Okay.
At this time, you can start your presentation at any time.
Good morning everyone.
Hello and welcome.
Today, I am honored that I will be doing a webinar for you on staff roles in
training for your pressure ulcer prevention program.
This is a really exciting topic that's important in the overall pressure ulcer
prevention program.
Before we get started with the actual content, let me tell you a little bit
about me.
Currently, I am a board-certified wound and ostomy nurse who, for over 25 years,
has served as the clinical editor for the journal Advances in Skin and Wound
Care.
I'm also the vice president for the World Council of Enterostomal Therapists, or
the WCET; a faculty member at Excelsior College School of Nursing in Albany, New
York; and I'm the author of over a hundred peer-reviewed journal articles and
two wound care books.
In the past, I have been the president of the National Pressure Ulcer Advisory
Panel, or the NPUAP, and a consultant to the Centers for Medicare and Medicaid
Services, or CMS, on the revision for guidance to surveyors for F-Tag 314 on
pressure ulcers and section M skin conditions for long-term care, long-term
acute care hospitals, or LTACs, and Inpatient Rehabilitation Facilities Patient
Assessment Instrument, or IRF-PAI.
I've also been involved in several pressure ulcer initiatives to reduce the
incidence of pressure ulcers, working on a systems level.
And I'll try to weave in my experiences about those initiatives throughout the
presentation.
Today, I want to talk to you about some of the key elements that are contained
in the AHRQ Pressure Ulcer Prevention Program tool kit.
I want to talk about the roles and the duties of staff, how you organize, within
your institution and your plan, particularly at the unit level, because that's a
really key area because that's where the patients are.
So, doing the development of the plan at that level is key to having effective
interventions.
We'll talk about training the staff on the new practices that they're going to
need or revisions of practices for reducing pressure ulcers in your institution.
Now, these topics were previously introduced to you in your one-day training,
but today we're going to revisit them in a little bit more depth.
I'm sure you'll have questions during the presentation, so I'm going to ask you
to write them down, and, at the end, you should follow up with your quality
improvement specialist after the webinar to address them.
Also, at the end of the presentation, there is a list of resources with the full
citations for some of the references that I'll be alluding to today during the
seminar.
So, with that said, let's get started with some more detail about how you can
help to reduce pressure ulcers in your hospitals.
As you see here, there are some key elements to the program.
First of all, pressure ulcers are a skin phenomenon.
So, in your pressure ulcer reduction program, you need to make sure that there
is a comprehensive skin assessment done by your staff.
And there was a separate webinar done by Dr.
Karen Zulkowski that covers this topic in great detail.
So, I would refer you to that and all of her suggestions or recommendations of
how to do it and how to incorporate that from a systems point of view.
You also need to have standardized pressure ulcer risk factor assessment.
Again, there is a whole detailed webinar on this very topic, which I have
previously done.
So, you might want to take a look at that webinar because it goes into great
detail about how to use standardized risk factor assessment tools, how to look
at risk factors beyond those tools, and how to group them all together in a
comprehensive review of risk assessment for the individual in your hospital.
And then that seminar also included care planning and implementation to address
those areas of risk in great detail.
So, from a systems point of view, you need to look at this as a joint plan
within your hospital.
Who is going to be delivering the messages to what group of people, how should
they be delivered, and how are you going to measure the effect of all these
elements of a successful pressure ulcer reduction program?
Here, we see some of the teams or components to successful pressure ulcer
reduction programs.
There are four suggested teams that you might want to assemble in your
institution.
And as you can see here, the roles and duties for each of them need to be
clearly defined and made clear to all that are involved.
And I'll talk about each of them, the implementation team, the wound care team,
the unit team, and the skin -- and the unit champions throughout today's
webinar.
So, what you are doing is you are really helping to assess what the knowledge is
in your institution, what your current care practices are, how do you want to
change them, and then putting that change into action in your institution.
On this slide, you'll see some of the interdependence of these teams and their
relationships.
And this diagram you will find in the AHRQ tool kit.
Excuse me.
You'll see that the implementation team is really looking at the big picture in
terms of the fact that they will be designing and implementing, and many times
have overall responsibility for the pressure ulcer change project.
They usually are at the highest administrative level, but a good representation
of clinical and administrative people, and across the interdisciplinary team of
professionals will really enhance your implementation team.
Your wound care team are your experts in skin and wound care within your
institution.
They serve as the resources for staff as well as for patients and families.
And it all comes down to the unit-based team.
These are the people who are providing the care to the patients and their
families day in and day out.
So, they are actually doing the pressure ulcer risk assessments and the care
planning.
