Case In Point
When Northwest Community Hospital (NCH) decided to open an attack on pressure ulcers in 2004, the facility’s quarterly prevalence rates for this major cause of patient morbidity and mortality consistently exceeded the benchmarks of the National Database of Nursing Quality Indicators (NDNQI).
The hospital was working toward NDNQI Magnet status, a marker of excellence in nursing care, and it needed a significant reduction in pressure ulcer prevalence rates, among other things, to achieve that recognition. At the same time, protecting patients from this debilitating and potentially fatal complication was a natural outgrowth of the hospital’s commitment to quality care.
A multifaceted pressure ulcer prevention and care program launched in 2005 has enabled the 428-bed facility, located in Arlington Heights, Ill., to drastically reduce pressure ulcer prevalence and keep rates below NDNQI benchmarks since the third quarter of 2006. Currently, the hospital is working toward a rate of zero.
According to Diane Davis-Zeek, R.N., a certified adult nurse practitioner and wound, ostomy and continence care consultant at NCH, attaining this goal is not out of the realm of possibility. She credits much of this progress to backing from a forward-thinking administration willing to empower clinical care management to invest carefully in innovative products and implement evidence-based strategies.
Not only did clinical staff have senior management’s wholehearted “buy-in” before the program began, but the program was leadership’s idea, Davis-Zeek says. “They knew they had a problem. They came to us as a wound-care team and said ‘What do we need to do to fix this?’ The reason we were successful is that we had a supportive administration.”
A product of care
Although Davis-Zeek says the introduction of new products has not been cheap, she believes the hospital has recouped its investment in what has been saved on treatment and in a reduced risk of litigation. The cost to heal a pressure ulcer can reach an estimated $40,000. Nationally, costs associated with ulcer treatment and lost worker productivity top $2 billion annually, and the Centers for Medicare & Medicaid Services (CMS) no longer reimburses for hospital-acquired pressure ulcers.
Buoyed by management’s commitment, a task force of clinical care directors and the hospital’s team of wound/ostomy consultants have overhauled NCH’s pressure ulcer, incontinence care and skin care policies, procedures and protocols. The task force also organized a “Skintastics” team of floor staff representatives from each of the hospital’s adult units and has researched, tested and implemented a host of leading-edge products and approaches to care.
Prevalence rates dropped precipitously in the third quarter of 2006 “when all of these measures began to take effect,” Davis-Zeek reports. Rates decreased from an average of 16 percent to 4 percent in critical care and from 11 percent to under 7 percent in the medical units. Although prevalence initially went up in step-down cardiac care, “This is still a work in progress, and our numbers continue to improve,” Davis-Zeek says. “Our pressure ulcer prevalence remains significantly below benchmark with each quarterly study and we are aiming for zero. It takes time to educate staff and change [their] practice.”
The effort in this regard began in 2005 with the reeducation of staff on pressure ulcer prevention using the Braden Scale, a well validated risk assessment tool for the development of pressure ulcers. A Braden score of less than 18 tells a caregiver that a patient is at risk and that interventions are warranted. (Interventions may include a special mattress to relieve pressure, regular repositioning and turning of the patient, a nutritional consultation and management of moisture due to incontinence.)
The nursing staff had Braden Scale training in the past but had not been using the tool consistently. A new policy increased the frequency of the tool’s use for every adult patient.
Along with reinvigorated training in the identification and care of at-risk patients came a comprehensive look at current thinking regarding pressure ulcer risk factors and prevention strategies.
Responsibility for the overhaul fell to the task force in the first quarter of 2006. The group based all of its policy, procedure and protocol changes on a review of the scientific literature, current National Institutes of Health and Agency for Healthcare Quality and Research guidelines and recommendations, and Wound, Ostomy and Continence Nurses Society (WOCN) best practices and guidelines. Davis-Zeek and her colleagues also kept abreast of new findings and trends by attending WOCN’s annual conference and other wound- and skin-related seminars.
