M2 : Mobility and Moisture Strategies that Drive Nurse ... 1 M2 : Mobility and Moisture Strategies...

12/4/2011

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M2 : Mobility and Moisture Strategies that Drive Nurse & Patient Safety Outcomes

Kathleen M. Vollman MSN, RN, CCNS, FCCM, FAANClinical Nurse Specialist/Educator/Consultant

ADVANCING [email protected]

Northville, Michigan©Vollman 2011

Disclosures

Sage Products Speaker Bureau & Consultant

Hill-Rom consultant

E.L. Lilly

Eloquest Healthcare

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Session Content

• Prevention is key

• Nursing care interventions directed at:– Eliminating Skin Injuries- bathing &

moisture

• 44,000 to 98,000 preventable death in hospitals related to medical errors annually (IOM report, 1999)

• 92,888 deaths directly attributable to safety indicators between 2005-2007 (HealthGrades 2009)

– Failure to rescue, pressure ulcers and post-op infections

• National Patient Safety Goals include prevention of HAIs

• HAIs the 5th leading cause of death

• Lack of reimbursement for preventable injury

• 2013-lowest percent improvement/ 1% total Medicare cut• $50 billion in total costs for preventable injury

It is Time to Change!!

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Advocacy Starts with Us

Patient Advocacy/Safety Related to Clinical Practice

• Nurses knowledge of the Evidence based care

• Ability to deliver the care to the right patient at the right time, every time it is needed

• The ability to communicate patient concerns in a concise, data driven manner and take appropriate action

• Understanding the chain of command when faced with resistance

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Pressure Ulcer Facts

• 4th leading preventable medical error in the United States

• 2.5 million patients are treated annually in Acute Care

• NDNQI data base: critical care 5-14% ~ ~ 22%

• Incidence in acute care 7%

• 60,000 persons die from pressure ulcer complications each yr

• LOS ~ 3x longer

• PU related hospitalizations 80% from 1993 to 2006

• Cost to treat PU $43,000 as a secondary dx

• National health care cost $10.5-17.8 billon dollars for 2010

Dorner, B., Posthauer, M.E., Thomas, D. (2009), www.npuap.org/newroom.htmWhittington K, Briones R. Advances in Skin & Wound Care. 2004;17:490-4.Reddy, M,et al. JAMA, 2006; 296(8): 974-984

Preventable Events: Pressure Ulcers

• Pressure ulcers (PUs) can be identified, measured, and reported

• Usually preventable (Long term care divides pressure ulcer reimbursement into avoidable & unavoidable)

• Significant body of scientific evidence is available to guide practice and prevent Pus

• CMS reported 257,412 cases of preventable pressure ulcers as secondary diagnosis

• October, 2008: Stage III and IV PUs acquired after admission will not be reimbursed

• Documented POA by a provider (a physician or any qualified practitioner legally accountable for establishing a patients diagnosis & must sign the comprehensive initial skin assessment

www.cms.hhs.govwww.qualityforum.orgwww.cms.hhs.gov/HospitalAcqCond/Downloads/poa_fact_sheet.pdf

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Protecting Against Injury

Implement Interventional Patient Hygiene

Interventional Patient Hygiene

Hygiene…the science and practice of the establishment and maintenance of health

Interventional Patient Hygiene….nursing action plan directly focused on fortifying the patients host defense through proactive use of evidence based hygiene care strategies

Incontinence Associated Dermatitis Prevention

Program

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INTERVENTIONAL PATIENT HYGIENE(IPH)

Oral Care/ Mobility

VAP/HAP

Catheter Care

CA-UTICA-BSI

Skin Care/ Bathing/Mobility

HASISSI

HAND

HYGIENE

Patient

Vollman KM. Australian Crit Care, 2009;22(4): 152-154

Fortifying Host Defense Against Injury & Invasion:

Reducing Risk for Hospital Acquired Skin Injuries

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Types of Hospital Acquired Skin Injury

• Injury caused by pressure• Injury caused by moisture• Injury caused by devices• Injury caused during care activities

NPUAP, EPUAP & AHRQ

• National Pressure Ulcer Advisory Panel

– www.npuap.org

• European Pressure Ulcer Advisory Panel

• Agency for Healthcare Research and Quality

– www.ahrq.gov

– National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure ulcer prevention & treatment :clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.

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Shear

Friction MOISTURE

Pressure Ulcers

A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.

Moisture increases the friction coefficient

Adapted from Barb Bates-Jensen

What Causes a Pressure Ulcer?

• Mechanical loading• Pressure• Friction• Shear

• Tissue tolerance• Ability of skin and

supporting structures to redistribute pressure

• Affected by extrinsic and intrinsic factors

Adapted from Barb Bates-Jensen

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Deep Tissue Injury (DTI)

• High risk patient population-ICU– Immobility– Poor perfusion states

• Purple in color, “blood blister”– The area may be preceded by

tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

• Wound deteriorates quickly • Usually progresses muscle, bone • Heels are high risk areas

Consensus statementFleck, C. (2007). Suspected DTI, FAQs. Advances in Skin & Wound Care. 20(7),413

www.ndnqi.org

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New Definitions

• Stage I:– Intact skin with non-blanchable redness of a

localized area usually over a bony prominence.

– Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure ulcer prevention & treatment :clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.

New Definition

• Stage II:– Partial thickness loss of dermis presenting as a

shallow open ulcer with a red pink wound bed, without slough.

