities

• 850 licensed beds

• 225,000 annual ER

visits

• 260 employed

physicians

• 550 active medical

staff

• 8,000 employees

• Level 2 trauma

center

• Clinical leadership

in all major service

lines

Post Acute Care

Long

Term

Acute

Care

Hsptl

Inpatient

Rehab

Facility

Palliative

Care &

Inpatient

HospiceFree

Standing

Skilled

Nursing

Facilities

Home

Health &

Hospice

Services

P.A.C.E.

Senior

Living

Facilities

Emergency

Mental Health

Inpatient

Child/Adol

Adult

Geriatric

Residential

Treatment:

Child/Adol

Chemical Dep

Rivermont

Schools

Outpatient

Psychiatric

Services

Centra PACE

• In February 2009, Centra PACE, opened

its first site in Lynchburg, Virginia.

• Service area includes urban and rural

areas of central Virginia.

• ~110 Participants

Centra PACE Expansion

• In January 2013, Centra PACE, opened its

second site in Farmville, Virginia, approximately

an hour away from Lynchburg.

• Service area is a rural area in the center of

Virginia.

• ~ 70 participants

Level 2

• Unusual incidents that result in serious adverse

participant outcomes OR negative media coverage

related to the PACE organization.

• Incidents meet reporting thresholds as defined by July

2015 Guidance

• Require reporting to CMS (DMAO), Regional Office, and

State Administrating Agency

• Majority require an internal investigation of the

occurrence, with the goal of identifying failures and

improvement opportunities.(RCA)

Background

“An investment in knowledge always pays the best interest”.

- Benjamin Franklin

• How are pressure ulcers staged?

• What is a level 2 pressure ulcer?

Level 2 Pressure Ulcers

Acquired while enrolled in PACE (includes a

pressure ulcer that is present upon enrollment, but

worsens after enrollment):

• Unstageable

• Stage IV

• Stage III

Stage 1

Stage 2

Stage 3

Stage 4

DTI

Unstagable

9

Braden Scale Challenges

“Tis a great confidence in a friend to tell him your faults; greater to tell him his.”

- Benjamin Franklin

• Subjective: “always”, “occasionally”, “limited”

• Moisture: “linen changes”

• Activity: “majority of shift”

• Nutrition: “every meal”

• Friction: “bed or chair”

Warner-Maron, Annals of Long Term Care, May 2015

Plan CheckCurrent Metrics

March 2015

Goals:

2014 FMV Rate: 2.6% per month

2014 LYN Rate: 2.1% per month

Team Members

Dawn Stanley, FMV Int Ctr Mgr Kendra Kerr, Int LYN Ctr Mgr

Renee Gilliam, FMV Clinic Coord Jenny Link, LYN Clinic Coord,

Cassandra Hurt, FMV HCC Carol Arthur,LYN HCC

Meagan Waller, FMV Dietician Brenda Meredith, LYN Dietician

Verna Sellers, MD Kimberly Woodley, Facilitator

Carol Emerson, CODA Chrissette Brooks, Outcomes Specialist

Do● Print hard copies of graph and Treatment/Prevention Research -Complete

● Review graph and research prior to next meeting. - Complete

● Add Therpy Rep to Team - Complete

● Assure Clinic Nurse Can Attend - Complete

● Determine scoring - Continues

● Deveiop interventions - Continues

● Steps required for implementation - Continues

ACT:

● Review PACE Pressure Ulcer Policy prior to next meeting - Team● Evaluate wording for mobility and moisture - make "frequent" less subjective - Kim

● Because Moisture is so key; calculate total score using a weighted score of

0,1,2, 4 - Kim

Pressure Ulcer Reduction

Mission Statement: Reduce the percertange of participants, who acquire any

pressure ulcer after enrollment into the PACE program or a pressure ulcer that

is present upon enrollment worsens. This rate includes all pressure ulcers

regardless of the location or stage when it is initially identified.

2015 Goal is to reduce the Centra rate to ≤ 1.5% of PACE participants will

acquire a pressure ulcer in any given month or have a pressure ulcer present on

admission worsen. This is a stretch goal.

FMV 1.8% 1.8%

LYN 1.0% 1.9%

Centra PACE 1.3% 1.9%

Site

Percentage of Participants w/

Acquired Pressure Ulcers

during month.

