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Joyce Black, PhD, RN, CWCN, FAANUniversity of Nebraska Medical Center

Omaha, NE

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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

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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

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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

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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

However, the positive outcomes from multilayer foam dressings was just emerging!

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Reduce the intensity of the pressure◦ Support surfaces◦ Multilayer foam dressing to reduce the pressure◦ Offload the heel

Reduce the duration of the pressure◦ Turning and repositioning

Reduce the effect of shear◦ Keeping the head of the bed low◦ Multilayer foam dressings to reduce shear forces

Improve the health of the skin◦ Giving nutrition and hydration ◦ Keeping the skin clean and dry◦ Protecting damaged skin

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Optimal Patient

Outcomes

Optimal Patient

Outcomes

Consistent Care Delivery

Consistent Care Delivery

Quality/PerformanceStrategy

Quality/PerformanceStrategy

Organizational Support on all levels

Organizational Support on all levels

EB Practice for HAPI PreventionEB Practice for HAPI Prevention

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Consider applying a polyurethane foam dressing to bony prominences (e.g., heels, sacrum) for the prevention of pressure ulcers in anatomical areas frequently subjected to friction and shear (B/1)

Lack of clarity in discussion about actual structure of dressing

Not all studies cited used polyurethane foamMany polyurethane foam dressings on the

marketImportant to know how they work and if they

can reduce pressure, shear or microclimateDressings do not replace the rest of prevention! (C/1)

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Use of prophylactic dressings over bony prominences reduced the relative risk of pressure ulcers by 0.21 (p = 0.0006) ◦ Moore and Webster, The Cochrane Database of Systematic

Reviews, 2013, 8 (8) Use of prophylactic dressings reduce pressure

injury in immobile patients ◦ Clark, Systematic review of the use of dressings in the

prevention of pressure ulcers, Int Wound J 2014,11,(5),460-471

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What is the effectiveness of implementing a single PI prevention in ICU compared to bundled intervention?

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From; Tayyib, 2016, Systematic Review in Worldviews On Evidence Based Nursing

Santamaria (IWJ, 2015)◦ Dressing group 7/161◦ Control group 27/152 Diff stat sig at p = 0.002

Kalowes (AJCC, 2016)◦ Dressing group 1/184◦ Control group 7/183 Diff stat sig at p = 0.001

Quili (Chin J MS Nur, 2010)◦ Dressing group 0/26◦ Control group 3/26

8/371 with drsg ulcerated37/361 without drsg ulcerated

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Thul in ICU (2015)◦ Dressing 1/39◦ Control 19/83

Park in ICU (2014)◦ Dressing 3/52◦ Control 23/50

Brindle in OR/ICU (2012)◦ Dressing 1/50◦ Control 4/35

Cubit in General care (2012)◦ Dressing 1/51◦ Control 6/58

Brindle in ICU (2010)◦ Dressing 0/41◦ Control 3/52

Castelino in OR◦ Dressing 0/104◦ Control 12/114

6 /337 with dressings ulcerated67 /392 without dressings ulcerated

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21 studies of patients in ICU◦ Inconsistent reporting of baseline and numbers of

patients being compared

Baker, 2014; Bateman, 2014; Bateman, 2013; Boesch, 2012; Cano, 2011; Castelano,2012; Chaiken,2012; Edwards, 2014; Gentry, 2010; Haggard, 2014; Hasley, 2015, Hsu, 2010; Johnstone, 2013; Kiely,2012; Koener, 2011; Kuo, 2014; Lentz, 2013; Muldoon,2010; Santamaria, 2015; VanCapellen, 2011; Walsh, 2012

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100 patients planning on cardiac surgery◦ Randomly dressed with Mepilex Border Sacrum

preoperatively 15 lost to follow up 50 intervention 35 control◦ Following surgery, control group had dressing

removed 4 of 35 ulcerated – mostly DTPI◦ Treatment group stayed dressed 1 ulcerated after 12 days

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Brindle and Weglin, JWOCN 2912

Determining what is “an OR acquired ulcer”◦ Seldom visible at

end of case Cautery, device and

prep solution burns visible early

How many of your PrI start in OR?