– May also present as an intact or open/ruptured serum-filled blister.

• Further description:– Presents as a shiny or dry shallow ulcer without

slough or bruising.* – This stage should not be used to describe skin tears,

tape burns, perineal dermatitis, maceration or excoriation.

National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure ulcer prevention & treatment :clinical practice guideline. Washington, DC: NationalPressure Ulcer Advisory Panel; 2009.

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New Definitions

• Unstageable:– Full thickness tissue loss in which the base of the

ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

• Further description:– Until enough slough and/or eschar is removed to

expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.

National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure ulcer prevention & treatment :clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.

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Shear & Friction

• Skin shear stress is an internal stress caused when adjacent surfaces rub across each other, which results in twisting and tearing of the underlying blood vessels and leads to tissue ischemia and localized tissue death.

• Friction is used to describe all phenomena that relate to interface properties and sliding of surfaces with respect to each other. This type of injury is often seen on the elbows or heels due to rubbing against bed sheeting and/or from re-positioning in bed

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Moisture Injury: Incontinence Associated

Dermatitis

• Inflammatory response to the injury of the water-protein-lipid matrix of the skin– Caused from prolonged exposure to

urinary and fecal incontinence

• Physical signs on the perineum & buttocks– Erythema, swelling, oozing,

vesiculation, crusting and scaling

Brown DS & Sears M, OWM 1993;39:2-26Gray M et al OWN 2007;34(1):45-53.

Impact of Moisture

• Urinary and fecal incontinence are common in the acute care setting, occurring in more than one-third of hospitalized adults.

• Humidity/Moisture: – Strain at which the skin breaks is 4x greater

with excess moisture than dry skin

– Moisture increases the risk of shear & friction damage

Nicolopoulos CS, et al. Arch Dermatol Res. 1998;290:638-640Bliss DZ, et al. Nurs Res.2000;49:101-108.Gray M, et al. Adv Skin Wound Care. 2002;15(4):170-175.

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Suspect Risk Factors for IAD

• Low serum albumin 40x higher risk• Chronic exposure to moisture• Fecal & urinary incontinence• Mobility subscale < 3• Use of a containment device• Alkaline pH• Overgrowth or infection with pathogens• Friction

Gray M, JWOCN 2004; 31(1 Suppl):S2-SJunkin J, et al. J Wound Ostomy Continence Nurs 2007;34(3):260-269

Prevalence & Incidence Assessment for IAD

Junkin J, Selek JL. J WOCN 2007;34(3):260-269

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The things included in the measurement becomes relevant, the things omitted are out of

sight out of mind

Peter F. Drucker

Pressure Ulcers – Risk Factors

1. Immobility 87.0%

2. Fecal Incontinence 56.7%

3. Malnutrition 54.4%

4. Decreased Mental Status 50.7%

5. Peripheral Vascular Disease 28.1%

6. Urinary Incontinence 27.0%

7. Diabetes 23.7%

Maklebust & Magnan. Adv in Wound Care. 1994;7(6):25-42

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So Why Should You Care?

Extendedstay

Labor Intensive

Recoverable $?

Huge Cost11 Billion

Patient Discomfort - Pain & Suffering

Family

Other complications now possible!

Lawsuits

JCAHO

Pressure Ulcers – Risk Factors

“Patients with fecal incontinence were 22 times more

likely to have pressure ulcers than patients without fecal

incontinence.”

When impaired mobility is combined with fecal

incontinence those odds rise to 37.5 times more likely.

Maklebust & Magnan. Adv in Wound Care. 1994;7(6):25-42

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Six Essential Elements of Pressure Ulcer Prevention

• Admission Assessment

• Reassess Daily

• Inspect Skin Daily

• Manage Moisture

• Optimize Nutrition and Hydration

• Minimize Pressure

http://www.ihi.org/IHI/Programs/Campaign/accessed 3/29/2008

Getting Started: 5 Million Lives Campaign2-Steps to Preventing Pressure Ulcers

Identify patients at risk

• Reliably implement prevention strategies for all patients who are identified at risk– Maintain healthy skin

– Minimize pressure

– Manage moisture

– Nutrition & hydration

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Identify Patients at High Risk

Risk Assessment On Admission, Daily, Change in Patient Condition

• Use standard EBP risk assessment tool• Research has shown Risk Assessment Tools are more

accurate than RN assessment alone.• Braden Scale for Predicting Pressure Sore Risk

– 6 subscales• Rated 1-4

– Pressure on tissues• Mobility, sensory perception, activity

– Tissue tolerance for pressure• Nutrition, moisture, shear/friction

– Score 6-23

www,ihi.org; Macklebust,JA (2009) The Braden Scale reliable assessment to effective interventions

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Braden Validation Scales

Levels of Risk:Mild 15-18, Moderate 13-14, High 10-12, Severe <9

Incidence of Pressure Ulcers in Neuro ICU• 186 NICU patients• Assessed within 12 hrs of admission with pictures/Braden

and re-examine every 4 days or at d/c from unit• Measured: risk factors, tested usefulness of the Braden as

a predictor

• Results– 23/186 patients developed a pressure ulcer (12.4%)– Braden scale independent predictor of development– >16 Braden score no ulcer– Being under weight was a significant, distinct factor– Risk of a stage II ulcer significantly increases with a Braden

score < 13

Fife C, et al. CCM 2001;29:283-290

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Identification of Risk

• Use of multiple methods to visually cue staff as to which patients are at risk• Stickers of chart or outside patients door

• Post days since last pressure ulcer data

• Change documentation tools to ensure admission & daily risk assessment

• Education of staff

Ayello EA, et al. Advances in Skin & Wound Care. 2002;15(3):125-131

Fortifying Host Defense:Preventing Skin Injury

Minimize Pressure

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Nurse!!!