As I mentioned, the implementation team and what they do, they are looking at
the big picture.
What are the procedures and policies that we want to have in place in our
institution?
In some of the hospitals that I have done consulting, I have found that the
implementation team, if they have a highly engaged administrator on their team,
they tend to have much more success.
First of all, it sends a very strong signal to each and every person on the unit
that pressure ulcer prevention, pressure ulcer care is really important in our
institution, the fact that a high-level administrator is on the team.
So, think about that when you're designing who is going to be on your particular
team in your hospital.
The wound care team, they are the people who keep up to date on all the details,
all the clinical guidelines, and hopefully by now you have had a chance to look
at the newly released at the end of 2014 National Pressure Ulcer Advisory Panel,
EPUAP, or the European Pressure Ulcer Advisory Panel, and the PPIA, which is the
Pan Pacific Panel for Pressure Injury, pressure ulcer guidelines.
These are a revision of the guidelines that were put out in 2009 by the NPUAP in
collaboration with the European Pressure Ulcer Advisory Panel.
So, this international guideline really serves as a resource for your content
experts to look at what the evidence is saying in terms of what needs to happen
in your hospital about pressure ulcer prevention.
So, if you haven't already read it, you can go to the NPUAP website, which is
www.npuap.org, and you can download, for free, the quick version of this
guideline for your use.
Now, obviously, the wound care team, because of their clinical and their
knowledge expertise, are a resource about what is the most current happenings in
terms of skin and wound care practices.
Use them wisely because they are there to help you.
They are a fabulous resource.
Now, the unit team, as I mentioned earlier, they're the ones who are actually
implementing the direct patient care.
They're the ones touching the skin, bathing the skin, transferring the patient,
doing the pressure ulcer risk assessment.
They're doing the skin assessment.
Now, I want to emphasize a very important fact that has been a recurring theme
through several of these webinars, that pressure ulcer risk assessment includes
doing a skin assessment as well as standardized tools.
Two of them go hand-in-hand, no pun intended, since you'd be using your hands to
be looking at the skin.
So, please, make sure that everybody on your unit understands the role that skin
assessment plays with pressure ulcer risk assessment.
They're the ones who will actually be implementing the interdisciplinary plan of
care to prevent pressure ulcers.
And I did talk about that in more detail in another webinar, but remember that
you need to address any risk factors that the patient may present with.
So, it's not just about the overall score, there is also any risk factors.
For example, if your patient is incontinent, you need to address the
incontinence, regardless of what a total Braden score may be.
If the patient has nutritional deficits, you need to address that.
If the patient has comorbidities, which we know impacts on circulation, then we
need to take care to prevent skin breakdown as a pressure ulcer.
If we're looking at medication profiles, for example.
So, all of these factors need to be looked at in the plan of care, and then
everybody, from an interdisciplinary point of view, needs to understand and know
what we're doing for the patient.
And, of course, we've all heard the mantra that if you didn't write it down, you
didn't document it, you didn't do it.
So, you need to make sure that all the wonderful care that you have done for
your patients, that you actually did document it in the medical record.
So, each team member needs to know what they are doing.
And throughout the AHRQ tool kit there are some reminders that will help you in
terms of writing down what each person can do.
If helps to let people know what these roles, what these duties are new, and
help them to navigate the newness of something.
Most of us get excited about new things, but there's also a little sense of, you
know, can I really do this, do I really want to do this can be another thing.
So, certainly attitude is going to come into play for staff.
So, make sure that you help them with this change to what they'll be doing now
for the patient.
Make sure that everything that people are doing for pressure ulcer prevention is
in line with the practice act for your state.
Now, sometimes there is resistance and there are barriers for people to
fulfilling their role, and that is best addressed by looking and assessing
people's attitudes and helping people with change to their new roles, having
them feel confident, having them feel competent, having them feel comfortable is
very important in terms of overcoming barriers.
So, ask them, and we'll talk a little bit more about that later on.
And make sure that people have adequate preparation, that they have been
oriented, and that they know what they're supposed to do, and that they
understand how you're going to be monitoring the work.
And don't forget temporary staff.
You know, in some institutions, besides your regular staff, you have temporary
staff that may come -- be doing the actual care on the unit, so make sure you
know how they know what your practices are and what your pressure ulcer
prevention initiative looks like so they can participate.
You are responsible for all staff in your institution that are providing care.
So, the concept of unit champions is well-described in the literature.
It's one of the strategies that works very well.
And how many you need is really going to depend on the size of your hospital and
what your staffing capability is.
Now, obviously, it's optimal if, on every shift, on the unit, there was somebody
who was adequately trained to be this resource, which is what the unit champion
is.
