Marlyn Conti , BSN, MM, CPHQ Patient Safety Initiatives Manager Intermountain Healthcare
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Intermountain-led CMS Hospital Engagement Network Pressure Ulcer Prevention June 24, 2014 Affinity Call Marlyn Conti , BSN, MM, CPHQ Patient Safety Initiatives Manager Intermountain Healthcare
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Intermountain-led CMS Hospital Engagement Network Pressure Ulcer Prevention June 24, 2014 Affinity Call. Marlyn Conti , BSN, MM, CPHQ Patient Safety Initiatives Manager Intermountain Healthcare. Outline for Discussion. Review of the HEN Pressure Ulcer work - PowerPoint PPT Presentation
Transcript of Marlyn Conti , BSN, MM, CPHQ Patient Safety Initiatives Manager Intermountain Healthcare
Intermountain-led CMS Hospital Engagement Network
Pressure Ulcer PreventionJune 24, 2014
Affinity Call
Marlyn Conti , BSN, MM, CPHQPatient Safety Initiatives Manager
Intermountain Healthcare
Outline for Discussion
• Review of the HEN Pressure Ulcer work • “Just-one-thing” Recommendations• High performers• 2014 plans for improvement:
Overall Progress Through Q1 2014
Intermountain HEN 2012-Q1 2014 Pressure Ulcer PSI 3
Intermountain HEN 2012-Q1 2014 Pressure Ulcer PSI 3
Intermountain HEN 2012-Q1 2014 Pressure Ulcer >= Stage 3
Intermountain HEN 2012-Q1 2014 Pressure Ulcer >= Stage 3
Intermountain HEN 2012-Q1 2014 Pressure Ulcer >= Stage 2
Intermountain HEN 2012-Q1 2014 Pressure Ulcer >= Stage 2
Intermountain HEN 2012-Q1 2014 Pressure Ulcer Prevalence
Intermountain HEN 2012-Q1 2014 Pressure Ulcer Prevalence
Just One Thing MatrixRecommendations
Getting Started Working Harder Ahead of the Curve
Appoint a leadership supported team or work group to drive improvement & education SWAT (or champion) teams that includes unit nurse.(moderate-high level of evidence)
Adopt decision algorithms for nursing staff to select appropriate surfaces , physical therapy and dietary referrals(moderate-high level of evidence)
Establish monthly prevalence studies or collect incidence data from electronic medical records, then feed that data back to the SWAT teams.(moderate-high level of evidence)
High Performing Hospital Highlight…Pressure Ulcer PSI 3
Most Improvement
BAYLOR MEDICAL CENTER AT WAXAHACHIE
THE HEART HOSPITAL BAYLOR PLANO
BAYLOR MEDICAL CENTER AT CARROLLTON
BAYLOR MEDICAL CENTER AT IRVING
BAYLOR REGIONAL MEDICAL CENTER AT GRAPEVINE
BAYLOR MEDICAL CENTER AT GARLAND
BAYLOR ALL SAINTS MEDICAL CENTER AT FW
DENVER HEALTH MEDICAL CENTER
PROVIDENCE SEASIDE HOSPITAL
PROVIDENCE PORTLAND MEDICAL CENTER
Lowest Rates
PROVIDENCE PORTLAND MEDICAL CENTER
SUTTER MEDICAL CENTER OF SACRAMENTO
BAYLOR ALL SAINTS MEDICAL CENTER AT FW
DENVER HEALTH MEDICAL CENTER
MILLS PENINSULA HEALTH SERVICES
BAYLOR MEDICAL CENTER AT IRVING
BAYLOR MEDICAL CENTER AT GARLAND
BAYLOR REGIONAL MEDICAL CENTER AT GRAPEVINE
BAYLOR REGIONAL MEDICAL CENTER AT PLANO
EDEN MEDICAL CENTER
High Performing Hospital Highlight…
Most Improvement
BAYLOR MEDICAL CENTER AT IRVING
THE HEART HOSPITAL BAYLOR PLANO
HILLCREST BAPTIST MEDICAL CENTER
SANPETE VALLEY HOSPITAL - CAH
BAYLOR REGIONAL MEDICAL CENTER AT PLANO
BAYLOR UNIVERSITY MEDICAL CENTER
HEBER VALLEY MEDICAL CENTER
SEVIER VALLEY MEDICAL CENTER
PARK CITY MEDICAL CENTER
THE ORTHOPEDIC SPECIALTY HOSPITAL
Pressure Ulcers >= Stage 3
Lowest Rates
UTAH VALLEY REGIONAL MEDICAL CENTER
MCKAY DEE HOSPITAL CENTER