This burn occurred in the OR; visible at end of case

Prep solution burn

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Braden not predictive (He, Lie, 2014)

Anesthesia Severity Assessment Scores (ASA)◦ ASA ≥ 3 higher risk (O’Brien, 2013)

◦ 1 pt increase in ASA increases odds by 149% (Fred, 2012)

Use of CP bypass Time in OR◦ 2.5 hours of more◦ Every 30” after 4

hours increases risk by 33% (Schoonhoven, 2002)

Position on OR table◦ Prone

Low BMI/High BMI (O’Brien, 2012)

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Open heart cases baseline was16.7% incidence

71 patients having cardiac surgery

Following use of the dressing, zero patients ulcerated

Prone cases◦ 104 dressed Zero ulcers◦ 114 without dressings 12 ulcers

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Braden does not predict heel ulcer risk well◦ Braden score 15 +/- 3

Aspects missing◦ Leg mobility Can vs does◦ Diabetes or Peripheral

neuropathy ◦ Vascular status or perfusion

Delmore, B. Risk factors associated with heel pressure ulcers in hospitalized patients. JWOCN 2015, 42 (3), 242-248

Does the patient movelegs independently?◦ Does versus can

Does the patient have normal or delayed capillary refill? Palpable pulses?

Does the patient have normal sensation?

Does the patient wear TEDs?

When these factors are present… patients are at risk

Heels need to be floated from the bed

Boots can be used◦ Often cannot ambulate◦ Often too hot to wear

Pillows can be used◦ Don’t stay under the calf◦ Migrate to under the knee◦ Fall off of the bed◦ Don’t fully elevate the heel◦ Are placed under the heel

• As organizational “Pressure Ulcer” rates decreased MDR PrIs became much more apparent

• MDRPrIs often were misidentified or “excused”• That’s just what happens

when...”• Not typically tracked, trended or

reported• May not be easy to prevent

• device may be an essential diagnostic/therapeutic component of treatment

• Although most are avoidable, not all are

What is a “medical device”? Fit the device to the patient◦ Measure devices for proper fit

Pretreat the skin with thin foam dressings ◦ Work with other disciplines to assure this

happens Remove or move daily to see the skin Be aware of edema Devices can be “lost” in bariatric

patient skin folds

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Not much data to support benefits of one surface over another

General recommendations◦ ICU = high immersion with low air loss◦ General units = foam with alternating pressure◦ Bariatric beds for those over 350 lbs

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Early mobility programs call for extend sitting

Position patient for stability and ability to perform usual activities (SoE= C; SoR = )◦ Tilt the seat back to

prevent sliding◦ Place feet on foot rest or

foot stool

This patient is not safe in this chair, nor is he sitting on the chair cushion

Are not designed for pressure redistribution

Need a seat cushion Ulcers develop after 4-6

hours of sitting Patient needs repositioning

hourly if not moving or restrained

Call, Pedersen, Bill, et al. Enhancing pressure ulcer prevention using wound dressings: What are the modes of action? Int Wound J 2015, 12, 408-413

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A powerful, validated tool for analyzing tissue deformationFinite Element Modelling

Within Wound care FE modelling can facilitates quantification of internal strains and stresses in weight bearing parts (heels and buttocks)  ‐ Levy & Gefen, 2016

Red indicates elevated stress levels

Blue indicates no increase in stress

Multinational expert panel examined evidence on dressings for PIP and MDR PI prior to guidelines in 2014◦ Black, IWJ 2013

Black, IWJ 2014◦ Advocated for Mepilex

dressings to prevention

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Body position: clinical practice vs standard1

◦ Study of 74 patients in which the change in body position was recorded every 15 minutes for an average observation time of 7.7 hours◦ 49.3% of observed time showed no body position

change for >2 hrs, and 2.7% had every-2-hour demonstrable body position change

Positioning prevalence2

◦ Prospectively recorded, 2 days, 40 ICUs in the United Kingdom◦ Average time between turns, 4.85 hours

1.Krishnagopalan S, et al. Crit Care Med. 2002;30:2588-2592.2.Goldhill DR, et al. Anaesthesia. 2008;63:509-515.

