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Stopping Pressure UlcersOne Root Cause at a Time

June 27, 2012

Today’s Presenter

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Melody A. Malone, PT, CPHQQuality Improvement Consultant

TMF Health Quality Institute

About TMF

TMF Health Quality Institute focuses on improving lives by improving the quality of health care through contracts with federal, state and local governments, as well as private organizations. For more than 40 years, TMF has helped health care providers and practitioners in a variety of settings improve care for their patients.

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TMF is the Quality Improvement Organization (QIO) for Texas

About the QIO Program Leading rapid, large-scale change in health

quality:• Goals are bolder.• The patient is at the center.• All improvers are welcome.• Everyone teaches and learns.• Greater value is fostered.

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Objectives

The learner will be able to:• Facilitate completion of the Facility-Acquired

Pressure Ulcer (FA PU) Investigation Tool• Identify potential areas for root causes• Identify potential areas for systems

improvement

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Pressure Ulcer DefinitionAny lesion caused by unrelieved pressureresulting in damage of underlying tissues.

Source: F314 42 CFR 483.25(c), U.S. Department of Health & Human Services Agency for Healthcare Research and Policy. www.ahrq.gov. National Pressure Ulcer Advisory Panel Monograph (pp. 181).

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Polling Question:

Do you have facility-acquired pressure ulcers in your setting?

Yes No I don’t know Doesn’t apply

in my setting

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Quiz…

Why focus on pressure ulcers?

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Actual harm to the patient!

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Facility-Acquired Pressure Ulcers

Develop in the health care facility AFTER admission

FA PUs cause:• Pain to the resident• Scarring of the body• Increased risk of infection• Increased costs of care

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National Partnership for Patients Goal “Keep patients from getting injured or sicker.

By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010.”

Partnership for Patients. U.S. Department of Health & Human Services. April 2011. Retrieved from: http://www.healthcare.gov/news/factsheets/2011/04/partnership04122011a.html

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Pressure ulcers are a problem!

NH Quality Measure: High-risk residents with PUs in Texas: 7.4% 1

• 4,007 HR residents with a PU out of 54,479• 87,533 nursing home residents in Texas 2

1 Facility Quality Measure (2011 Q4)2 Regulatory Services Fiscal Year 2011 Annual Report January 2012

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Pressure ulcers are a problem!

12% hospitalized patients developed at least 1 pressure ulcer during the stay

• 383 surgical patients out of 3,225

Tschannen, D., Bates, O., Talsma, A. and Guo, Y. Patient-specific and Surgical Characteristics in the Development of Pressure Ulcers. American Journal of Critical Care

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Nursing Homes in TMF’s Previous QIO Contract

Reduced FA PUs from 39% (237) December 2009 to 32% (130) June 2011

*47 nursing homes

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How do we change this and…

Keep it fixed?

We focus on quality improvement (QI).

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If Pressure Ulcers are “IN”

Then nothing can be “OUT”

If all systems are GO – no pressure ulcers!

Got pressure ulcers?

You’ve got systems failures!

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The most fundamental reason a problem has occurred

(When performance does not meet expectations)

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Root Cause

Facility-Acquired PU Investigation Tool

Incident report and root cause analysis tool Privileged & Confidential Work Product of the

QAA Committee Takes the focus off the individual and puts it

on the system

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Facility-Acquired PU Investigation Tool

Compile and analyze:• Clinical• Environmental• Operational issues that contributed to the development of a

pressure ulcer

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Facility-Acquired PU Investigation Tool

Focus the team to:• Gain the ability to anticipate issues for risk

identification • Enhance staff knowledge• Take action to implement interventions• Boost the ability to sustain improvements• Critical thinking

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Nursing Home Results

Three nursing homes (NH) during three years:• 1 NH achieved > 400 days between the

development of an FA PU.• 1 NH achieved two cycles of > 100 days

between the development of an FA PU.• 1 NH achieved one cycle of 100+ days.

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Nursing Home Results, continued

Plus, they had other significant periods of time between new FA PUs, such as:

69, 76, 78, 103 and 148 days

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Process for Use of the Tool

Begin tool when PU is identified – day 1• Resident/patient changes start today!