DIXIE REGIONAL MEDICAL CENTER
LDS HOSPITAL
AMERICAN FORK HOSPITAL
RIVERTON HOSPITAL
VALLEY VIEW MEDICAL CENTER
BAYLOR MEDICAL CENTER AT IRVING
ALTA VIEW HOSPITAL
PRESBYTERIAN HOSPITAL
High Performing Hospital Highlight… Pressure Ulcers >= Stage 2
Lowest Rates
THE HEART HOSPITAL BAYLOR PLANO
BAYLOR MEDICAL CENTER AT WAXAHACHIE
PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER
PROVIDENCE MEDFORD MEDICAL CENTER
BAYLOR HEART AND VASCULAR HOSPITAL
PROVIDENCE HOOD RIVER MEMORIAL HOSPITAL
BAYLOR MEDICAL CENTER AT IRVING
BAYLOR REGIONAL MEDICAL CENTER AT GRAPEVINE
PROVIDENCE PORTLAND MEDICAL CENTER
BAYLOR UNIVERSITY MEDICAL CENTER
• *Most Improvement– Only 2 Hospitals haveReported Q1 2012 and Q 1 2014 data
High Performing Hospital Highlight…
Most Improvement
BAYLOR HEART AND VASCULAR HOSPITAL
BAYLOR MEDICAL CENTER AT WAXAHACHIE
THE HEART HOSPITAL BAYLOR PLANO
DENVER HEALTH MEDICAL CENTER
CASSIA REGIONAL MEDICAL CENTER
DELTA COMMUNITY MEDICAL CENTER
SANPETE VALLEY HOSPITAL - CAH
BAYLOR MEDICAL CENTER AT IRVING
LDS HOSPITAL
BAYLOR REGIONAL MEDICAL CENTER AT PLANO
Pressure Ulcers Prevalence – All stages
Lowest Rates
THE HEART HOSPITAL BAYLOR PLANO
BAYLOR MEDICAL CENTER AT WAXAHACHIE
ST PATRICK HOSPITAL
UPPER CONNECTICUT VALLEY HOSPITAL
SCOTT & WHITE HOSPITAL-ROUND ROCK
BAYLOR HEART AND VASCULAR HOSPITAL
SCOTT & WHITE CONTINUING CARE HOSPITAL
THE ORTHOPEDIC SPECIALTY HOSPITAL
HEBER VALLEY MEDICAL CENTER
DELTA COMMUNITY MEDICAL CENTER
Practice Survey• Do you have a pressure ulcer prevention team?
Yes/No– If yes, Is your team multidisciplinary? Yes/No– If yes, how frequently do they meet?– Do they have resources to collect/interpret/review
data?• Comments (free text)
• What tools do you use to assess and properly stage a pressure ulcers? (free text)– Posters, fact sheets, etc, other (free text)
Practice Survey• Do you have skin and/or pressure ulcer assessment
prompts embedded in your EMR? Yes/No– If yes, how often are they reported or prompted
• Who receives the reports• What are the expected actions
– To determine if reassessing patients at established frequencies
• What is the one intervention that has had the most impact in reducing pressure ulcers? (free text)
• What is the most innovative approach to reducing pressure ulcers?
Pressure Ulcer Scenario9 M/O female infant with congenital anomalies requiring tracheostomy with an un-cuffed trach placed. Secretions were very difficult to manage and the MD indicated that re-intubation would be ‘impossible’ for this baby. Trach ties were very tight in order to hold the tube in place. The first trach change was performed 7 days after the initial placement and a stage IV pressure ulcer was found from the trach ties.
What could have been done??
Pressure Ulcer Scenario40 Y/O male, admitted with altered level of consciousness related to hepatic encephalopathy, hypotension and abdominal ascites. Patient had several large volume paracentesis performed with rapid re-accumulation of fluid. The decision was made by the physician and the patient's mother to provide comfort measures only and the patient was transferred to inpatient hospice. 4 days after hospice transfer, a stage III pressure ulcer was found on his coccyx.
– What this preventable?– What would you have done??
2014 plans for improvement
• Collect and share best practices across our network hospitals & system in a single document
• Share practice bundles?
