Joyce Black, PhD, RN, CWCNUniversity of Nebraska Medical Center,

Omaha Nebraska US

Brno November 2016Joyce Black jblack@unmc.edu 1

Study of Adult Nursing Units using NDNQI data◦ 1381 hospitals from all 50 states from 2008-2010

Outcome data, changes in rates after ruling/payment change of: ◦ Pressure ulcers

◦ Injurious falls

◦ Central line associated bloodstream infections

◦ Catheter-associated urinary tract infections

Waters, Daniels, Bazzoli et al. Effect of Medicare’s nonpayment for Hospital Acquired Conditions: lessons for future policy. JAMA 2015, 175 (3), 347-354

Brno November 2016Joyce Black jblack@unmc.edu 2

11% reduction in CLABSI’s - sustained

10% reduction in CAUTI’s – sustained

.5% reduction in rates of falls - flat

1% reduction in rates of stage III and IV pressure ulcers – sustained slow decline

“We acknowledge the concern that not all pressure ulcers are avoidable. However, we believe improving screening to identify ulcers on admission will improve quality of care.” Institutes of Medicine, 2007

Brno November 2016Joyce Black jblack@unmc.edu 3

Standardized practices had been developed and tested for CLABSI and CAUTI

Practice change was fewer steps

Practice change may have only had to occur once or once a day

Practice change involved fewer people and products

Brno November 2016Joyce Black jblack@unmc.edu 4

Pressure injury reduction requires more than admission assessments to change the outcomes!

Processes of care are more nebulous with some decisions made at the bedside

Nurses carry out assessment and planning but may not do the turning

Brno November 2016Joyce Black jblack@unmc.edu 5

Assessment of the skin upon admission◦ Identifies existing pressure ulcers

◦ Does this assessment always get done?

◦ Is this assessment always accurate?

Do nurses know pressure injury/ulcer from other skin problems?

How is a treatment plan chosen?

Assessment of risk for pressure ulcer/injury◦ Risk assessment tools and/or clinical judgement

◦ Prevention plan developed

Brno November 2016Joyce Black jblack@unmc.edu 6

Guide Communication about Risk Plans◦ Who actually does the prevention?

◦ How does the bedside caregiver know when and where to position the patient?

◦ Do staff know how to turn patients without causing their own back injury?

◦ Does nurse know and when to examine skin beneath preventive dressing?

◦ How does the nurse obtain speciality beds during off hours?

◦ How well is nutrition being addressed?

◦ How is skin care being provided? And by whom?

Brno November 2016Joyce Black jblack@unmc.edu 7

Recognize their world view◦ Numbers and dollars

Make them aware of pressure injury data in your facility◦ Use root cause analysis findings into quality

improvement plans

How many of your PI start in OR? ER? ICU?

Target education and interventions to the staff in high risk areas

Brno November 2016Joyce Black jblack@unmc.edu 8

Present current HAPI/FAPI rates and cost◦ Stage 1 and 2 = $2,770.54

◦ Stage 3 and 4 = $71,500.00 to $127,000.00

Cost Data from:

Padula, Mishra, Makic et al. Improving the quality of pressure ulcer care with prevention: A cost effective analysis. Med Care 2011, 49 (4), 385-392

Brem, Maggi, Neirman et al. High cost of stage IV pressure ulcers. Am J Surg ,2010 200 (4), 473-477

Brno November 2016Joyce Black jblack@unmc.edu 9

Current hospital rate is 2.5% ◦ 2% stage 1 and 2 and 0.5% stage 3 and 4

Annual acute admissions are 24,557

◦ 491 stage 1 and 2 at $2,771 = $1,360,561

◦ 122 stage 3 and 4 x $71,500 = $8,723,000

◦ 122 stage 3 and 4 x $127,000. = $15,494,000

Total spent on HAPI last year = $25,577,561.00

Brno November 2016Joyce Black jblack@unmc.edu 10

Find out where the pressure ulcers are starting

Without knowing the history of this pressure ulcer, it is impossible to know where to make changes

Brno November 2016Joyce Black jblack@unmc.edu 11

High risk patients◦ In OR over 3 hours

◦ Prone for surgery

◦ Perfusion problems

Heart lung machine

Consider age of ◦ Mattress

◦ Positioning devices

Consider use of dressings as additional protection

Brno November 2016Joyce Black jblack@unmc.edu 12

Many ulcers on the sacrum from being supine with HOB up◦ Was the patient turned?

◦ Can the patient be turned?

◦ How old is the bed?

◦ Are preventive dressings being used?

Brno November 2016Joyce Black jblack@unmc.edu 13

Incidence high in ICU and pediatrics (30-95%)

Oxygen delivery systems are the most common device

Prevention?◦ Pad the skin under the

device

◦ Move or remove the device daily if possible

Brno November 2016Joyce Black jblack@unmc.edu 14

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