If you can't have on every shift, perhaps you can have at least on one shift.
And don't forget weekends.
There usually are less people around, so having somebody available also on a
weekend is optimal.
And if it can't be on your particular shift or unit, maybe you can share between
two shifts if somebody needs to call somebody from another unit.
It's best to have an actual care provider or a bedside RN who is a unit
champion.
One of the ways to do this is to ask for volunteers.
Usually when people volunteer, they're more enthusiastic, they're more
interested in pressure ulcer prevention, and more likely to be a cheerleader for
your initiative.
So, that's a strategy that you might want to do.
I don't [indiscernible] nursing assistants or nursing attendants and your
licensed practical or licensed vocational nurses.
You want them involved, too, particularly since many times they may be the ones
that are seeing the skin more than the RN.
And you really want a coordinated team of all levels of nursing personnel as
well as your interdisciplinary care.
And, if possible, try to have your unit champions that probably are going to be
on your staff for a while to avoid the unnecessary reorientation of people.
So, commitment is an important thing.
Now, one of the things that some hospitals have done is that unit champions
actually get a bonus, and the bonus can be financial or the bonus can be an
extra conference day or something very tangible so that being a unit champion
has a built-in reward other than the title.
For some people, title is enough, or a button designating them as the pressure
ulcer unit champion, but in many institutions when money and an actual day off,
or conference attending being paid for really helps to make people more
motivated to be a unit champion.
And make sure people on your unit know, well, if my unit champion is off or not
working on my shift, what do I do, where do I get resources, is there another
unit I can call, who do I contact when I need that kind of information.
And when you look at who should be your unit champion, you can see here that
there's quite a list.
And certainly somebody who's involved in professional practice, somebody who can
communicate well with all levels of staff.
And I think that's very important because people will listen to the message from
the messenger when somebody communicates in an appropriate manner, has the right
attitude.
We need to know that the unit champion knows how to use their links and
networking to all other staff members.
I think it's essential that they have the respect of their peers and they're not
seen as somebody who's hoarding information but somebody that's helping with
information.
So, if they have the respect and admiration of their peers, people are more
likely to go to the unit champion and ask questions without fear that the unit
champion's going to think that they're dumb or you should have known that, or
how come -- you know, I know this, how come you don't know that.
So, I think that's really important how the peers on the unit see the unit
champion and how respected they are.
That they have a positive image of their unit and they really set the tone for
the level of care that everybody wants on the unit.
Unit champion has to have good problem-solving skills because sometimes it
requires really drilling down on a situation and seeing what's going on, and
being open to all kinds of information and every pressure ulcer occurs, really
looking at the situation and helping everyone to understand how this happened
and how we can prevent this in the future.
They need to have the ability to work with all the key stakeholders.
So, you need a unit champion who will be able to communicate with people at the
administrative level, people who are certified, for instance, in skin and wound
care, and will not feel intimidated.
And I think that it's key that they are passionate and that they have knowledge
about pressure ulcers.
I think passion is the most important thing.
You know, we help them get the knowledge, but without passion they really are
not going to do a good job of being the unit champion.
It can be perceived as a burden rather than somebody who can really help
facilitate care on their unit.
That's because unit champions really serve as a liaison amongst the different
teams that I've already talked about and help resolve the issues related to
pressure ulcers.
For example, if when the pressure ulcer incident comes back for your particular
unit and it's not coming down, it's not being reduced, rather than coming back
and blaming the staff, they may be able to help the interdisciplinary team
understand that we have a third of our staff that's brand new to our unit and so
that we're in the process of orienting, and there's been a lot of change and a
lot of shift going on on our staff.
So, maybe when that settles down, we'll be able to see a reduction in pressure
ulcer incidence on our unit.
They're going to help to implement the pressure ulcer prevention strategies.
Remember, they're the cheerleaders.
They will help people know what the intervention plan should be.
And they're the ones that will help everybody when they are in there doing these
interventions over and over and over again, because one of the problems with
pressure ulcer prevention is that it's very routinized.
You've got to keep doing things over and over again, which for some staff is
boring, like doing risk assessments every shift, for example.
How many times am I going to need to do it?
So, keeping their enthusiasm up is important.
That's the cheerleader role.
And that they can safely go to the unit champion when they have questions
without fear of retaliation.
They are also very familiar with all the program goals, the care processes, and
they need to know the outcome of data.
And in a survey that I just published with Sharon Baranoski in Advances in Skin
and Wound Care in August 2014, we found it very interesting that in the survey
of nurses, only a little over a third of the nurses knew what their unit's
pressure ulcer incident rate was.