Research has shown that the sacrum and the heels are two of the most common sites of pressure ulcers. The hospital saw the prevalence of this type of pressure ulcer significantly decline during the trialing of the Prevalon heel protection boot, introduced in 2005 by Sage Products, Cary, Ill. The boot, which the task force has since implemented, elevates the foot and suspends the heel from the mattress, reducing pressure, friction and shear on feet, ankles and heels.
According to Jim Layer, vice president of research and development at Sage, the best pressure ulcer prevention products are “simple interventions that fit in with practices the nursing staff are already used to so that we’re not asking the staff to change a lot of what they’re doing.”
The hospital also has tackled prevention in the sacrum and other vulnerable areas by replacing egg-crate foam products with air-filled waffle mattress alternatives that redistribute pressure more evenly over bony prominences.
The hospital’s existing foam core mattresses had durable covers that were “so hard it made them like a rock,” Zeek says. The hospital at first attempted to replace the covers, but “it was very labor intensive for the housekeeping staff to replace all of these covers.” The hospital has implemented the waffle mattresses and chair cushions while it continues to evaluate new mattress options.
A major point they learned from the WOCN conference was the need to evaluate alternatives to diapers in managing incontinence. Diapers, which hold urine and fecal matter against the skin, play a major role in skin breakdown.
“We had to choose what was right for our hospital, but clearly, the literature was saying to get patients out of diapers,” Davis-Zeek says. She and her colleagues collected information and suggestions on strategies for retraining staff and reviewed products from a variety of vendors.
The hospital had two products already in-house that were not being used to their full potential, Davis-Zeek says: the ConvaTec (Princeton, N.J.) Flexi-Seal fecal management system for bedridden patients, which consists of a rectal tube designed to contain and divert liquid or semiliquid fecal waste, and the Hollister (Libertyville, Ill.) fecal collector, a rectal pouch that adheres to a patient’s peri-rectal skin and keeps stool away from the skin. Reeducating staff on how these products work has increased their use and decreased wound-care referrals for incontinence-related skin breakdown, according to Davis-Zeek.
The task force has trialed and implemented a pull-up adult incontinence brief and is currently evaluating external male catheters as well. For each product, the task force invited the vendor to conduct in-service sessions for the staff and provided additional education at individual unit skills labs. The task force also introduced a variety of advanced skin care products, which have been well received.
The 3M Tegaderm Absorbent Clear Acrylic Dressing, for example, allows patient care staff and physicians to see a wound without removing the dressing and further irritating a patient’s already vulnerable skin.
The dressing consists of a clear acrylic polymer pad that absorbs moisture and a top, breathable layer that acts as a barrier to contaminants. Another skin care product now in use on the units is 3M’s Cavilon No Sting Barrier Film, a quickly drying liquid that provides a breathable, transparent coating to shield skin from urine, feces and friction.
The Skintastics team has served as valuable conduits for the flow of product information and feedback to and from the task force and patient care staff, Davis-Zeek says.
“They are there on the front lines,” she says, and as a result, have played a pivotal role in winning staff support for new practices.
Open communication has been critical in that regard. The task force continues to meet quarterly, “but we get feedback on a daily basis, and when we have trials and are looking at a new product, we’re talking with the lead person on the unit every week, sometimes twice a week, and asking them what kind of feedback they’re getting [from patient care staff],” Davis-Zeek says.
The task force continues to scour the literature and data to keep tabs on best practices and new findings. “As we identify new problems, we begin to act on those, and as new practice recommendations come out, we change practices,” she says. For example, “we are currently looking at the process of wound documentation using photography which could be done by the bedside nurse.”
Changing behavior initially met with some resistance from staff who were used to doing things in certain ways, Davis-Zeek notes. “We had a lot of issues.” However, “[the task force] listened to every single comment that we got back and tried to get back to the unit and address their concerns,” she says. It also tried not to change a practice or take a product away without offering a new and better solution. “That’s one way the staff felt we were listening to them.”