resource nurse program.a nurse-initiated, evidence-based program to eliminate hospital-acquired...

PROFESSIONAL PRACTICE

Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.

136 J WOCN ■ March/April 2014 Copyright © 2014 by the Wound, Ostomy and Continence Nurses Society™

J Wound Ostomy Continence Nurs. 2014;41(2):136-141.Published by Lippincott Williams & Wilkins

Resource Nurse Program A Nurse-Initiated, Evidence-Based Program to Eliminate Hospital-Acquired Pressure Ulcers

Nancy Beinlich � Anita Meehan

■ ABSTRACT

This article describes the process used to establish a system-wide, sustainable team of staff nurses to serve as unit-based re-source nurses charged with aiding colleagues in the assessment, treatment, and prevention of pressure ulcers. A multidisci-plinary program was developed to address barriers in prevent-ing hospital-acquired pressure ulcers, including incomplete knowledge of causative factors, confusion in determining wound etiology, incorrect staging, inaccurate Braden Scale scoring, and inconsistent application of evidence-supported prevention interventions. The Resource Nurse Program was ini-tiated in a community-based 511-bed, acute care teaching hos-pital located in the Midwestern United States.

KEY WORDS: cost analysis, peer-to-peer learning, pressure ulcer prevention, resource nurse, HAPU

� Nancy Beinlich, MSN, RN, CWON, Director, Wound Center, Akron General Medical Center, Akron, Ohio. � Anita Meehan, MSN, RN-BC, CNS, ONC, Clinical Nurse Specialist, Gerontology, Akron General Medical Center, Akron, Ohio.

The authors declare no confl icts of interest.

Correspondence: Nancy Beinlich, MSN, RN, CWON, Akron General Medical Center, 400 Wabash Ave, Akron, OH 44307 ( [email protected] ).

DOI: 10.1097/WON.0000000000000001

■ Introduction

Preventing hospital-acquired pressure ulcers (HAPUs) is of paramount importance as healthcare providers focus on challenges related to providing high-quality, cost-effective care. A growing aging population, with associated in-creases in prevalence of chronic diseases and advancing technology that increases survival rates for victims of major trauma, all contribute to an increasing number of patients at risk for pressure ulcer (PU) development. 1 , 2 Pressure ulcers represent a signifi cant economic burden to the healthcare system; analysis of Medicare data fi nds that these wounds account for approximately $2.3 billion to 3.6 billion dollars in healthcare costs each year. 3

Given the signifi cant economic and healthcare burden associated with PUs, providers are challenged to look for cost-effective ways to prevent these lesions, especially when they are hospital acquired. Hospital acquired pres-sure ulcers are defi ned as a nurse-sensitive quality care indicator, implying that good nursing care can prevent their development. 4 A pilot survey of nurse's knowledge related to PU management conducted by Ilesanmi and associates 5 reports that effective prevention demands ade-quate knowledge of evidence-supported assessment and

prevention strategies as opposed to reliance on traditional or ritualistic practices.

Wound, ostomy and continence (WOC) nurses possess advanced knowledge in the assessment, treatment, and pre-vention of PUs and serve as an important resource for staff nurses. The specialized practice of the WOC nurse focuses on identifi cation of population trends, planning and imple-mentation of quality improvement strategies, and evalua-tion of outcomes. 6 While the WOC nurse is an effective resource for preventing PUs, there are insuffi cient numbers of these specialized clinicians, and not enough time to edu-cate the number of staff required to effectively assist in decreasing these preventable wounds in the acute care set-ting. 7 Monitoring risk and reduction of PUs also requires organizational support and unit-level interactions. 8

In 2009, while reviewing charts during clinical wound rounding, an advanced practice WOC nurse from the wound center of a 511-bed hospital located in the Midwestern United States identifi ed inconsistencies in both Braden Risk Assessment scores and initiation of appropriate interven-tions by staff nurses. During the same time period, the Centers for Medicare & Medicaid Services publically reported a change in policy that impacted reimbursement for treat-ment of HAPUs. These 2 events served as the impetus for development of a Resource Nurse program at our facility.