The Bath: The First Line Of Defense

Removal to Reduce Skin Injury

• Use of Liquid adhesive remover to prevent injury & remove residue– Prevents or reduces the incidence of skin tears

– Look for ones that do not use alcohol or acetone (drying)

– Grip and rip causes skin injury

– Product at point of care will enhance usage

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Who Does The Bath?

What Happens During a Bath in Addition to Cleaning?

• Complete assessment of the skin• Muscle tone & strength• Range of motion• Participation in ADL’s…physical & mental• Pain assessment with activity• Opportunity to communicate• Opportunity to identify coping, feelings of

powerlessness, depression, family support etc.• Fatigue factor

Assessments:

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Pressure Ulcers

Pressure

Shear

Friction

MOISTURE

Pressure Ulcers

SACRAL

HeelPressure

Ulcer

Pressure

Shear Friction

The Role of IPH in Improving Clinical and Economic Outcomes

• 21-bed SICU

• Prospective study:

– Staff education to improve knowledge base of the non-

licensed staff

– Patient intervention component to improve

communication of pressure ulcer risk to the registered

nurses

• A pre and post intervention knowledge survey was conducted.

• Implemented Basinless Bath with Skin Check and Barrier

cloths with Peri Check

• Educated around the Skin Check label and proper usage.

Non-licensed staff received instruction in observational skills

and the facilities bathing and incontinence management

protocol were changed.Carr D, Benoit R. Advances in Skin and Wound Care.2009;22(2)

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The Role of IPH in Improving Clinical and Economic Outcomes

• Pressure ulcers decreased from 7.14% to 0%

• 100% of the staff were able to demonstrate adequate knowledge of hospital protocol and procedure after the intervention

• Department manager confirmed by random sampling of the audit tools that reported alterations in skin integrity was followed up by the responsible RN.

Outcomes

Carr D, Benoit R. Advances in Skin and Wound Care.2009;22(2)

Getting Started: 5 Million Lives Campaign2-Steps to Preventing Pressure Ulcers

Identify patients at risk

• Reliably implement prevention strategies for all patients who are identified at risk– Maintain healthy skin

– Minimize pressure

– Manage moisture

– Nutrition & hydration

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Strategies from the 5 million Lives Campaign

• Maintain healthy skin

• Manage moisture

• Minimize pressure

Optimal Hygiene

• ph balanced (4-6.8)– Stable pH discourages colonization of bacteria &

risk of infection– Bar soaps may harbor pathogenic bacteria– Skin pH requires 45 minutes to return to normal

following a ordinary washing

• Non-drying, lotion applied

• Multiple steps can lead to large process variation

• Excessive washing/use of soap compromises the water holding capacity of the skin

Voegel D. J WOCN, 2008;35(1):84-90Byers P, et al. WOCN. 1995; 22:187-192.Hill M. Skin Disorders. St Louis: Mosby; 1994.Fiers SA. Ostomy Wound Managment.1996; 42:32-40.Kabara JJ. et. al. J Environ Pathol Toxicol Oncol. 1984;5:1-14

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Impact of Wash Cloth/Soap Cleansing and Towel Drying on Skin

• Methodology• 15 healthy volunteers, 6 different W/D techniques

• 3 W/D techniques on each arm repeated twice with a 2hr rest period

• Measured: Transepidermal water loss (TEWL), skin hydration, skin pH and erythema

• Results:• TEWL increased with each type of W/D episode, further loss

with repeated procedures

• Increase skin pH with all W/D, esp with soap

Voegel D. J WOCN, 2008;35(1):84-90

Washing with soap & water and towel drying significantly disruptive effective on skin barrier function

Comparison of Basinless Bath to a Basin Bath

• 60 patient in a progressive & surgical unit in an acute care institution compared basin bath vs. comfort bath

• Served as their own control with the right side of the body bathed with basinless bath/ left side with a basin bath

• Required a partial or complete bath conducted over 3 consecutive days

• Measured:skin condition using SCDF, nurse satisfaction & patient satisfaction

Methodology:

Kron-Chalupa J et. al. Iowa City Veterans Medical Center

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Comparison of Basinless Bath to a Basin Bath

Questions BasinlessBath

Basin Bath

Overall preference

97% 3%

Nurse satisfaction

100% 0%

Time 10 minutes 21 minutes

SCDF (skin condition)

Significantly improved

Improved

Kron-Chalupa J et.al. Iowa City Veterans Medical Center

Traditional vs. Disposable Bath in Critically Ill Patients

• 40 patients in Surgical, Medical and CT ICU received both baths on different days

• Compare basin bath vs. disposable

• Measure: time, quality of bath, microbial counts on skin (periumbilicus & groin, nurse satisfaction & costs

Larson E. et al. AJCC. 2004; 13(3):235-41

Methodology:

Results:• No difference in quality or microbial scores

between the two bathing procedures• Fewer products used*, lower costs, less time and

higher nurse satisfaction with disposable bath*

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nurWse!

Spreading Microorganism

Traditional BathingWhy are there so many bugs

in here?