It actually was 38 percent knew what it was.
So, I think that it's really important that everybody on the unit should know
their pressure ulcer incident number.
Sometimes we assume that they do, but they need to know what their number is and
they need to know how it's trending, is it going up, is it staying flat, is it
going down, and help them to interpret the number because there might be reasons
why the pressure ulcer is not changing.
So, some other things are that they will help transfer knowledge about pressure
ulcer injury prevention, and that's where the new guidelines, there are 575
recommendations in the new NPUAP, EPUAP, EPPIA pressure ulcer clinical
guidelines.
So, everybody is not going to know all of them, but the unit champion can help
their peers on their unit know about the latest practices that will help prevent
pressure ulcers on their unit.
They will be involved in tracking the numbers on the pressure ulcers and make
sure that everybody knows what that number is.
They will serve as a unit expert and help bring information to the managers and
supervisors and peers and patients on what pressure ulcer prevention practices
are working on the unit, which ones are not, any problems that are being
encountered.
What about the equipment?
Is it available?
Are you having any problems using it?
Do you need to do any clinical trials of new equipment, for example?
What else do you need?
So, that the resources that you need on your unit are communicated to those that
have the administrative ability to make that happen.
And any related patient safety and clinical processes, what happens when my
patient goes off to let's say have a test, how does the staff in let's say a
procedure or x-ray know that this is somebody who's at pressure ulcer risk, and
we want to pay a lot of attention to the skin as you move them from the
stretcher onto the examination table, because we're really worried about the
fragility of their skin.
Also, be involved in doing the ongoing pressure ulcer surveillance and actually
collecting what the numbers are, and helping to look at the data outcomes from
those ordered to help interpret them and make sure this data flows up to the
implementation team as well as down to all the members on their unit.
They'll be involved in training their peers.
They'll be doing in-services.
And I find that short, little in-services usually are very good for on-the-unit
training.
Staff has very little time, so quick, I'm talking quick, five to 15 minutes, on
a very focused aspect of pressure ulcer prevention can be really helpful for the
unit champions to do.
They can help orient the new employees when they actually get to the unit.
They probably had something didactic in the new employee orientation, but how do
we implement this here?
What is the reality on our unit?
How do we get the support services?
Where are the skin care products kept on our unit?
How do we use them?
Where do we keep our pressure ulcer risk logs for patients on our unit?
So, this kind of information will be very important for the unit champion to
give to new employees.
The need for training and retraining or education is ongoing.
It's constant.
And certainly anytime any new equipment is brought in, they can be involved in
the training.
And also any spot checks to make sure that people haven't forgotten there's no
slippage in terms of how to use equipment, because sometimes, when you use
something for a long time, you start taking little shortcuts.
So, it's good to make sure everybody's doing everything the way that they should
be.
And, certainly, the patient and their family are a very important part of the
pressure ulcer prevention team.
So, what tools do they have?
Do they have pamphlets?
Do they understand how to do the education?
What elements need to be included?
And there is a patient booklet, and it's available in the AHRQ tool kit, that
staff can use.
And it's tool 3g in the resources at the back of the tool kit.
And it actually was created from the New Jersey Hospital Association Initiative,
which I served as the chairperson of.
And that patient education booklet is available in English and Spanish on the
New Jersey website.
So, you need to organize how communication and reporting is going to occur on
your particular unit.
So, many have lists that will identify who, on your institution, on your unit,
is at risk for developing a pressure ulcer.
An example of one of those is in the resource section of the back of the AHRQ
tool kit.
And I think one of the most important things that I've learned is staff is very,
very busy, so giving them some ideas of how to integrate the prevention
processes into their everyday work is really important, because they don't see
this as extra work but that this is necessary work, but how do I get it done
with all the other things that I have to do to take care of my patients.
People in the hospital are very sick, so it's important that we take care of
their skin and prevent pressure ulcers as well as all the other needs that they
come with.
So, there's a need for ongoing communication within the unit.
You need to use language that staff is going to understand so that you're not
talking above or below the level of the person.
And this is really important also when you're talking with your nursing
assistants.
They are a vital part of the team.
And explain to them what risk assessment is, why you're doing a Braden scale,
why you're asking them to cleanse the patient after every episode of
incontinence, because it makes the skin more vulnerable to breakdown from
pressure.
The skin can't tolerate pressure as much when it's wet or when it's very dry,
and that cleaning and putting that skin care protection product on the skin,
whether it be a cream, a lotion, or one of the liquid sealing products, is a
very important intervention.