■ Intervention

A multidisciplinary program was developed to address bar-riers in preventing hospital-acquired pressure ulcers, includ-ing incomplete knowledge of causative factors, confusion in determining wound etiology, incorrect staging, inaccurate

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J WOCN ■ Volume 41/Number 2 Beinlich and Meehan 137

Braden scoring, and inconsistent application of evidence-supported prevention interventions. This model assists in changing practice by supporting an interdependence of peers learning and teaching each other in pursuit of a com-mon goal of improving patient outcomes, in this instance, decreasing hospital-acquired pressure ulcers. 9

The proposal to create a Resource Nurse pilot program at our facility was initially presented to our Nursing Practice Council, which approved additional development. The chief medical offi cer and senior vice president of nursing also approved the proposal. Financial support was provided through the Wound Center operating budget, which contin-ues to fund the program. Resource Nurses are compensated at their hourly rate for completing 12 hours of peer educa-tion monthly. In addition, a quarterly incentive is awarded to participants who complete the required v36 hours of edu-cation per quarter. Resource Nurse time is beyond the par-ticipants’ scheduled hospital shifts. The pilot program began with 6 resource nurses, representing 5 medical-surgical units and 2 intensive care units. These units were selected because they were identifi ed by quarterly incidence and prevalence data as the units with the highest number of HAPUs.

The program director is a master's-prepared WOC nurse, who, in consultation with a gerontological clinical nurse specialist, developed the educational curriculum using current evidence and adult-learning methods. The teaching provided to Resource Nurses consists of a combi-nation of interactive Web-based and classroom instruc-tion, hands-on learning, and preceptor-guided clinical observation. The course includes evidence-supported risk assessment modalities, identifi cation and staging of wounds, accurate wound documentation, prevention of and intervention modalities for PU, principles and treat-ment of moisture-associated skin damage, and age-related PU risk factors. In addition, the hospital librarian provides a course on the use of software programs to enhance the Resource Nurses’ access to the professional literature.

We believe that ongoing mentoring and learning opportunities are essential for the long-term success and stability of our Resource Nurse program. Time is allocated to familiarize Resource Nurses with the responsibilities of their new role ( Table 1 ). The program director facilitates a mandatory monthly meeting that focuses on unit out-comes and shared accomplishments, along with challenges and barriers to prevent these wounds. These meetings are also used to critique pertinent journal articles and discuss opportunities for advancing program outcomes. These meetings are considered essential because they provide the opportunity to share unit experiences with each other, which has been shown to enhance and stimulate process improvement ideas and impact desired outcomes. 10

■ Program Outcomes

The Resource Nurse program facilitated clinically relevant practice improvements that impacted the moisture manage-

ment of skin, identifi cation of HAPU risk factors, and pres-sure redistribution sleep surfaces. After completing the educational program in 2009, Resource Nurses began to question existing clinical practices, linking environmental factors to skin breakdown. Environmental factors included both direct care techniques and corporate components, such as hospital-provided mattresses or seating surfaces and mois-ture climate control products. 8 For example, they observed that bed-making practices included multiple linen layers that reduced specialty surfaces ability to redistribute pressure and maintain optimal skin microclimate. 11

In 2010, the Resource Nurses recognized that peers were frequently identifying incontinence-associated dermatitis (IAD) as stage I or stage II PU. While IAD is a risk factor for PU development, we believe it is essential for nurses to differen-tiate these conditions since their prevention and treatment are not identical. 12 , 13 Incorrect identifi cation of IAD has neg-ative implications when reporting outcomes to the Nursing Dataset for Nursing Quality Indicators and other regulatory agencies such as the Centers for Medicare & Medicaid Services. Our hospital utilizes the Iowa Model of Evidence-Based Practice 14 as a guide in using research fi ndings for qual-ity improvement initiatives. The Iowa Model guides the nurse in identifying problem and knowledge-based triggers, assembling and critiquing literature, identifying priorities for the organization, forming a team, initiating a change in prac-tice, and evaluating the practice change using standardized measures of practice. This issue was a priority for the hospital due to recent federal regulatory reimbursement changes. After reviewing the literature, Resource Nurses provided unit-based education related to differentiating between IAD and a PU. They also pilot tested a practice change, which involved creating an evidence-supported nursing policy for bed

TABLE 1.

Resource Nurse Role Responsibilities

Unit-based in-service programs relating to incontinence-associated dermatitis and pressure ulcer prevention

Braden Scale checks/rounding on units, reviewing results/interventions with individual staff at bedside

Quarterly participation in Nursing Dataset for Nursing Quality Indicator pressure ulcer prevalence study

Participation in root cause analysis for hospital-acquired pressure ulcers

Monthly meeting with CWON/program director and geriatric CNS; education and review of activities, program planning/goals, process improvement initiatives

Providing quarterly unit journal club meetings relating to incontinence-associated dermatitis and pressure ulcer prevention

Individualized unit educational bulletin boards

Participation in annual nursing grand rounds

Involvement in Lean/Six Sigma processes pertaining to maintaining patient function

Participation in ongoing quality improvement programs/studies in preventing pressure ulcers