Prevelence of Participants

w/ Acquired Pressure

Ulcers.

Risk Score Low n=11

Low/Mod

n=5 Mod n=13 High n=13

11 1

12 0

13 0

14 1

15 1 2

16 1

17 0

18 2 1

19 2

20 1

21 1

22 1 1

23 6 2

24 1 1 1

25 3 3 1

26 2 0 1

27 5 1

11 5 13 13

Propose:

High: ≤ 21

Moderate 22 to 24

Low ≥ 25

0

1

2

3

4

5

6

7

11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

Numb

er of

Parti

cipan

t

Risk Scores

Risk Assessment Score

Low n=11

Low/Mod n=5

Mod n=13

High n=13

Centra PACE’s Risk

Assessment“He that can have patience can have what he will”.

- Benjamin Franklin

• Project has been active for 18 months

• SIXTH Revision

• Has not been clinically proven

• Has not been statistically determined to be

repeatable and reliable

• Numeric scores cannot be compared to Braden


Assessment• Scoring is weighted in relationship to the

“importance” of criteria as determined by the

team.

• Developed using stratified or selected sample to

assure inclusion of participants at a variety of

risk levels

• Has not yet replaced the Braden (but will when

team has ‘buy in’).

SENSORY PERCEPTION

ability to respond meaningfully

to pressure- related discomfort

1.Comple te ly Limite d

● Unresponsive (does not moan flinch or

grasp to painful stimuli due to diminished

level of consciousness or sedation

OR

● Limited ability to feel pain over most of

body

2 . Ve ry Limite d

● Responds only to painful stimuli. Cannot

communicate discomfort except by

moaning or restlessness

OR

● Has a sensory impairment which limits

the ability to feel pain or discomfort.

3 . S lightly Limite d

● Responds to verbal commands but

cannot always communicate discomfort

or the need to be turned.

OR

● Has some sensory impairment which

limits the ability to feel pain or discomfort

in 1 or 2 extremities.

4 . No Impa irme nt

● Responds to verbal commands. Has no

sensory defic it which would limit ability to

feel or voice pain or discomfort.

COGNITIVE IMPAIRMENT 1.La te , Se ve re Impa irme nt

● Nearly unintelligible verbal output

● Remote memory gone

● Unable to copy or write

● No longer grooming or dressing

● Motor or verbal agitation

● MMSE 0 to 10

2 . Middle , Mode ra te Cognitive

Impa irme nt

● Disoriented to date, place

● Comprehension difficulties (aphasia)

● Impaired new learning

● Getting lost in familiar places

● Delusions, agitation, aggression

● MMSE 11 to 20

3 . Ea rly, Mild Cognitive Impa irme nt

● Disoriented to date

● Naming difficulties (anomia)

● Recent recall problems

● Mild difficulty copying figures

● Decreased insight

● Problems managing finances

● MMSE 21 to 25

4 . Mild Cognitive Impa irme nt

●Report by patient or caregiver of memory

loss

● Objective signs of memory impairment.

● Mild construction, language, or

executive dysfunction.

● MMSE 26 to 30

MOISTURE

degree to which skin is exposed

to moisture (include feet)

0 . Inc ontine nt of Bla dde r a nd/or

Bowe l

● R equires changing every two hours.

1. Ve ry Moist

●Skin is often moist (socks/shirt are moist

to touch at changing ~ once a week)

●Incontinent at times (~ once a week)

●Requires assistance changing

●BMI ≥ 40 w/ multiple skin folds

2 . Oc c a siona lly moist.

● Skin is occasionally moist.(socks/shirt

are moist to touch at changing ~ once a

month)

● Two or fewer skin folds

● Moisture between toes

4 . Contine nt of bla dde r a nd bowe l

● Toilet self OR

● Able to change self w/o assistance

ACTIVITY

degree of physical activity

1. Be dfa st

● Confined to bed.

2 . Cha irfa st

●Ability to walk severely limited or non-

existent.

● Cannot bear own weight and/or must be

assisted into chair or wheelchair.

3 . Wa lks Oc c a siona lly

●Walks occasionally during day but for

very short distances with or without

assistance.

