Pressure Ulcers and the Patient Safety

1
Minnesotas Adverse Health Events

• Pressure Ulcers and the Patient Safety
• Communitys Response
• Trista Johnson, Ph.D., MPH
• Allina Hospitals Clinics, Vice Chair,
• MAPS Best Practice Subcommittee
• Julie Apold
• Patient Safety Registry Manager
• Minnesota Hospital Association

2
Adverse health events reporting law background

• The Minnesota Alliance for Patient Safety was
  formed in 2000.
• Key Partners Medical Association, Hospital
  Association, and Health Department
• Currently over 50 Minnesota organizations
  involved
• Momentum towards developing a reporting system
  based on NQF never events
• Adverse Health Care Event Reporting Law went into
  effect in 2003.

3
Goals of the law

• Not to punish errors by health care
  practitioners or health care facility employees.
• Insteadto balance quality improvement and
  accountability for public health safety.

4
When was the law implemented?

• Hospitals reported events to MHA from July 2003,
  to December 2004 as part of the laws transition
  period.
• Full implementation began on December 6, 2004.
• MDH required to begin reviewing submitted events.

5
What must be reported?

• Any of the 27 never events defined in law.
• Within 15 working days, initial information about
  the event must be reported.
• Within 60 days, findings of a root cause analysis
  and a corrective action plan must be reported.
• NO identifying information for any health
  professionals, employees or patients is included.

6
Sample NQF Reportable Events

• Care Management
• Medication error
• Maternal death
• Death from hypoglycemia
• Stage 3 or 4 pressure ulcers
• Environmental Events
• Death from electric shock
• Wrong gas delivered
• Patient burns
• Patient falls
• Criminal Events
• Abduction
• Sexual assault

• Surgical Events
• Wrong surgery
• Retention of foreign object
• OR or Post-op death
• Product or Device
• Contaminated drugs or blood
• Air embolism
• Patient Protection
• Infant discharged to wrong person
• Patient elopement

7
1st Public report

• MDH is also required by law to publish an annual
  report of events and corrective actions.
• First report released in January, 2005.
• 99 events were reported by hospitals during the
  transition period.
• The most frequently reported events were foreign
  objects (31 events) left in patients after
  surgery, followed by stage 3 or 4 pressure ulcers
  (24 events).

8
Best Practices Subcommittee

• Subcommittee of MAPS
• Charge Serving organizations to successfully
  identify and advance effective patient safety
  efforts
• Reviewed Adverse Health Event Data
• Noted that surgical issues were currently being
  addressed by the Safest in America group and
  others.
• Agreed to focus on addressing pressure ulcers.

9
Information Gathering

• The subcommittee began gathering information on
  pressure ulcer best practices in acute care
  settings.
• Assessed aggregate root cause analyses findings
  for pressure ulcer events.
• Reviewed local and national guidelines and tools.
• Convened an expert panel of practitioners from
  Minnesota hospitals to share best practices and
  barriers.

10
Root Causes

• Documentation
• Inconsistent
• Incomplete
• Knowledge
• Inadequate skin inspection
• Selection of mattress
• Communication
• Between staff, units, and facilities

11
Root Causes (cont)

• Tools/Equipment
• Bed selection tools not available
• Equipment not readily available
• Bariatric patients
• Delays in assessment/intervention
• Focus on treatment rather than prevention
• At-risk status not effectively communicated
• Lack of awareness re how quickly pressure ulcer
  can develop

12
NCPS hierarchy of actions

• Weaker actions (rely on memory)
• New procedures/policy
• Training
• Intermediate actions (some checks balances)
• Checklist/cognitive aid
• Redundancy
• Stronger actions (force the correct action)
• Physical changes to facility
• Simplify process/remove unnecessary steps
• Standardize equipment or process

13
Corrective Actions

• Education
• Include assessment and documentation as
  competency
• Development of tools
• bed decision-making algorithm
• bedside education tool for repositioning
• Develop/revise protocols/policies
• FMEA of assessment process

14
Corrective Actions

• Develop standing orders for wound care nurse
  which includes recommendations for specialty
  beds, dietary supplements and wound cares.
• Change orders from PRN to Do based on Braden
  score.
• Incorporate skin into daily rounds
• Family conferences for at-risk patients/patient
  education

15
Expert Panel

• Initial meeting with hospital wound care experts
  in December, 2004.
• Follow-up work session April 1, 2005
• Pre-session survey of hospitals on
  practices/barriers.
• Presentations from hospitals on innovative
  efforts in their facilities.
• Facilitated discussion on best practices and
  barriers.

16
Survey Results - Incidence

• Staff collecting data varies
• WOC nurses only
• Skin care nurse teams
• Nursing assistants with WOC nurses
  assisting/serving as resource
• Collection tools vary
• NDIQI magnet status tool
• Hill-Rom National Survey
• Internal tool

17
Survey Results - Assessment

• All hospitals report using Braden Scale
• Braden Q Scale for pediatrics
• Population targeted for assessment varies
• All patients
• Adult med/surg and ICU
• Pts. bed bound, chair bound, requiring assistance
  to transfer or existing ulcer
• Timing for assessment completion varies
• Initial - 4 to 24 hours after admission
• Re-assess every 24 hours or change in status

18
Survey Results - Inspection

• Skin inspection practice varies
• Timing
• Skin assessment within 4 hours of admission and
  with any change in condition
• Assessment within 24 hours of admission and every
  24 hours after
• On admission and every 24 hours
• Every shift (not always completed)
• Population
• All patients (not always completed)
• Screening for Peds, OB and Ambulatory at
  admission skin inspection if high-risk

19
Information Gathering - Key Findings

• Key to eliminating Stage III IV pressure ulcers
  is pressure ulcer prevention.
• Initial Hypothesis hospital staff know what to
  do problem is barriers to implementation.
• Current Hypothesis There are barriers to
  implementation but there is also an education
  need.
• Lack of recognition by hospital staff of the
  importance of their role in pressure ulcer
  prevention
• Need for resources/tools specific to acute care
  setting
• Need for accessible equipment and tools for
  selection of equipment.

20
Subcommittee AIMS

• Develop and bring the business case for pressure
  ulcer prevention to hospitals create case for
  purchase of pressure redistributing equipment.
• MHA developing will work with CEOs
• Increase front-line staff awareness of the
  importance of pressure ulcer prevention (put a
  face on the problem).
• Awareness campaign planning in progress.
• Make prevention tools and strategies readily
  available to acute care hospitals.
• Pressure Ulcer Prevention Protocol for acute care

21
Subcommittee Goals

• To achieve reduced incidence of Stage I II
  pressure ulcers in patients cared for in
  Minnesota acute care hospitals to lt1.
• To eliminate Stage III and IV pressure ulcers in
  patients cared for in Minnesota acute care
  hospitals.