And I never cease to be amazed how important it is to really help empower the
nursing attendants, and how their actions are really important for pressure
ulcer prevention.
They may not see it that way, but once you put it in that kind of language that
they understand what they should be doing and how it contributes to the overall
effort, you can really see a difference sometimes in people's willingness to do
the plan of care that they need to do.
Obviously, people need to understand that they -- what they can do and also what
cannot be done.
So, unit champions give updates at regular meetings of the implementation team,
how we're doing, any barriers we see.
Even unit managers are going to give updates about the data from their staff and
how processes are flowing, and what their rates are.
Staff can document the pressure ulcer risk or presence on daily flowsheets.
And many times everybody needs to know where that flowsheet is.
Some people who have electronic medical systems, that can be electronically
triggered as a data element, so it doesn't have to be a handwritten flowsheet,
but for those of you who don't have electronic, there is a sample of that in the
resource section of the AHRQ tool kit.
Staff examines the patient at risk.
Interdisciplinary skin rounds are very helpful.
Everybody sees from a different point of view, so the more eyes that look at the
patient and look at the skin, having an integrated team, and I think that that's
where we're going in the future of healthcare, and skin rounding is a wonderful
way of having that interdisciplinary team do it.
It's not blaming people, but it's what can we see about this person's skin, what
are we doing, and what should we be doing in addition to what we're already
doing.
And then any other patient safety issues, what do we need to change in the care
plan, and just having five minutes in of quick, little meetings, rather than
long meetings can be helpful to help change behaviors and change and update the
plan of care for the patient.
Certainly, sharing risk and skin assessment information during shift reports is
very important.
This is one of the key areas we found in the New Jersey Collaborative, is that
when you made the information come alive, that it wasn't just buried in the
patient's medical record but it actually was important and useful information,
that people were more apt to do the skin assessments, they were more apt to do
the pressure ulcer risk assessment and do the interventions, because they knew
it was valued.
When what you do is valued, people tend to do it.
If people feel it's not valued, sometimes they can be reluctant to do the
procedures and interventions that are required.
Don't forget also to tell the patient and their families what their skin or
pressure ulcer risk is.
It's also very important to make sure the patient and the family understand why
you're constantly looking at their sacral area or why you're looking at their
heels, that these are areas where the skin can break down.
Interestingly enough, in the study that I did that was published in Advances in
Skin and Wound Care, people did report about the same level of percentage, 36
percent, that they knew their facility pressure ulcer incidence rate.
Remember, it's important that they know what is available on their particular
unit.
Because, remember, pressure ulcers are localized areas of skin injury.
So, localized care, localized knowledge of the staff is really important.
I mentioned the importance of nursing assistants and making sure that they have
adequate knowledge.
And there actually is a sheet that you can use that's in the resource section of
the AHRQ tool kit which you can give to nursing assistants that if they see a
problem with a patient's skin while they're bathing or moving the patient from
the bed to the chair, and it just doesn't look right or there's something
unusual with the patient, even if they may not know what the problem is or that
it's a pressure ulcer or some other skin problem, they can just mark the form
and give it to the nurse so that the nurse can get in there later on and do a
full assessment for the patient.
So, I think rethinking how we use our nursing attendants can be very, very
helpful.
And there actually has been a study done by Susan Horn and her colleagues -- and
that resource is at the end slide, so do take a chance to take a look at them --
of how they educated the CNAs.
This was done in actually long-term care, but it certainly could be applicable
in acute care, and made them a very important and valuable member of the
multidisciplinary team to help in the early identification of pressure ulcers,
because frontline workers who see the skin and care for it every day might be
the ones that might see an early problem.
And by using a tool that they could identify skin problems and giving it to the
nurse, the overall percentage rate, there was a 42 percent decline in pressure
ulcers in the 21 facilities that were involved in this implementation
initiative.
So, they went from four percent to 2.3 percent.
It can certainly -- the evidence shows that harnessing the resource of your
nursing assistants in a different way can really make a difference.
I already mentioned -- I'm just going to go back for one second.
I already mentioned about the guidelines that are available, the new NPUAP,
EPUAP, PPIA guidelines, that there are skin booklets out there.
We mentioned the New Jersey Hospital Association.
You can go to their website.
And having education materials readily available for staff, whether it's a
pocket guide or a pocket guide book that they can have.
Some institutions have little cards that can attach to the staff badge that they
have with them.
Some institutions create them.
Some use education materials that are created by companies that make wound care
products, but readily available I think is the key so that staff can get
information when they need it.
So, communication needs to be done on a regular basis and needs to be thorough
in terms of are we doing the interventions that we need to be doing for our
patients, are we communicating them, and have we streamlined some of the
processes so that it makes it a little easier for the patient -- for the staff
to care for the patient.