Bath Water: A Source of Health Care Acquired Microbiological Contamination

• Compared normal bath water with chlorhexidine bath water on 3 wards

• Without Chlorhexidine: All samples + for bacterial growth (14/23 > 105 cfu/ml)

• With Chlorhexidine: 5/32 grew bacteria with growth 240 to 1900 cfu/ml

• Gloved hands/bathing: objects touch grew significant numbers of bacteria

•

Shannon RJ. et.al. Journal of Health Care, Compliance & Safety Control. 1999;3(4):180-184

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Bath Basins: Potential Source of Infection

• Multicenter sampling study (3 ICU’s) of 92 bath basins

• Identify & quantify bacteria in patients basins

• Sampling done on basins used > 2x in patients hospitalized > 48 hours & preformed 2 hours post bath

• Cultures sent to outside laboratory

• Qualitative vs. quantitative measures used to exclude growth that may have occurred in transport

• Bathing practices not controlled & no antiseptic soaps used to bathe

Johnson D, et al. Am J of Crit Care, 2009;18:31-40

Bath Basins: Potential Source of Infection

• Results– 98% of all cultures grew some

form of bacteria after plating or enrichment

• Enrichment Results– 54% enterococci. 32% for gram -

, 23% for S aureus and 13% VRE (statistically significant)

– <10% growth rates for: MRSA 8%, P aeruginosa 5%, C albicans 3% & E coli 2%

Johnson D, et al. Am J of Crit Care, 2009;18:31-40

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Large Multi-Center Basin Evaluation For Presence of MDRO’s

• 88 hospitals from US & Canada

• From July 2007 to February 2011

• Randomly selected basins for damp swab culture

• External lab tested for MRSA & VRE & gram – bacilli

• All basins were clean & were not visibly soiled

Methodology

Results:• 1103 basins: 63.2% contaminated• 385 basins (34.9%) from 80 hospitals were colonized with VRE• 495 basins (44.9% ) from 86 hospitals had gram-negative bacilli• 36 basins (3.3%) from 28 hospitals had MRSA

Kaye, et al. Presented at SCCM January2011, SHEA 2011

Waterborne Infections Study

• Hospital tap water is the most overlooked source for Health Care Acquired pathogens

• 29 evidenced-based studies present solid evidence of waterborne Health Care Acquired infections

• Transmission occurs via drinking, bathing, items rinsed with tap water and contaminated environmental surfaces

Anaissie E. et. al. Arch Int Med. 2002; 162:1483-92

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Waterborne Infections Study

• Conservative estimates suggest significant morbidity and mortality from waterborne pathogens

• Immunocompromised patients are at the greatest risk

• Recommendation I: Minimize patient exposure to hospital tap water via bottled water and pre-packaged, disposable bathing sponges

Anaissie E. et. al. Arch Int Med. 2002; 162:1483-92

Bacteria Biofilm

• Organized communities of viable & non-viable microorganisms protected within a matrix of extracellular polysaccharides, nutrients & entrained particles

• Adhere to inert material (plumbing)

• Bacteria contain within Biofilm may be transmitted to at risk patients by direct contact with water used for ingestion, ice, washing

Cervia JS, et al. Arch Intern Med, 2007;167:92-93

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ICU & Hospital Water Samples

• Systematic review published studies 1998-2005– 9.7%-68.1% of random ICU water samples + for

Pseudomonas aeruginosa– 14.2%-50% of patient infections were due to genotypes

found in ICU water

• 9 hospital in New York city– Bacteria recovered in every hospital– 4-14 species identified– 1/3 organism known to be responsible for HAI’s

Trautmann M, et al. Am J of Infect Control, 2005;33(5):S41-S49, Cervia JS, et al. Arch Intern Med, 2007;167:92-93

Bathing with CHG Basinless Cloths

• Prospective sequential group single arm clinical trial

• 1787 patients bathed• Period 1: soap & water

• Period 2: CHG cloth cleansing

• Period 3: non-medicated basinless cloth bath

Veron MO et al. Archives Internal Med 2006;166:306-312

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26 colonization's with VRE per 1000 patients days vs. 9 colonization's per 1000 patient days with CHG bath


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Effect of CHG Cloth Bath of HAI’s in Trauma Patients

• Retrospective analysis 6 months before and after institution of CHG bathing

• 12 bed level 1 trauma center– 286 severely injured patients

bathes 2% CHG cloth– 253 severely injured patients

bathed without CHG cloth• Results: CHG bathed patients less

likely to acquire a CLA BSI (2.1-vs. 8.4), MRSA VAP 1.6 vs. 5.7 & rate of colonization was significantly lowers; 23.2 vs.69.4 per 1000 patient days

Evans HL, et al. Arch Surg, 2010;145:240-246

Basin Bath

Strategies for Bathing to Reduce Source Control & Improve Skin Defense

transmission of organisms time & effort # of suppliesHarmful soapsRough washclothsCold/tepid waterScrubbing technique

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EBP Recommendations to Achieve Offloading &

Reduce Pressure

• Turn & reposition every 2 hours (avoid positioning patients on a pressure ulcer)– Repositioning should be undertaken to reduce the duration

& magnitude of pressure over vulnerable areas– Cushioning devices to maintain alignment /30 ° side-lying

& prevent pressure on boney prominences– Use lifting device or other aids to reposition & make it easy

to achieve the turn– Assess whether actual offloading has occurred

Reger SI et al, OWM, 2007;53(10):50-58, www.ihi.orgNational Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel.Pressure ulcer prevention & treatment :clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.