Designated individual completes tool – day 1 or 2• Wound nurse or nursing leadership

Team reviews the tool – day 1, 2 or 3 Tests of change identified and plan developed

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Resident name: Melody Malone   Room number: 409  

Date ulcer identified: 4/14/2011  Time ulcer identified: 7:30 AM

Date of last full body skin assessment: 4/6/11Was ulcer found at this time? (circle)

YES NO

Ulcer is properly diagnosed as a pressure ulcer? YES NO

If NO, what type of ulcer is it? (circle) Arterial ulcer Diabetic neuropathic ulcer Venous insufficiency ulcer Other:________________________

Is the new ulcer in a site of a previously healed ulcer of any type? (circle) YES NO

Location of ulcer: Sacrum       Stage of PU at discovery: 2

Is resident diabetic? (circle)

YES NO IF yes, have blood sugars been within resident's usual range? (circle)

YES NO

Facility-Acquired PU Investigation ToolPrivileged Confidential Work Product of the QAA CommitteePage 1, First Quarter

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Prevention strategies that WERE in place PRIOR to ulcer development: (circle & add comments)

Mattress/Bed: Overlay on mattress Conventional Replacement Low Air Loss

Specialty Bed Other:      

Is bed functioning/used

properly? YES NO

Turning and repositioning program:YES NO Was it really

done?      

Heels floated:

YES NO Chair cushion:

YES NO Fit/Function properly:

YES NO

Facility-Acquired PU Investigation ToolPrivileged Confidential Work Product of the QAA CommitteePage 1, Second Quarter

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Nutritional interventions (list/circle): Multi-vitamin Vitamin C Zinc Other:_________

Protein powder/liquid: Daily Bid Tid Protein supplement: Daily Bid Tid

Other:                

Is nutritional intake what RD recommends? YES NO

Last 3 weights: Date: Weight: Date: Weight: Date: Weight: Last RD Visit:

4/3/11 206.6 3/1/11 205.1 1/28/11 207.3 4/19/2011

Laboratory Test History: {Note if lab value is: H = high / L = low / N = normal}

Date: Value:

3/19/11 {H/L/N}

Date: Value:

________ {H/L/N}

Date: Value:

________ {H/L/N}

Date: Value:

________ {H/L/N}

Pre Albumin: _______ ______ _______ ______ _______ ______ _______ ______

Serum Albumin: 2.4 L _______ ______ _______ ______ _______ ______

Total Protein: 5.6 L _______ ______ _______ ______ _______ ______

Facility-Acquired PU Investigation ToolPrivileged Confidential Work Product of the QAA CommitteePage 1, Third Quarter

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PU Risk Assessment Scores: (Braden, etc.) Date: 3/9/11 Score: 14 Date:12/9/10 Score: 14 Date:____ Score:___

Were risk assessment scores accurate?YES NO

Has resident been refusing PU prevention interventions? YES NO Other treatments?

YES NO

Has incontinence (bowel or bladder) or moisture been a problem unaddressed prior to ulcer?YES NO

Has pain been a problem unaddressed prior to ulcer?YES NO

Family notified of

ulcer:YES NO

CNA comm. tool/care plan

updated:YES NO

Physician notified of

ulcer:YES NO

Care plan updated:

YES NO

Facility-Acquired PU Investigation ToolPrivileged Confidential Work Product of the QAA CommitteePage 1, Fourth Quarter

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Resident name:

(Insert names of staff actually working with the resident)

Shift ulcer found: 1 shift prior:

2 shifts prior:

3 shifts prior:

4 shifts prior:

5 shifts prior:

6 shifts prior:

7 shifts prior:

8 shifts prior:

Date:4/14 4/13 4/13 4/13 4/12 4/12 4/12 4/11 4/11

Shift: days nights eve days nights eve days nights eve

Nurse:Millie Shirley Holley Millie Becca Ralph Anne Becca Ralph

CNA:Jeanine Chris Dawn Jeanine Stella Julie Dolores Chris Dawn

CNA:Ethel   Sue Ethel   Sue Mike   Dolores

CMA:Ilise   Mark Ilise   Fred Ilise   Mark

OTHER:                 