I'll give you some examples on the next slide.
One of the ways you can do this is by making some practices universal.
For instance, the most critically ill patients in your intensive care unit, many
hospitals have gone to having all these patients on pressure-redistributing
beds.
So, this eliminates the problem of deciding who needs to be on them, the
processes for ordering these beds, which, in some institutions, can be quite
time-consuming, then getting the beds there and set up.
So, universal practices might be a way to go.
Incorporating change into the routine care, for example, helping staff to
understand that when you're doing the skin assessment you can be doing double
duty.
For instance, when you're assessing breath sounds, you can be looking at the
patient's back and sacral area.
When you're looking at the abdomen, you can be looking to see if there are
continence or any skin issues that are going on with the patient.
So, the more that they don't see it as a separate action for pressure ulcer
prevention, the more likely staff will be to do it.
I already mentioned the importance of integrating the pressure ulcer risk data
so that staff know it, and also that it needs to be part of a shift handoff or
the patient handoff.
Make it easy to get equipment, and this is one of the lessons we learned from
the New Jersey Pressure Ulcer Initiative, is that if you lock up the equipment
and the lotions and creams and skin sealants that people need to use, it's an
extra step, people are not going to use it, and then the skin won't be
protected.
And if you have electronic health records, make an automatic trigger that will
suggest different care options.
So, for example, if you have a standardized risk assessment tool, such as the
Braden scale, if the sub-score for moisture comes up as a one, being low, let it
send a message to the caregiver, you know, consider using products that will
protect the skin.
You have different options, lotions, creams, and let them remember to use them.
Or that, if the patient's immobile, you need to get a support surface on the
bed, if they're not already on it.
So, other things that you can do is you can have automatic triggers or ideas to
be getting dietary consults for high-risk patients, if they have nutritional
deficits for example, or a consult for PT if somebody's immobile and needs to be
moving more, or OT.
Having the supplies handy.
Some hospitals have made skin carts, they put photos of the products on the
drawers of the skin carts or in the supply room, if that's where the products
are, putting photos of what this is for, even streamlining the number of
products that they have.
Too many choices is not good for staff to have.
Remember, dressings and products need to be available 24/7.
Hospitals are open 365 days a year, 24/7, so they need to have access to
dressings and products.
That dressing redistributing support is available for all critically ill
patients, I already mentioned that.
And prompts, now prompts can be visual or auditory, but I have to tell you that
this can be overdone.
So, there's a fine balance between reminding staff or when they become immune to
memory joggers, that "Oh, I need to go in there and turn the patient." So,
whether you use sound or they use charts, just to see what will work best for
your staff, and you may need to vary it.
So, think about where the data is in your patient record.
Is it scattered throughout the record or is there one form that people can find
the information?
So, you might need to redesign your documentation system.
Ask your staff, what do they think?
They're the ones that have to record the information, so help them to look at
that.
What other data in the patient's record can help you with risk factors?
For instance, you can take a look at the medication profile, you can take a look
at comorbidities, any patient history from the H&P that would alert that there
were skin problems.
And how can I put it in a logical flow so that people will be more apt to
collect it and organize it?
So, having one form for all this information is usually best in most hospitals.
So, training staff on these new practices, how do you manage process change?
It takes a lot of time.
It takes getting and addressing attitudes.
It's best if you're going to be implementing new procedures, new implementation
steps for pressure ulcer reduction, that you do it one unit at a time.
Ask for a unit to volunteer, for example.
Make sure they have the data.
You cannot manage change without data.
Get the staff excited and engaged.
Most nurses like a theme.
If you can reward them in some tangible way, whether it's sending them food,
giving them something that they value, a gift certificate to a spa day or
something that staff might enjoy can be helpful.
And remember that whenever you start out on an initiative, the pressure ulcer
incident rate will usually rise because people are more aware of the pressure
ulcers.
So, staff will need your cheerleading so that they don't think, "Here I am doing
all these good things and the rates are going up rather than going down." Help
them understand that that's part of the QI process.
And demonstrate them and help watch what they're doing, but do it in a
non-blaming way so that people don't feel that, "Oh, if I make a mistake it's
going to have bad consequences for me on my overall staff evaluation," but help
them to bridge the gap between the new knowledge and what they need to do.
So, by making them feel that they're in a safe learning environment, they will
feel the importance of buying into the pressure ulcer prevention initiatives
because you have supported them.
Take the guidelines and tailor them to your hospital.
For example, the new guideline says to do a pressure ulcer risk assessment
within eight hours of hospital admission.