Reduce Pressure

• Turn & reposition every 2 hours (avoid positioning patients on a pressure ulcer)– Use active support surfaces for patients at higher risk of

development where frequent manual turning may be difficult– Heal-protection devices should elevate the heel completely (off-

load) in such a way as to distribute weight along the calf• Uses pillows to offload if expected immobility < 8hrs• Uses device is expected to be immobile > 8hrs

– Progressive mobility program– 2 clinical trials currently underway to examine turning regimes

on pressure ulcers & other outcomes in acute & ICU patients (2011) Reger SI et al, OWM, 2007;53(10):50-58, www.ihi.org

National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure ulcer prevention & treatment :clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009. /www.clincialtrials.gov

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Successful Prevention of Heel Ulcers and Plantar Contracture in the High Risk Ventilated Patients

• Sedated patient > 5 days• May or may not be intubated• Braden equal to or less than 16

• Skin assessment and Braden completed on admission

• All pts who met criteria were measured for ROM of the ankle with goniometer, then every other day until pt did not meet criteria

• Heel appearance, Braden and Ramsey scores were assessed every other day and documented

• Identified and trained ICU nurses completed the assessments

Study Inclusion Criteria

Procedure

Results

Meyers T. J WOCN 2010;37(4):372-378

53 sedated patients over a 7 month period

Heel Ulcer Reduction

Brainard NR et al Captial Healths Best Practice Wound Care Conference 10/2008

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EBP Recommendations to Reduce Shear & Friction

• Use lifting/transfer devices & other aids to reduce shear & friction.• Mechanical lifts

• Transfer sheets

• 2-4 person lifts

• Turn & assist features on beds

• Loose covers & increased immersion in the support medium increase contact area

National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure ulcer prevention & treatment :clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009www.ihi.rog

EBP Recommendations to Reduce Injury From Incontinence & Other Forms of Moisture

• Clean the skin as soon as it becomes soiled.• Use a protective cream or ointment on the skin to protect

it from wetness.• Disposable barrier cloth prevents unprotected episodes

(www.ihi.org 5 Million Lives Campaign)

• Use an incontinence pad and/or briefs to absorb/wick away wetness from the skin.

• Consideration of pouching device or a bowel management system

• Ensure an appropriate microclimate & breathability• < 4 layers of linen National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory

Panel. Pressure ulcer prevention & treatment :clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.Williamson, R, et al (2008) Linen Usage Impact on Pressure and Microclimate Management. Hill-Rom www.ihi.org

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Current Practice: Moisture

Management

Disposable Incontinence Pads

Airflow pads for Specialty Beds

Adult diaperReusable Incontinence pads

Challenges of Incontinence Care

• Individually packaged products are not always within reach during incontinence clean up

• Risk of unprotected skin is high

• Cleaning and protection usually done as separate activities

• Washcloths often become disposable when soiled

• Increased risk for contamination

• Not all products have a chemical barrier

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32 State Survey on Perineal Skin Care Protocols

• 76 protocols form Acute and LTC facilities

• Analyzed to determine correlation with evidence-based practices per the literature

• HPIS (Healthcare Products Information Services) data used to evaluated amount sold to each facility

• HPIS data compared to urinary & fecal incontinence prevalence data

Methodology:

Nix D et al. Ostomy/Wound Management 2004;50(12):59-67

Results:

• All 76 protocols lack 1 or more interventions considered important in perineal care

• 75% included use of skin protectants

• Analysis against HPIS data and incontinence data suggests under utilization of skin protectants (< 10 cents per day vs. $1.35)

Clever K. OWM. 2002;48(12): 60-67

Evaluating the Efficacy of a Uniquely Delivered Skin Protectant and Its Effect on the Formation of

Sacral/Buttock Pressure Ulcers

• Retrospective/prospective quasi-experimental study• 57 bed LTC• Data collected 3 months before use & 3 months following

conversion• Demographics comparable between groups

– Age, LOS, mobility in bed, transfer between surfaces, incontinence of bowel/bladder, BMI, albumin and concurrent disease scale

• Pre-data revealed 12 residents with incontinence developed 15 sacral stage 1 & 2 ulcers.

• Monthly incidence rates over 9 months 4.7%

Methodology:

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Clever et al. “Pressure Ulcer” Study

Evaluating the Efficacy of a Uniquely Delivered Skin Protectant and Its Effect on the Formation of Sacral/Buttock Pressure Ulcers

Old Standard of Care

July 2000 to

March 2001

New Standard of Care

May to July 2001

Feb to April 2002

4.7%

0.5%0.5%

Average Monthly Incidence of Sacral/Buttock Pressure Ulcers

Old standard of care compared to use of

Comfort Shield®

as preventative*

89% Reduction in Incidence

*No significant differences in impact variables between groups

Clever K. OWM. 2002;48(12): 60-67

What Lies Beneath the Patient

• Linen– Linen increases entrapment of

moisture– Creates wrinkles– May increase risk of skin

compromise– Limit linens on all beds

• Especially on pressure redistribution beds and low air loss beds

– Newer ICU beds are pressure redistribution surfaces

– www.npuap.org/npuap_s31_tdposition statement on bed surface terminology

Williamson, R, et al (2008) Linen Usage Impact on Pressure and Microclimate Management. Hill-Rom

Brostrom, J. et al (1996). Preventing skin breakdown: nursing practices, cost, and outcomes. Applied Nursing Research

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SAFE PATIET HANDLING

Number, Incidence Rate, & Median Days Away From Work for Occupational Injuries RN’s with

Musculoskeletal Disorders in US, 2003 – 2009

Bureau of Labor Statistics, U.S. Department of Labor, February 14, 2011. Numbers for local andstate government Unavailable prior to 2008

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National Problem of Ergonomic Injury in Healthcare Services

COST FACTORS In 1990, the annual cost of back injury ranged from

$50 to $100 billion in the US

One low back injury: $40,000

Indirect costs outweigh direct costs 5:1

$20 billion per year is spent annually on workers compensation costs associated with musculoskeletal disorders (MSDs)

$100 billion per year is spent on indirect costs

Injured nurses constitute about 1/4 of all claims and 1/3 of total compensation costs.