Q 2 hr turning with interface pressure map to highlight areas of pressure◦ Sig reduction in PI

over stage 2

◦ Behrendt, 2014

Q 2hr turning with a turn team◦ Sig reduction in PI

over stage 2

◦ Still, 2014

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Study of residents in long term care on foam mattresses◦ 942 Residents at moderate to high risk for PI◦ Turned randomly Q 2,3 and 4 hrs◦ Compliance with turning measured

Outcomes◦ Pressure injury formation was the same at all frequencies Q 2 hr = 2.5% Q 3 hr = 0.6% Q 4 hr = 3.1%

◦ Pressure injury formation did not differ by riskHigh risk = 1.8%

Moderate risk = 2.1%Bergstrom, et al, 2013 JAGS

Turning to 30 degrees may be difficult◦ Quality of pillows◦ Number of pillows

Use of wedges Use of turning and positioning systems Improved outcomes with use of a turn and

position system (Powers, 2016)◦ Fewer pressure ulcers (6 in SOC, 1 in PPS, p = .042)◦ Angle of turn better (31° in PPS, 22° in SOC)◦ Patients remained in position after 1 hour

Incontinent patients risk for PI higher◦ Prevalence increased from 4.1% to 16.3% ◦ Incidence also higher from 2.6% to 13.6%

Multiple layers of linen each increase the pressure on the sacrum regardless of HOB elevation ◦ Pressure at sacrum on LAL increased from 20 to 64%◦ Pressure at sacrum on foam increased from 6 to 29%

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Lachenbruch, Ribble. Pressure Ulcer Risk in the Incontinent Patient. JWOCN. 2016, 43 (3), 235-241.Williamson, Lachenbruch, The effect of multiple layers of linens on surface interface pressure: results of a laboratory study. Ostomy Wound Management 2013, 59 (6), 38-47

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Recognize their world view◦ Numbers and dollars◦ Be aware of pressure injury data in your facility◦ Move 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

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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

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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◦ 61 stage 3 and 4 x $71,500. = $4,361,500◦ 61 stage 3 and 4 x $127,000. = $7,747,000

Total spent on HAPI last year = $13,469,061.00

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Usage and cost data for high cost and/or high volume items

Clinician request for new products

World class companies provide 40 hours of training for their “reps” yearly◦ How much training does your

team get?

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Create a list of attributes for the product◦ What do you want the product to do? Or not do?◦ Create a grid that lists Clinical benefits Safety features Ease of use Look at 360 degrees of product use◦ Involve direct caregivers (Magnet)◦ Development of grid provides data devoid of opinion

and emotion Decision becomes transparent

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Cost per item now x volume = annual expense

Cost per new item x volume (can remain the same or change) = projected expense

Hopefully, will show annual savings

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What is the cost of the problem you are trying to solve?◦ What is your annual pressure ulcer incidence and

actual number of patients with ulcers?◦ What are pressure ulcers costing your system?

◦ Compute the number of cases you would need to prevent to recoup your cost

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Look for studies that show Number Needed to Treat (NNT) Values◦ the number of patients you need to treat to prevent

one additional bad outcome (pressure ulcer) ◦ Study of silicone dressings for prevention of

pressure ulcers in ICU reported a NNT of 10 10 patients would be treated with dressings to prevent

1 pressure ulcer (Santamaria, 2013)

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Team needs to examine options for products Measure products performance and

attributes against the grid Choose best 2-3 Ask companies to trial the products◦ Will need staff training on products

Monitor performance of new product◦ Is it doing what you want it to do?◦ Are you seeing the results you want to see?

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Root Cause Analysis on all Full Thickness HAPI Goal to determine when and where ulcer began◦ Not to blame, but to guide care and focus education

Start with first notation of PI, stage, location◦ Go back into the record and examine events 48 hours for DTPI 72 -96 hours for Stage 3,4 and Unstageable ◦ Consider location of ulcer and determine position of

patient at the time pressure was applied to body◦ Ask “could anything been done differently at that

time?”

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Guide Communication about Risk Plans◦ How does the bedside caregiver know how, when

and where to position patient?◦ Do staff know how to turn patients without causing

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?

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Additional training◦ Information available in

real time Additional recognition◦ This button became a

coveted item Several have gone on to

become wound nurses!

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Optimal Patient

Outcomes

Optimal Patient

Outcomes

Consistent Care Delivery Consistent

Care Delivery

Quality/PerformanceStrategy

Quality/PerformanceStrategy

Organizational Support on All Levels

Organizational Support on All Levels

EB Practice for HAPI PreventionEB Practice for HAPI Prevention

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