Facility-Acquired PU Investigation ToolPrivileged Confidential Work Product of the QAA CommitteePage 2, First Third

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In the same 72 hour period as above, note the changes of condition the resident had PRIOR to the ulcer being found. Mark: YES or Y if present. If NO changes of condition have occurred, check this box: Cognition level                  

Physical activity level                  Urinary incontinence                  Bowel incontinence                  

Mobility – ability to change and control body position                  

Usual food intake pattern                  Usual water/liquid intake pattern                  Pain                  

Started new medication(s)                  Developed multi-system organ failure                  

Become a hospice candidate or recipient                  

Started refusing care                  

Other: fever, difficulty breathing, shear factor with HOB up, if any new devices were used, etc. (Note issues.)

                 

Shift ulcer found:

1 shift prior:

2 shifts prior:

3 shifts prior:

4 shifts prior:

5 shifts prior:

6 shifts prior:

7 shifts prior:

8 shifts prior:

4/14 4/13 4/13 4/13 4/12 4/12 4/12 4/11 4/11

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Determination of root cause for PU development, both resident and system level:      

Resident sitting up in the chair all the time              

Action plan for resident and system improvements:            

Resident to bed after meals                

                    

      4/15/2011   

Signature of Investigator Date investigation completed 

          4/15/2011   

DON signature Date reviewed 

          4/15/2011   

Administrator signature Date reviewed

Facility-Acquired PU Investigation ToolPrivileged Confidential Work Product of the QAA CommitteePage 2, Last Third

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Determination of Root Cause and Quality Improvement Plan

Usual findings: Superficial causes Not systems issues

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NH’s Root Causes Included: Resident on hospice Refuses care Resident has

increased pain Resident leans to side Resident does not eat

well Constant motion

Resident has loose stool episode before skin breakdown

Heels pressing against geri-chair while up during the day

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What were the REAL root causes?

Findings from compiling the 65 FA PU Inv. Tools:

43% did not have a validated risk assessment timely prior to the FA PU

42% mattress/bed was not appropriate to the level of risk prior to the FA PU

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REAL Root Causes, continued

38% gap between last full body skin assessment

20% care plan not updated with risk changes

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REAL Root Causes, continued

31% did not have nutritional interventions prior to the FA PU

34% abnormal lab values identified to the FA PU were unaddressed

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Training on the Tool is Available

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Action Items

Share the FA PU Investigation Tool with your QI team.

View the training webinar. Have someone use it, review it and learn. Implement a test of change. Celebrate your successes. Count your days between FA PUs!

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Q&A (during a polling question)

Will you try using the FA PU Investigation Tool?

Yes No Doesn’t apply

in my setting

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References Department of Health & Human Services, Centers for

Medicare & Medicaid Services Appendix PP/483.25(c)/Pressure Sores/Tag F314. Guidance to Surveyors for Long Term Care Facilities

Facility Quality Measure Report. (2011 Quarter 4). Partnership for Patients. U.S. Department of Health &

Human Services. April 2011. Retrieved from: http://www.healthcare.gov/news/factsheets/2011/04/partnership04122011a.html

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References, continued Regulatory Services Fiscal Year 2011 Annual Report

January 2012. Texas Department of Aging and Disability Services.

Tschannen, D., Bates, O., Talsma, A. and Guo, Y. Patient-specific and Surgical Characteristics in the Development of Pressure Ulcers. American Journal of Critical Care. 2012;21:116-125 doi: 10.4037/ajcc2012716

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Additional information can be found at:

Agency for Healthcare Research and Quality (AHRQ). www.ahcpr.gov

www.npuap.org

http://qmweb.dads.state.tx.us

http://TexasQIO.tmf.org

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Contact

Melody Malone, PT, CPHQQuality Improvement Consultant

TMF Health Quality Institute214-632-2238

melodymalone@txqio.sdps.orghttp://TexasQIO.tmf.org

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This material was prepared by TMF Health Quality Institute, the Medicare Quality Improvement Organization for Texas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 10SOW-TX-C7-12-81