So, is that possible in your institution?
Help them to understand the resources that they need to make that happen, and
that there's adequate time for their training and that they have the supplies
available.
Now, the implementation team, they're also important in managing the change
process.
Remember that they're looking at the big picture.
They're helping to guide and coordinate all the change processes from a systems
point of view.
They're going to help support the unit during the rollout and at all phases of
your pilot as you try to reduce pressure ulcers.
They're going to work with the staff.
They're going to work with the middle managers.
They're going to work with the bedside care providers, and they'll bring that
information back up to senior leaders and administrators.
Again, they need to have a strong link to the interdisciplinary team and to
hospital leadership.
They're going to be working with the unit champions and the unit leaders.
They're going to continuously gather feedback, again, in a non-blaming
environment.
They'll track the changes in the pressure ulcer rates and interventions, and
make sure that everybody understands what those rates are.
So, before you start, make sure that the team is comfortable, that you've met
with all of the implementation team and the unit champions, that everybody knows
what their role and duties are.
You cannot rely on memory here.
So, what are our prevention policies here, what are the interventions we have to
choose for and accommodate based on the individual characteristics of the
patient that we have on our hospital unit?
How do I adjust roles and paths of communication?
You know, who -- how do I decide this?
When do I know when to call in a consult for somebody who's just not moving, or,
you know, the patient is not cooperating, the patient does not want to
participate in the plan of care?
So, somebody else is going to come in here and talk to the patient and the
family about the importance.
Maybe they're just not hearing me, they need to hear it from somebody else from
the skin and wound care team.
And you need to talk about how you're going to address and overcome some of the
barriers to adhering to this plan.
So, during the rollout, remember, you constantly need to remind the staff about
why this is important.
Remember that hospitals no longer get reimbursement for pressure ulcers that
occur during the hospital stay.
Staff may not remember that.
Remember, that reimbursement is important because that's how the hospital has
the money to do paychecks.
So, this is why we want to prevent pressure ulcers from an economic point of
view, just in terms of the hospital will get the reimbursement that it needs to
have its own financial health, as well as for the patient, because pressure
ulcers are painful and can really delay the patient's discharge from the
hospital.
So, involving the staff, getting them enthusiastic about pressure ulcers.
Remember, a lot of staff didn't really learn about pressure ulcers in their
initial education.
So, getting their enthusiasm up really requires some creativity, but most people
like an initiative that has a theme.
And keeping them informed about progress is really important.
So, if some staff members resist change, that's going to happen.
Anticipate that it will happen.
Find out why they are resistant.
Ask them.
Find out what's going on.
Maybe this is the third initiative.
So, today is pressure ulcers.
Last week, it was falls.
Next week, what is it going to be, and there's just too much change going on.
So, find out what's going on on the institution, or are people just rotating too
often to nights because staffing levels are down?
Ask the staff what's happening.
They'll tell you.
They're talking about it, so they might as well be talking to you so that you
can come up with a plan of care to happen.
In certain areas of the hospital, staff may never have been involved in pressure
ulcer prevention.
One of those areas that comes to mind, and I'm not picking on the emergency
department, but since a large percentage of patients who are admitted to the
hospital come through the ED, that's a logical place to involve them in a
pressure ulcer reduction initiative, but, quite honestly, in the past they have
not.
If you take a look at an article by Dr.
Saro [ph] and colleagues, which was done in -- I believe it was done in
Australia in the ED, what they did is they really looked at trying to engage the
staff in a culture shift, if you will, in a mindset shift about how important
the emergency room is as a starting point for pressure ulcer prevention.
When you do pressure-redistributing mattresses, have you ever looked at the
stretchers that people lay on in the emergency room?
You have your most critically and hemodynamically unstable patients, yet do they
have a support mattress?
Is it outdated?
When was the last time it was replaced?
How narrow is it, even for people of a usual BMI, but what about our bariatric
patients with higher BMIs, and they're lying on these stretchers for a long
period of time?
So, if the patient has a cervical collar, is it padded?
There are studies out there that have indicated that the type of cervical collar
can make a difference and increase the number of pressure ulcers from medical
devices.
So, take a look at that.
You may need to change your practices.
You may need to change your equipment.
It might be the equipment.
So, take a look at that.
And you may need to delay launch of an initiative if too much is going on in
your institution.
Education is really critical, and you need to identify any knowledge gaps.
And, in the tool kit, the AHRQ tool kit, you have a copy of the Pieper tool,
which has now been updated to the Pieper-Zulkowski tool.
And I have to tell you that pressure ulcers is an interdisciplinary initiative.
