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Joyce Black, PhD, RN, CWCNUniversity of Nebraska Medical Center,
Omaha Nebraska US
Brno November 2016Joyce Black [email protected] 1
Study of Adult Nursing Units using NDNQI data◦ 1381 hospitals from all 50 states from 2008-2010
Outcome data, changes in rates after ruling/payment change of: ◦ Pressure ulcers
◦ Injurious falls
◦ Central line associated bloodstream infections
◦ Catheter-associated urinary tract infections
Waters, Daniels, Bazzoli et al. Effect of Medicare’s nonpayment for Hospital Acquired Conditions: lessons for future policy. JAMA 2015, 175 (3), 347-354
Brno November 2016Joyce Black [email protected] 2
11% reduction in CLABSI’s - sustained
10% reduction in CAUTI’s – sustained
.5% reduction in rates of falls - flat
1% reduction in rates of stage III and IV pressure ulcers – sustained slow decline
“We acknowledge the concern that not all pressure ulcers are avoidable. However, we believe improving screening to identify ulcers on admission will improve quality of care.” Institutes of Medicine, 2007
Brno November 2016Joyce Black [email protected] 3
Standardized practices had been developed and tested for CLABSI and CAUTI
Practice change was fewer steps
Practice change may have only had to occur once or once a day
Practice change involved fewer people and products
Brno November 2016Joyce Black [email protected] 4
Pressure injury reduction requires more than admission assessments to change the outcomes!
Processes of care are more nebulous with some decisions made at the bedside
Nurses carry out assessment and planning but may not do the turning
Brno November 2016Joyce Black [email protected] 5
Assessment of the skin upon admission◦ Identifies existing pressure ulcers
◦ Does this assessment always get done?
◦ Is this assessment always accurate?
Do nurses know pressure injury/ulcer from other skin problems?
How is a treatment plan chosen?
Assessment of risk for pressure ulcer/injury◦ Risk assessment tools and/or clinical judgement
◦ Prevention plan developed
Brno November 2016Joyce Black [email protected] 6
Guide Communication about Risk Plans◦ Who actually does the prevention?
◦ How does the bedside caregiver know when and where to position the patient?
◦ Do staff know how to turn patients without causing their own back injury?
◦ Does nurse know and when to examine skin beneath preventive dressing?
◦ How does the nurse obtain speciality beds during off hours?
◦ How well is nutrition being addressed?
◦ How is skin care being provided? And by whom?
Brno November 2016Joyce Black [email protected] 7
Recognize their world view◦ Numbers and dollars
Make them aware of pressure injury data in your facility◦ Use root cause analysis findings into quality
improvement plans
How many of your PI start in OR? ER? ICU?
Target education and interventions to the staff in high risk areas
Brno November 2016Joyce Black [email protected] 8
Present current HAPI/FAPI rates and cost◦ Stage 1 and 2 = $2,770.54
◦ Stage 3 and 4 = $71,500.00 to $127,000.00
Cost Data from:
Padula, Mishra, Makic et al. Improving the quality of pressure ulcer care with prevention: A cost effective analysis. Med Care 2011, 49 (4), 385-392
Brem, Maggi, Neirman et al. High cost of stage IV pressure ulcers. Am J Surg ,2010 200 (4), 473-477
Brno November 2016Joyce Black [email protected] 9
Current hospital rate is 2.5% ◦ 2% stage 1 and 2 and 0.5% stage 3 and 4
Annual acute admissions are 24,557
◦ 491 stage 1 and 2 at $2,771 = $1,360,561
◦ 122 stage 3 and 4 x $71,500 = $8,723,000
◦ 122 stage 3 and 4 x $127,000. = $15,494,000
Total spent on HAPI last year = $25,577,561.00
Brno November 2016Joyce Black [email protected] 10
Find out where the pressure ulcers are starting
Without knowing the history of this pressure ulcer, it is impossible to know where to make changes
Brno November 2016Joyce Black [email protected] 11
High risk patients◦ In OR over 3 hours
◦ Prone for surgery
◦ Perfusion problems
Heart lung machine
Consider age of ◦ Mattress
◦ Positioning devices
Consider use of dressings as additional protection
Brno November 2016Joyce Black [email protected] 12
Many ulcers on the sacrum from being supine with HOB up◦ Was the patient turned?
◦ Can the patient be turned?
◦ How old is the bed?
◦ Are preventive dressings being used?
Brno November 2016Joyce Black [email protected] 13
Incidence high in ICU and pediatrics (30-95%)
Oxygen delivery systems are the most common device
Prevention?◦ Pad the skin under the
device
◦ Move or remove the device daily if possible
Brno November 2016Joyce Black [email protected] 14
Brno November 2016Joyce Black [email protected] 15