Source: US Department of Labor, Occupational Safety and Health Administration

Cost of Negative Patient & Nurse Outcome

1. Shreve J et al 2010. The Economic Measurement of Medical Errors. http://www.soa.org/files/pdf/research-econ-measurement.pdf. Accessed January 17, 2011.

2. Bennett R, et als . J Am Geriatr Soc. 2000 Jan;48(1):97-99.3. National Safety Council. (2010). Injury Facts®, 2010 Edition. Itasca, IL.

Zeek, D & Malandrina R. Case Study: Northwest Community Hospital, 2010

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Mobility(Repositioning q2hrs,

Shear & Friction)

Moisture Management

The Routine

• Barriers:– Time to turn: 3.5-5min up to 17minutes– People resources– Current equipment not user friendly

• Staff perceived barriers– 41/49 in-bed activities

• Unstable VS (59%) & low respiratory and energy reserves (46%) most common reasons for restricting activity

• 34% stated safety issues/falling or tube/catheter integrity

• 27% reported sedation

Draw Sheet/Pillows/People

Bates-Jensen et al 2003Xakellis, et al 1995Gefen et al 2008Winkelman C, 2010;

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Question: Given today’s current workload and patient complexity, how would you rate the difficulty in achieving your unit’s turn repositioning protocol?

1. Very Difficult

2. Difficult

3. Not Difficult

Question: On average, how long does it take to reposition a patient with your current practice?

1. 2 Minutes

2. 5 Minutes

3. 8 Minutes

4. 10 Minutes

5. 10+ Minutes

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Question 5: What are your currently using to turn & reposition patients?

1. Lift Systems (removed after use)

2. Lift System (stays underneath the patient)

3. Glide Sheet (removed after use)

4. Draw Sheets

5. Turn & Assist Mechanism (part of bed)

6. Other____________________________

Question 6: What are your currently using to sustain a lateral position once the patient is turned?

1. Pillows

2. Foam Wedges

3. Blankets

4. Other

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Question 7: How often does a patient move “out of position” following a turn?

1. Very Often

2. Rarely

3. Not Sure

Question 8: Have you ever suffered from an injury as a result of repositioning or turning a patient?

1. YES

2. NO

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Identify Patients at High Risk

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Risk Assessment on Admission, Daily, Change in Patient Condition

• Use standard EBP risk assessment tool• Research has shown Risk Assessment Tools are more

accurate than RN assessment alone• Braden Scale for Predicting Pressure Sore Risk

– 6 subscales• Rated 1-4

– Pressure on tissues• Mobility, sensory perception, activity

– Tissue tolerance for pressure• Nutrition, moisture, shear/friction

– Score 6-23www,ihi.org; Macklebust,JA (2009) The Braden Scale reliable assessment to effective interventions

Current Practice: Turn & Reposition

Draw Sheet/Pillows/Layers of Linen Lift Device

Specialty BedTransfer Device

Disposable Slide Sheets

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Reduce Pressure

• Turn & reposition every 2 hours (avoid positioning patients on a pressure ulcer)– Repositioning should be undertaken to reduce the duration

& magnitude of pressure over vulnerable areas– Cushioning devices to maintain alignment /30 ° side-lying

& prevent pressure on boney prominences– Use lifting device or other aids to reposition & make it easy

to achieve & sustain the turn– Assess whether actual offloading has occurred

Reger SI et al, OWM, 2007;53(10):50-58, www.ihi.orgNational Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel.Pressure ulcer prevention & treatment :clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.

Do We Even Achieve the Minimum Mobility Standard…

“Q2 Hours in ICU’s”?

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Krishnagopalan S. Crit Care Med 2002;30:2588-2592

Body Position: Clinical Practice vs. Standard

• Methodology– 74 patients/566 total hours of observation– 3 tertiary hospitals– Change in body position recorded every 15 minutes– Average observation time 7.7 hours– Online MD survey

• Results– 49.3% of observed time no body position change– 2.7% had a q 2 hour body position change– 80-90% believed q 2 hour position change should occur

but only 57% believed it happened in their ICU

Goldhill DR et al. Anaesthesia 2008;63:509-515

Positioning Prevalence: UK ICU’s

• Methodology– Prospectively recorded, 2 days, 40 ICU’s in the UK– Analysis on 393 sets of observations– Turn defined as supine position to a right or left side lying

• Results:– 5 patients prone at any time, 3 .8% (day 1) & 5% (day 2) rotating beds– Patients on back 46% of observation– Left 28.4%– Right 25%– Head up 97.4%– Average time between turns 4.85 hrs (3.3 SD)– No significant association between time and age, wt, ht, resp dx, intubation,

sedation score, day of wk, nurse/patient ratio, hospital

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HemodynamicInstability

Is it a Barrier to Positioning?