It is not just about the nurses.
In a study by Levine, for example, they found that physicians had pressure ulcer
knowledge using the Pieper tool about 68 percent, whereas in repeated studies
that I've done with Karen Zulkowski measuring nurses' knowledge it's been in the
C level and in the 70's.
So, again, assessing staff knowledge and helping them to fill in those knowledge
gaps are really important.
One of the areas we find is that people who think that just because the
patient's on a pressure-redistributing mattress, they don't need to be turned
and repositioned, and that is not true.
And then knowing where you are, where do you want to go, and creating an
educational plan to address those gaps in your institution is the way to go.
And that's where your education staff will be very helpful.
Remember that adults learn best through methods that build on their previous
learning experiences.
That's how we learn as adults.
So, vary your techniques to prevent what I call education fatigue so that it's,
you know, how many webinars do people really want to listen to, how many online
programs, how many lectures do people really want.
If you use posters, vary them, vary the location of them, because otherwise
people become blind to them.
Some people have found that putting a very short poster in the staff bathroom is
a way.
People like to read in the bathroom, so that might be one intervention for
education that will help them.
Having newsletters, some institutions this is a very powerful tool.
One institution I know, when suddenly there was no newsletter of the month,
people were actually asking for it because they really came to value it.
It needs to be active.
It needs to be didactic.
So, perhaps having somebody shadow or follow the wound, ostomy and continence
expert in your institution is a way to really make it alive, or embedding that
person for a day to be on a unit and working with various staff to see how their
practices are is really one way of making it come alive.
So, I hope that I've given you some ideas.
I do want to mention the importance of organizing that plan at the unit level.
For example, I did talk about the emergency room.
I also do want to mention the operating room, which is another area that I've
done some initiatives to decrease pressure ulcer incidence.
So, you could take a look at my work which has been published with Barbara
Delmore in the Journal of Wound, Ostomy & Continence, a journal, where we
decreased pressure ulcers in our surgical patients by implementing a wristband
for those patients and identified those at high risk after surgery, for example.
Some other universal practices that you might want to consider are sheer force
reduction, and one of the ways, it has been mentioned in the new guidelines and
there's growing evidence, is by using foam dressings.
And there's been a variety of studies out there that have reported success in
reducing pressure ulcers by using foam dressings prophylactically.
Again, I think one of them is on the resource list at the next couple of slides,
and that would be one by Cubit, where they actually put soft silicone sacral
dressing on the critically ill patients in the emergency room to reduce sheer on
these patients.
And they found that the patients that did not have the sacral dressings were 5.4
times more likely to develop a pressure ulcer injury than those who did.
So, again, that could be part of your universal practices.
Decrease in the amount of time that people have between identifying risk and
actually providing the interventions is another way of helping staff.
And, again, that has to do with getting the equipment to staff in a timely way.
Remember that training is paramount.
In the survey that I published with Sharon Baranoski, only a third of nurses
indicated that they had received sufficient education on wound care in their
nursing education, basic education program.
So, you know, make sure that people have that information.
And just because they've been in practice for a while doesn't mean that they
don't need an update because there's new evidence coming out all the time on
pressure ulcer prevention.
And we need to make sure that people are up to date with the new guidelines.
I want to thank you for being such great listeners.
I'm sure that you will have questions, and, again, please refer those to your QI
specialist.
And here's some of the resources that I mentioned.
I talked about the survey.
The article by Berlowitz and VanDeusen and Parker was part of the grant from the
AHRQ tool kit.
And we actually have evidence tables from different initiatives around the
country, from hospitals and long-term care facilities, and what works and what
did not work on them.
Certainly, there are resources in the tool kit in the back about assigning
responsibilities for best practice bundles, a staff role, and education.
I just mentioned the Cubit talk about reducing pressure ulcers in the ED, and
there are others that look at intensive care areas in hospitals.
I couldn't list them all.
There's the Horn study that talks about CNAs.
And then the Levine study in terms of physicians, and I think that's a big
barrier that people feel, that pressure ulcers are only in the role of the
nurse.
It is an interdisciplinary effort.
No hospital has been successful that hasn't made this interdisciplinary.
So, getting doctors and other healthcare specialists onboard is really
important.
I mentioned the Naccarato study that was done in terms of emergency departments.
The Niederhauser article that was published in Advances in Skin and Wound Care,
and that is open access.
The Sharkey article with Susan Horn about how to, once again, use nursing
attendants to do early detection of skin problems, and then some of the work
I've done on education.
And, with that, I want to wish you lots of success in your initiatives.
Be well.
Keep the skin intact.
Thank you.
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