138 Beinlich and Meehan J WOCN ■ March/April 2014

making. The policy reduced the number of linen layers used when making a bed, optimizing the pressure-redistribution qualities of the sleep surface. 10 The use of a quilted under pad, chux pad, and bath blanket (for patient lifting) was elimi-nated in favor of a single contour sheet and single layer draw sheet. Adult incontinence briefs, commonly used for bedrid-den and incontinent patients, were replaced with a polymer-based disposable under pad. These interventions reduced both moisture- and pressure-associated skin breakdown. A review of chart audit data focusing on WOC consultation for IAD revealed 56 consults for dermatological/rash (used as a proxy for IAD) in 2009. Thirty consultations occurred in 2010 and 1 occurred in 2011; these changes represent a 98% decline over 3 years.

During the same time period, Resource Nurses partici-pated in a root cause analysis to investigate key factors con-tributing HAPU development in our facility. 15 A data collection tool was developed to trace probable contributing factors in patients who developed pressure-related wounds. Analysis showed that patients who developed HAPUs in our facility tended to be older and immobile for greater than 3 hours (usually due to admission via our emergency depart-ment, longer surgical procedures, or time spent in the post-anesthesia care unit). Based on consultation with a geriatric clinical nurse specialist, Resource Nurses also examined HAPU development in patients with indwelling urinary catheters. Data collection began in the second quarter of 2009 and ended in 2012. Analysis revealed that the 67% of patients who developed a HAPU had an indwelling urinary catheter in place on the day prevalence was measured. While more research is required to ascertain casualty, existing evi-dence suggests that they are associated with an increased likelihood of HAPU occurrence. 16 , 17

In addition, a literature review retrieved an article that reviewed fi ndings from animal model and human subjects suggest that a period of immobility that lasts for more than 3 hours increases the likelihood of PU formation, and the risk is higher when this period is extended. 17 They also retrieved a randomized trial that found that the use of a viscoelastic operating room (OR) mattress resulted in fewer PUs when compared to a standard surgical mattress. 18

Therefore, Resource Nurses initiated a limited pressure-mapping project comparing the 2-inch mattress used in our ORs to a 4-inch Viscoelastic mattress. An outside fi rm was engaged that specialized in pressure mapping to assist with data collection and analysis. The 4″ surface was com-pared to the surface used in cardiac cases, a 2″ mattress, heating blanket, and gel overlay. The comparison data showed that the 4-inch Viscoelastic mattress outper-formed our hospital-owned mattress ( Table 2 ). The data obtained from this project encouraged administration to purchase 2 new OR mattresses for patients undergoing extended surgical procedures. Ultimately, all OR table sur-faces were replaced with the 4-inch Viscoelastic mattress, except for 2 ORs in the third quarter of 2012. Data col-lected to evaluate the effect of these changes revealed a

decrease of 85% and 80% in occurrence of HAPUs in the ICU in 2011 and 2012, respectively, and a decrease of 63% and 100% on the orthopedic unit in 2011 and 2012, respectively. The general surgery unit experienced a 100% decrease in HAPUs in both 2011 and 2012 ( Figure 1 ).

Initial successes led to a desire to add new Resource Nurses in additional areas with a high risk for PU develop-ment. In early 2011, 8 additional staff nurses from the emer-gency department, perioperative and operative care settings, neuroscience intensive care step-down units, and the health system’s rehabilitation facility joined the program.

Despite initial education and changes in multiple aspects of HAPU prevention, Resource Nurses observed ongoing variability in Braden Scale scores and inadequate knowledge of differential diagnosis of stage I and II PU versus IAD. Acting under guidance of the program direc-tor, the Resource Nurses developed two 30-minute con-tinuing education programs. One highlighted the proper

FIGURE 1. Surgical HAPU prevalence. ICU indicates intensive care unit; HAPU, hospital-acquired pressure ulcer.

TABLE 2.

Pressure Mapping Using Heating Blanket and Gel Overlay

2″ mattress4″ Viscoelastic

Mattress

Head, mm Hg

Average 15.73 7.59

Maximum 64.53 20.61

Scapula, mm Hg

Average 7.13 4.62

Maximum 20.72 10.46

Sacrum, mm Hg

Average 7.46 4.39

Maximum 34.93 13.52

Heels, mm Hg

Average 17.66 18.06

Maximum 40.95 40.24




use of the Braden Scale for Pressure Sore Risk and the other focused on differential diagnosis of IAD versus PU, along with preventive interventions. These programs were offered to all staff on their units, including professional nursing staff and housekeeping and nursing assistants. The educational sessions included PowerPoint presenta-tions, interactive discussion, and demonstration of avail-able products for prevention and/or treatment.