???

Hemodynamic Status

• No differences noted in hemodyanmic variables between supine & positions

• Lateral turn results in a 3-9% decrease in SVO2 which takes 5-10 minutes to return to baseline

• Appears the act of turning has the greatest impact on any instability seen

• Minimize factors which contribute to imbalances in oxygen supply & demand

Winslow, E.H. Heart and Lung, 1990 Volume 19, 557-561.Price P. CACCN, 2006, 17(1):12-19.

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Vollman KM. Crit Care Nurs Clin of North Amer, 2004;16(3):319-336.

Patients at Risk for Intolerance to Positioning

• Elderly

• Diabetes with neuropathy

• Prolonged bedrest

• Low Hb an cardiovascular reserve

• Prolonged gravitational equilibrium

EBP Recommendations to Reduce Shear/Friction &

Staff Injury

Use Lifting/Transfer Devices & Other Aids to Reduce Shear & Friction…..the Reality

National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure ulcer prevention & treatment :clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009www.ihi.rog

Mechanical Lifts ≠ Lift sheet has to be removed and replaced for each use

2-4 Individuals to assist with draw sheet to lift/turn ≠ Resource challenges & risk of caregiver injury

Disposable/Reusable Glide/Transfer Sheets ≠ Sheet has to be removed and replaced for each use.

Turn & Assist Bed Mechanism ≠ Currently not used to its potential

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Surface Selection International Guidelines

• Use a higher specification foam mattress (Viso-elastic polymer foam) rather than standard hospital foam mattress for patients at risk (A)

• Use active support surface/overlay or mattress for patients at higher risk where frequent manual turning is not possible (B)

• Continue to turn and reposition regardless of the surface the patient is on (C)

• Unsure heels are free from the surface of the bed (C)• Pillows are a short term therapy for elevation of heels (B)• For patients not alert or cooperative use a heel device that

distributes the weight along the calf (C)National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure ulcer prevention & treatment :clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.

Pressure Ulcers

Pressure

Shear

Friction

MOISTURE

SACRALMOBILITY

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M2

Mobility Moisture

Protocol

M2 = Mobility & Moisture Protocol

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Outcomes of A Mobility Protocol/Program

• incidence of VAP

• time on the ventilator

• days of sedation

• incidence of skin injury

• delirium

• ambulatory distance

• Improved function

Staudinger t, et al. Crit Care Med, 2010;38.Abroung F, et al. Critical Care, 2011;15:R6Morris PE, et al. Crit Care Med, 2008;36:2238-2243 Pohlman MC, et al. Crit Care Med, 2010;38:2089-2094Schweickert WD, et al. Lancet, 373(9678):1874-82. Thomsen GE, et al. CCM 2008;36;1119-1124Winkelman C et al, CCN,2010;30:36-60

LEVEL I LEVEL II LEVEL III LEVEL IV LEVEL V

Progressive Mobility ContinuumIncludes complex, intubated, hemodynamically unstable and

stable intubated patients; may include non-intubated Includes intubated, non intubated hemodynamically stable/stabilizing, no contraindications

RASS -5 to - 3 RASS -3 & up RASS -1 & up

*Mobility is the responsibility of the RN, with the assistance from the RT’s Unlicensed Assistive Personnel and PT/ OT. PT and OT may assist the team with placement to the appropriate mobility level of activity, always prioritizing patient and provider safety. Placement is based on clinical judgment.

RASS 0 & up

***If the patient is intolerant of current mobility level activities, reassess and place in appropriate mobility level***For each position/activity change allow 5-10 minutes for equilibration before determining the patient is intolerant

START HERE

RASS 0 & up

ToleratesLevel IVActivities

Ambulate progressively longer distances with less

assistance x2 or x3/day with RN/PT/RT/UAP

Tolerates Level I

Activities

Refer to the following criteria to assist in

determining mobility level

YESNO

Start at level II and progress*

Start at level I*

o PaO2/FiO2 > 250

o Peep <10

o O2 Sat > 90%

o RR 10-30

o No new onset cardiac arrythmias or ischemia

o HR >60 <120

o MAP >55 <140

o SBP >90 <180

o No new or increasing vasopressor infusion

o RASS > 3

Perform Initial mobility screen w/in 8 hours of ICU

admissionReassess mobility level at

least every 24 hours(Recommended at shift Δ)

Goal: upright sitting; increased strength and moves

arm against gravity

PT consultation prnOT consultation prn

Goal: Increased trunk strength, moves leg against

gravity and readiness to weight bear

PT: Active Resistance Once a day, strength

exercises

OT consultation prn

ACTIVITY:Self or assisted Q 2 hr turning

1.Sitting on edge of bed w/RN, PT, RT assist X 15 min.

2.Progressive bed sitting PositionMin.20 min. 3X/d

OrPivot to chair position 2X/d


1.Bed sitting PositionMin.20 min. 3X/d;

2.Sitting on edge of bed; stand w/ RN, PT, RT assist

3.Active Transfer toChair (OOB) w/ RN/PT/RT assist Min. 3X/d

PT x 2 daily & OT x1 daily


1.Chair (OOB) w/ RN/PT/RT assist Min. 3X/day

2.Meals consumed while dangling on edge of bed or in chair

Goal: stands w/ min. to mod. assist, able to

march in place, weight bear and transfer to

chair

PT x 2 dailyOT consult for ADL’s

Goal: clinical stability; passive ROM

ACTIVITY:Q 2 hr turning

*Passive /Active ROM 3x/d

1. HOB 45º X 15 min.2. HOB 45º,Legs

in dependant position X 15 min.

