stop patients at critically pressure ulcer...
TRANSCRIPT
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Innovations to Stop Pressure Ulcers among Patients at Critically
High Risk for Pressure Ulcer Development – a Multidisciplinary
Approach
August 30, 2016
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The presenters have no interests to disclose.
This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with PVA. PESG, PVA, and all accrediting organization do not support or endorse any product or service mentioned in this activity.
Deborah Long, MSN, RN, CRRN, LNC Marci Ruediger, PT, M.S.
Holly Stevens, RD, LDN, CNSC2
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Learning Objectives
At the conclusion of this activity, the participant 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 patients who are at highest risk for pressure ulcers in an inpatient rehabilitation setting.
• Describe the contributions of various interdisciplinary team members in a pressure ulcer prevention collaboration.
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CE/CME Credit
If you would like to receive continuing education credit for this activity, please visit:
http://PVA.cds.pesgce.com
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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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96 Bed Inpatient Acute Rehab Hospital
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About Magee
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About Magee
Outpatient Satellite Clinics
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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 hours10
WOC Team
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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 13
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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
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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?
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Inflammatory Response to Illness, Surgery, Trauma
Malnutrition
Hospital Acquired Conditions, Including
Pressure Ulcers
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.
Making the Connection
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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.
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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
‐ Meet at least 80% of protein at admission
‐ Meet 100% of the calorie, protein and fluid needs by day 3
‐ Use tube feeding formulas with liquid modular proteins‐ easily tolerated
Clinical Nutrition Innovations
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Nutrition Take‐Aways for Acute Care
• Feed as soon as metabolically stable
• 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, FaloneW, 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.
• DeJongG, 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.
• 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, [email protected]
Deborah Long, MSN, RN, [email protected]
Holly Stevens RD, LDN, CNSC40