In order to demonstrate their support of peer-to-peer learning, unit directors assisted the Resource Nurses in scheduling learning times for the staff. The Resource Nurse scheduled multiple program times during a 3- to 4-hour period during day and evening shifts; this schedule allowed education of 2 to 4 staff members while their peers cared for patients. This education model allows for improved staff attendance at educational programs, given that it is very diffi cult to allow staff to be away from the unit for extended periods of times. Approximately 350 employees attended the sessions across the health system. This strategy was selected because it has been shown that offering education at the unit level promotes a spirit of inquiry for nurses to embrace evidence-supported prac-tices, and it enhances patient outcomes. 19

Resource Nurse team members also developed a 30-minute educational program that was incorporated into the medical/surgical core course and provided to new RNs during their orientation process. This program focused on the Resource Nurse program, Braden Scale for Pressure Sore Risk, and preventive/treatment strategies for PU or IAD. Resource Nurses also provide education to nursing assistants at their monthly meetings.

■ Impact on PU Prevalence and Occurrence

Data from our PU prevalence study revealed a steady de-cline in HAPU prevalence since the inception of the pro-gram in 2009 ( Figure 2 ). For example, data from 2009 through 2012 revealed a 77% decrease in the number of HAPUs ( Figure 3 ). Data from the Nursing Dataset for Nursing Quality Indicator survey tool suggest that nurses

were independently initiating prevention strategies earlier in the patient stay, and more consistently recognizing pa-tients at higher risk for HAPU development.

While prevalence data are the most commonly used approach for benchmarking HAPUs with other hospitals, we have also found that measuring HAPU occurrence is equally useful for determining costs associated with HAPU end determination of effective strategies for their preven-tion. We measure HAPU occurrences throughout the cal-endar year, which provides a more longitudinal measurement that the monthly point prevalence data generated by the PU prevalence study program. Data anal-ysis prior to and following initiation of the Resource Nurse program revealed a 44% reduction in HAPU occurrence between 2009 and 2012 ( Figure 4 ). Root causes analysis of the rise of HAPU occurrence from 2009 to 2010 was attrib-uted to increased consistency when reporting following the interdiction of a new form and associated education that emphasized the need to accurately measure HAPU occurrence. This increase in reporting was also attributed to the actions of the Resource Nurse program director who reviewed all reports with quality improvement staff to

FIGURE 4. HAPU incidence. HAPU indicates hospital-acquired pressure ulcer.

FIGURE 2. HAPUs prevalence. HAPU indicates hospital-acquired pressure ulcer.

FIGURE 3. HAPUs by quarter prevalence. HAPU indicates hospital-acquired pressure ulcer.



140 Beinlich and Meehan J WOCN ■ March/April 2014

verify that each was accurate and excluded any wounds relating to moisture-associated or friction skin breakdown.

■ Cost

Potential cost savings related to HAPU prevalence were estimated by determining the number of patients at risk for developing PU using a cumulative Braden Scale score of 18 or less, minus the number of patients who actually developed a HAPU ( Figure 5 ). Additional costs were pro-vided by the facility's fi nancial department and based on estimate direct costs, and the mean increase in length of stay; this fi gure was based on an average based on HAPU and PU present on admission. Even when the cost of the Resource Nurse program was subtracted from the potential cost saving, our fi nancial department calculated a net re-duction in cost of $447,456 in 2010, $794,280 in 2011, and $504,000 in 2012 ( Figure 6 ).

Actual cost savings were calculated using 2 outcome measures: HAPU prevalence and occurrence from 2009 to 2012. Prevalence data revealed 43 fewer HAPUs, resulting in an annual cost reduction of $135,880. Comparison of occurrence data revealed 19 fewer HAPUs, revealing an

annual cost reduction of $51,236. Even when the cost of the Resource Nurse program over a 3-year period was con-sidered, the total cost savings for the hospital was approx-imately $95,120 ( Figure 7 ).

■ Conclusions

Today's healthcare environment demands quality improve-ment programs that demonstrate sustainable improvement in quality and fi nancial benefi t. 20 Our experience suggests that the development of the Resource Nurse program re-duced the prevalence and occurrence rates of HAPU in our health system as well as costs related to HAPU develop-ment. We have observed that the creation of the Resource Nurse fostered teamwork and encouraged collaboration and critical inquiry, resulting in sustainable changes in clinical practice. We have observed that the creation of the Resource Nurse program fostered teamwork and encour-aged collaboration and critical inquiry, resulting in sustain-able changes in clinical practice, as evidenced by the continued decrease in HAPU prevalence through the fi rst

FIGURE 7. Actual variable cost savings. FIGURE 6. Potential fi nancial savings.