●Spends majority of time in bed or in

chair.

4 . Wa lks Fre que ntly

● Walks at least once every two hours

during waking hours.

NUTRITIONNutrition risk assessment w ill be

assessed by RD in semiannual/ annual

assessment. Rated on a scale of 1-4

as a skin core under "other" in skin

part of nutritional assessment.

1. Ne e ds proba bly not be ing me t

(two or more of the following

fa c tors)

● Weight loss or BMI ≤ 23

● Poor/ fair intake in Center

● No appetite; poor intake

● Interventions in place to meet nutritional

needs, but status remains compromised

● Totally dependent for feeding

/hydrating

2 . High Risk (two or more of the

following fa c tors)

● Weight loss due to insuffic ient calories

● Dependent and/or refuses

supplements/food

● Intake is primarily "empty calorie food"

● BMI ≤ 23

● Takes > 40 minutes to eat

● Upper GI or mouth issue effecting PO

3 . Mode ra te Risk (one or more of

the following fa c tors)

● Weight stable but questionable protein

intake.

● Dependent on supplements

● Intake is primarily "empty calorie food"

● BMI ≤ 23

● Upper GI or mouth issue effecting PO

● Weight Loss Pattern

4 .Low Risk

● Weight stable indicative of calories to

spare protein.

● Intake is primarily balanced diet from

"My Plate"

● Adequate food resources

● Able to feed self without problems

FRICTION & SHEER 1. Ma ximum Assista nc e

● Requires moderate to maximum

assistance in moving.

● Complete lifting without sliding against

sheets is impossible.

● Frequently slides down in bed requiring

frequent repositioning with maximum

assistance.

2 . Ne e ds Assista nc e

●Maintains relatively good position in

chair or bed most of the time but

occasionally slides down, and needs

assistance for repositioning.

4 . No Assista nc e

●Maintains relatively good position in

chair or bed most of the time .

● Needs no assistance in repositioning.

Scoring:

5 to 11 High Risk of developing a Pressure Ulcer

12 to 17 Moderate Risk of developing a Pressure Ulcer

18 to 24 Mild Risk of developing a Pressure Ulcer

Centra PACE Pressure Ulcer Risk Assessment

Braden Risk Assessment

• Five Risk Categories

– Very High Risk: Total Score 9 or less

– High Risk: Total Score 10-12

– Moderate Risk: Total Score 13-14

– Mild Risk: Total Score 15-18

– No Risk: Total Score 19-23

– Sample of n=36: 92% of Participants scored

“mild” or “no risk”; which means only 8%

identified as moderate or greater.


Assessment• Three Risk Categories

– High

– Moderate

– Mild

• Sample of n=36: 25% score moderate


Assessment Sample (n=36)

Braden

• 92% Mild or Very Mild

• 8% Moderate

• 55% Participants score 17

Centra

• 75% Mild

• 25% Moderate

Centra PACE’s Level 2

“By failing to prepare, you are preparing to fail.”

- Benjamin Franklin

• 83 year old Male

• Participant lived alone at home, and was receiving end of life/ palliative care

services in home. Participant’s wishes were that he die in his home, which

he did.

• Significant diagnoses include CAD, Dementia, Depression, Diverticulosis,

Esophageal stricture, Gait disturbance, Hemiplegia, Hyperlipidemia, HTN,

MI old, PVD, PHB, Anemia, Anxiety, Atherosclerosis, A-fib, Cataract, CVD,

CKD stage 3,

• IDT team’s main concerns related to participant prior to event: Fall with

injury, Impaired skin integrity, End of life/palliative care in home (includes,

minimally weekly visits by PACE Nurse Navigator), Assist participant and

family with end of life process, and Adverse reactions to medications


In home Personal Care Aide called Nurse Navigator and described wound on

hand near palm protector. PACE Nurse Navigator made home visit and found

stage III pressure ulcer in the area between the pointer finger and the thumb.

Identification of risk points and their potential contribution to the event:

•No documentation of education being provided to family or Personal Care Aide

on use of Palm Protector which potentially may have led to improper use of the

Palm Protector

•OT assessment did not list palm protector as a brace or splint in 06/08/15 OT

assessment which potentially may have led to improper use of the Palm

Protector. Assessment had been done in person prior to 06/08/15, but was not

documented until that time.