3. HOB 65º,Legs in dependantposition X 15 min.

4. Step (3) & full chair mode X20 min. 3X/d

Or Full assist into cardiac

chair 2X/day

ACTIVITY:

HOB > 30º*Passive ROM 2X/d performed by RN, or

UAP_________________

CLRT/Pronationinitiated if patient

meets criteria based on institutional

practiceOR

Q 2 hr turning

Goal: Increase distance in ambulation & ability to perform some ADLs

ToleratesLevel IIIActivities

ToleratesLevel II

Activities

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Purpose: The purpose of the Turn and Position System with Microclimate Body Pad is to help the caregiver achieve the goal of:

• Offloading pressure (turning) q2 hrs or more frequently to reduce the risk of pressure ulcers

• Maintaining a lateral position• Controlling the microclimate to eliminate the risk of moisture related skin injury.

• Reduce shear & friction by repositioning with a glide sheets that is able to stay under the patient (breathable)

• Eliminates lift movements by the caregiver


Indications for use:1. Patient requires assistance in turning q2 hrs or

more frequently and/or Braden’s mobility score of 1

2. Mobility protocol in use3. Incontinence of urine or stool or a Braden’s

moisture score of 2 or less4. BMI>30, weight up to 350lbs, unequally

distributed adipose tissue making positioning difficult

5. High risk patients; likely to be ventilated >24 hrs, History of a previous pressure ulcer, evidence of significant third spacing or low albumin

6. Intractable pain with movement

Contraindications:1. Unstable spine

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Attitude &

Accountability

Factors Impacting theability to Achieve QualityNursing Outcomesat the Point of Care

Achieving the Use of the Evidence For Mobility & Moisture

ValueVollman KM. Australian Crit Care, 2009;22(4): 152-154

Resource & System•Breathable glide sheet/stays•Foam Wedges•Microclimate control•Reduce layers of linen•Wick away moisture body pad

• Pre-intervention 90 days before trial FAPU

• 90 days during the trail FAPU

• Cost reduction after paying for the device

Linda Flockhart RN BSN Manager CVICUClare Fielding RN BSN CVICU

Presented at 17th Annual Wound Care Conference, Toronto, Can 11/3-6/2011

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M2: Mobility and Moisture Protocol to Drive Care: Implementing Best Practices with Ease

– 1st step: Collection of baseline data

– 2nd step: Evaluating resources

– 3rd step: Education on products and processes

– 4th step: Implementation of the M2 protocol

– 5th step: Sustaining change in practice

– 6th step: Evaluate outcomes


1st Step: Collection of baseline data • Direct observation of current status on Q2hr turning• Nosocomial pressure ulcer rates (NDNQI) • Incontinence associated dermatitis rates (IAD Form)• Staff musculoskeletal injuries (Employee Health)• Cost-analysis of patient and staff injuries

Junkin J, Selek JL. J WOCN 2007;34(3):260-269

IAD Tool

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In God We Trust!


2nd Step: Evaluating resources to help staff achieve the right care, at the right time with the right pt

• Slide/Glide sheet that remains underneath the patient to reduce shear/friction & aid with turning

• Foam wedges to help sustain the turn & also check for sacral offloading

• Large enough wick away pad to remove moisture while creating an appropriate microclimate for the patient

• Tools inside the patients room (turn clock)

• Unit or hospital wide musical cues

• A protocol Winkelman C, et al. Crit Care Nurse, 2010;30(2):S13-S16National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure ulcer prevention & treatment :clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.

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3rd Step: Education on products and processes• Education on the evidence based strategies• Process built for documentation of new

protocol• Education on any new products and how they

will be used• Re-education when necessary to ensure

appropriate use• Use of reference cards• Build into orientation


4th Step: Implementation of the M2 protocol • Integrate into any existing progressive mobility protocol• Rounding to ensure appropriate utilization• Select focused patients for protocol (3 types)

Indications for use:1. Patient requires assistance in turning q2 hrs or more frequently and/or Braden’s

mobility score of 12. Mobility protocol in use3. Incontinence of urine or stool or a Braden’s moisture score of 2 or less4. BMI>30, weight up to 350lbs, unequally distributed adipose tissue making

positioning difficult5. High risk patients; likely to be ventilated >24 hrs, History of a previous pressure

ulcer, evidence of significant third spacing or low albumin6. Intractable pain with movement

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5th Step: Sustaining change in practice with frequent observation , encouragement and re-education as necessary

• Skin rounds/time frequency

• Hand-off communication

• Skin liaison/champion nurses

• Creative strategies to reinforce protocol use

• Visual cues in the room or medical record

• Rewards for increase compliance

• Yearly competencies on beds or positioning aids to ensure correct and maximum utilization


6th Step: Evaluate outcomes using comparison of data measurements pre and post implementation

• Direct observation measurement to ensure turning and repositioning is occurring

• Nosocomial pressure ulcer rates (NDNQI)

• Incontinence associated dermatitis rates (IAD Form)

• Staff musculoskeletal injuries (Employee Health)

• Cost-savings analysis of patient and staff injuries post change in practice (including any new product costs)

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We all are responsible for the safety of our patients & ourselves…Own the Issues

•“If not this, then what??”•“If not now, then when?”•“If not me, then who??”

Be Courageous

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