FIGURE 5. Hospital-acquired pressure ulcer (PU) prevalence outcomes.




2 quarters of 2013 ( Figure 8 ). The Resource Nurse program continues to be a hospital supported and funded program.

KEY POINTS

✔ The Resource Nurse program encourages staff nurses to explore causative factors related to PU development.

✔ Peer-to-peer learning/teaching is an effective strategy to reach bedside nurses.

✔ Resource Nurses are empowered to change practice.

✔ The Resource Nurse program is a cost-effective way to reduce HAPUs.

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still far to go . Ostomy Wound Manage . 2012 ; 58 ( 2 ): 6 . 2. VanGilder C , MacFarlane GD , Harrison P , Lachenbruch C ,

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3. Primiano M , Friend M , McClure C , et al. Pressure ulcer preva-lence and risk factors during prolonged surgical procedures . AORN J . 2011 ; 94 : 555-566 .

4. Centers for Medicare & Medicaid Services . Medicare program: proposed changes to the hospital inpatient prospective pay-ment systems for acute care hospitals and the long-term care

hospital prospective payment system and proposed fi scal year 2011 rates . Fed Regist . 2010 ; 75 ( 85 ): 23851-24047 .

5. Ilesanmi RE , Ofi BA , Adejumo PO . Nurses’ knowledge of pres-sure ulcer prevention in Ogun State, Nigeria: results of a pilot survey . Ostomy Wound Manage . 2012 ; 58 ( 2 ): 24-32 .

6. Wound, Ostomy and Continence Nurses Society . Wound, Ostomy and Continence Nursing: Scope and Standards of Practice . Mt Laurel, NJ : Wound, Ostomy and Continence Nurses Society ; 2010 .

7. Hiser B , Rochette J , Philbin S , Lowerhouse N , TerBurgh C , Pietsch C . Implementing a pressure ulcer prevention program and enhancing the role of the CWOCN: impact on outcomes . Ostomy Wound Manage. 2006 ; 52 ( 2 ): 48-59 .

8. Harrison M , Mackey M , Friedberg E . Pressure ulcer monitoring: a process of evidence-based practice, quality, and research . Jt Comm J Qual Patient Saf . 2008 ; 34 ( 6 ): 355-359 .

9. McKeachie WJ , Svinicki MD . Active learning: cooperative, col-laborative, and peer learning . In: McKeachie WJ , Svinicki MD , eds. McKeachie’s Teaching Tips: Strategies, Research, and Theory for College and University Teachers . 12th ed . Boston, MA : Houghton Miffl in ; 2006 : 213-220 .

10. Carson D , Emmons K , Falone W , Preston A . Development of pressure ulcer program across a university health system . J Nurs Care Qual . 2012 ; 27 ( 1 ): 20-27 .

11. Williamson R . Impact of linen layers to interface pressure and skin microclimate . J Wound Ostomy Continence Nurs. 2009 ; 36 ( 3s ): s62 .

12. Gray M , Bliss DZ , Doughty DB , Ermer-Seltun J , Kennedy-Evans KL , Palmer MH . Incontinence-associated dermatitis: a consensus. J Wound Ostomy Continence Nurs. 2007 ; 34 ( 1 ): 45-54 .

13. Junkin J , Selekof J . Beyond “diaper rash”: incontinence-associated dermatitis: does it have you seeing red ? Nursing . 2008 ; 38 ( 11) (suppl ): 56hn1-56hn10 ; quiz 56hn10-1.

14. Titler M , Kleiber C , Steelman V , et al. The Iowa Model of evi-dence-based practice to promote quality care . Crit Care Nurs Clin North Am . 2001 ; 13 ( 4 ): 497-509 .

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16. Cameron AP , Wallner LP , Forchheimer MB , et al. Medical and psychosocial complications associated with method of bladder management after traumatic spinal cord injury . Arch Pys Med . 2011 ; 92 ( 3 ): 449-456 .

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18. Nixon J , McElvenny D , Mason S , Brown J , Bond S . A sequential randomized controlled trial comparing a dry visco-elastic poly-mer pad and standard operating table mattress in the preven-tion of post-operative pressure sores . Int J Nurs Stud . 1998 ; 35 ( 4 ): 193-203 .

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FIGURE 8. HAPUs fi rst- and second-quarter prevalence. HAPU indicates hospital-acquired pressure ulcer.


resource nurse program.a nurse-initiated, evidence-based program to eliminate hospital-acquired...

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