•Home Care 06/10/15 assessment did not list Palm Protector in DME list and it

was not addressed in POC for skin which may have led to skin breakdown.


• Therapy will develop a log that will list DME, date issued, participant name,

education conducted (check off), and documented in EMR (check off) which

should include with whom education occurred and date. Outcomes

Specialist will audit process from July to December to assure

implementation.

• A question will be added to Home Care Assessments regarding the

participant using a brace or splint. The EMR has been updated with fields

for the device and for education that is provided to family/PCA, etc.

• The EMR has been updated with fields for education provided by Therapy

to family/PCA etc. Outcomes Specialist will audit to assure compliance.

• Educate Therapy to notify Dayroom C.N.A. if nail care needs to be

performed.


• Develop a Therapy specific email list.

• Therapy will utilize the “Daily to Do List” to better communicate within

Therapy.

• When an assessment is done off site or away from a computer, down time

form will be used.

• Develop an education module for skin assessment.

• Active Performance Improvement Team Pressure is working to reduce

Acquired Pressure Ulcers. Currently, the team is working to develop a Risk

Assessment Tool that addresses the PACE population. Other future work

will involve revision of current policy and assure appropriate interventions

for risk levels.

IDT Approach to Prevention

“Instead of cursing the darkness, light a candle.”

- Benjamin Franklin

• Providers/ Clinic

– Skin assessment using a risk assessment tool,

minimally during annual/semi annual, but more if

participant is at high risk.

– Pre/Post Respite skin assessments

– Recommendation of skin barriers ointments

– Treatments to prevent worsening if breakdown

occurs


• Dietician: Nutrition– Hepatic proteins (albumin/pre-albumin) are not markers of malnutrition but do correlate with

mortality & morbidity and thus are useful indicators of illness severity

– Protein intake should be 1.25-1.5 gm/kg; severe illness or injury may need 2.0 gm/kg

– Energy intake should be 30-35 cal/kg

– Arginine stimulates insulin secretion, promotes the transport of amino acids into cells, and

supports the formation of protein in the cells. “There is growing body of moderate-quality

evidence supporting the positive effect of supplementation with additional protein, arginine,

and micronutrients to promote pressure ulcer healing.”

– Vitamin C can be met usually with diet.

– Zinc deficiency may cause loss of appetite, abnormal taste, impaired immune function, and

impaired wound healing. On the other hand, “high-serum zinc levels may inhibit healing,

impair phagocytosis, interfere with copper metabolism and induce a copper deficiency

(copper is essential for collagen cross-linking.)”

2015 White Paper from the National Pressure Ulcer Advisory Panel.


• Home Care:

– Educating Participants/Families/Caregivers:• Proper hygiene

• Keeping participants dry

• Changing Pads pull ups

• Changing positions

• Use of skin barriers ointments

• Notifying PACE at the first sign of skin breakdown

• Well fitting shoes

• Brace/splint fit

– Assuring pressure release devices are in use

– In home/facility skin assessments


• Activities/Dayroom:

– Keeping participants dry

– Changing Pads pull ups

– Toileting Schedule

– Use of skin barriers ointments

– Notifying Clinic at the first sign of skin breakdown

– Assuring pressure release cushions are in use


• Therapy:

– Well fitting shoes

– Brace/splint fit

– Pressure release devices- cushions,

mattresses, etc.


• Transportation:

– Evaluation of routes, if possible LIFO (Last in,

first off)

– Cushions/ Dysum mats

Reduction“You may delay, but time will not.” - Benjamin Franklin

• 2013: 3.1%

• 2014: 2.2%

• 2015 YTD: 1.3%

Number of Participants

with Acquiring a

Pressure Ulcer during

the month/PMPM

Acquired Pressure Ulcer Rate Trend

Jan'13 to Aug'15

Final Thoughts

• Pressure Ulcer Risk Assessment should be a part of the

semi annual/annual/ and unscheduled assessments

• Developing a Risk Assessment tool to address the

PACE population may be beneficial

• Regardless of the tool used, an IDT approach to

prevention is necessary for success.

level 2 pressure ulcers are a pain in the @&%! part 2 2 pressure...level 2 pressure ulcers are a...

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