FEATURE
A Single Long-Term Acute Care Hospital Experience with a Pressure Ulcer Prevention Program Daniel L. Young1, PT, DPT, Cathy Borris-Hale2, MHA, BSN, RN, Margaret Falconio-West3, BSN, RN, APN/CNS, CWOCN, DAPWCA & Debashish Chakravarthy3, PhD, FAPWCA 1 Department of Physical Therapy, School of Allied Health Sciences, University of Nevada, Las Vegas, NV, USA 2 Specialty Hospital of Washington-Hadley, SW Washington, DC, USA 3 Medline Industries, Inc., Mundelein, IL, USA
Keywords
Abstract
Pressure ulcer; hospital-acquired; nosocomial; quality improvement; pressure ulcer prevention program. Correspondence Daniel L. Young, Department of Physical Therapy, School of Allied Health Sciences, University of Nevada, Las Vegas, 4505 S. Maryland Parkway Box 453029, Las Vegas, NV 89154-3029. E-mail: [email protected] Accepted July 4, 2014. doi: 10.1002/rnj.178
Purpose: The occurrence of pressure ulcers (PrUs) challenges care facilities. Few studies report PrU reduction efforts in long-term acute care (LTAC). This study described the PrU reduction efforts of a single, LTAC facility using the Medline Pressure Ulcer Prevention Program (mPUPP). Design: This study was a quasi-experimental, quality improvement project, with pre- and postmeasurement design. Methods: Outcomes were tracked for 24 months. The mPUPP was implemented in month 11. Education for caregivers was provided through an interactive web-based suite. In addition, all Patient Care Technicians attended a 4-week 1-hour inservice. New skin care products were implemented. The facility also implemented an algorithm for treatment of wounds. Findings: There was a significant reduction in the mean monthly hospitalacquired PrU (nPrU) rate when preprogram is compared to postprogram. Conclusions: Sustainable nPrU reduction can be achieved with mPUPP. Clinical Relevance: LTAC hospitals could expect to reduce nPrU with education and incentive of caregivers.
Introduction Pressure ulcers (PrUs) are a persistent problem in health care. PrUs are wounds that develop when pressure and shear are applied to the tissues. We have increasing knowledge about the negative clinical and economic impacts of these ulcers. In fact, of the 1–2 million people with a PrU each year, 60,000 will die from complications related to that PrU annually (Russo, Steiner, & Spector, 2006; Thomas, Goode, Tarquine, & Allman, 1996). This increased attention may also be due in part to the growing body of knowledge surrounding their costs. In the United States, it is estimated that PrU-related care costs exceed $11 billion annually, with each ulcer contributing between $500 and $70,000 (Beckrich & Aronovitch, 1999; Brem et al., 2010; Russo et al., 2006).
224
What may be the greatest reason for the increased attention is the knowledge that these ulcers are largely preventable (Cuddigan, Berlowitz & Ayello, 2001; NPUAP, 2001; Van Gaal et al., 2009). Thus, the greatest efforts to address the problems of morbidity, mortality, and costs for PrUs should lie in their prevention. It is important to distinguish between efforts to better identify PrUs and efforts to reduce or prevent PrUs. Prevention efforts involve identification and reduction of risk factors, while identification efforts focus on classification of an existing PrU. This article will focus on the former. Health care facilities’ efforts to implement change measures targeted at PrU reductions have been incentivized in different ways. Since 2008, Medicare has made an additional payment available to hospitals caring for © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 224–234
LTACH Pressure Ulcer Prevention Program
D. L. Young et al.
patients with a more severe PrU if that ulcer was present when the patient was admitted to the facility; however, if the ulcer developed while the person was already in the hospital (hospital-acquired or nosocomial), the payment is not available. National goals, such as those in Healthy People 2020, combined with nomenclature that PrUs are “quality of care indicators” are also strong incentives to reduce nosocomial PrUs (Ayello, 2011; Bergquist-Beringer et al., 2009; Kuhn & Coulter, 1992; Van Gaal et al., 2009; Vose et al., 2011). Background The literature and evidence base on nosocomial PrU reduction efforts has gradually increased in volume (Bale, Tebble, Jones, & Price, 2004; Bales & Padwojski, 2009; Beitz, 2011; Campbell, Woodbury, & Houghton, 2010; Horn et al., 2010; Jankowski & Nadzam, 2011; Lyman, 2009; Reddy, Gill, & Rochon, 2006; Shannon, Coombs, & Chakravarthy, 2009; Shekelle et al., 2013; Soban, Hempel, Munjas, Miles, & Rubenstein, 2011; Walsh et al., 2012). From this literature, several themes have emerged that can guide future efforts. First, these studies indicate that success is enhanced when a facility begins with a specific plan in place (Niederhauser et al., 2012). Being proactive and informed from the beginning will focus efforts and help move all of the stakeholders in the desired direction together. Next, the literature suggests that success is more likely when facilities are following best practices for prevention of PrUs (Niederhauser et al., 2012). Among the Agency for Healthcare Research and Quality (AHRQ) PrU prevention guidelines, six have been highlighted as particularly critical (Saliba et al., 2003): 1. Assessment of PrU risk on admission, 2. Reassessments of PrU risk regularly during admission, 3. Systematic skin inspection particularly of bony prominences at least once a day, 4. Nutritional support or supplement if needed, 5. Repositioning every 2 hours for immobile patients, 6. Pressure-reducing device when in bed for at-risk patients. The third theme for successful PrU reduction programs is employee education. A surprising lack of knowledge exists among healthcare workers regarding PrU risk factors and correct identification (Kottner, Raeder, Halfens, & Dassen, 2009; Stausberg, Lehmann, Kr€ oger, Maier, & Niebel, 2007; Stausberg & Kiefer, 2009; Young, Estocado, Landers, & Black, 2011). A fourth theme is ongoing monitoring and reporting of the PrU reduction program. © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 224–234
People will quickly forget the goals for PrU reduction if not reminded and encouraged with measures of success. The fifth theme is having skin care specialists available and identified. While a base level of knowledge for all caregivers is necessary, individuals with advanced knowledge and focused purpose enhance success. The final theme from the literature for successful PrU reduction programs is having specific triggers for action. Some examples include PrU risk scale scores being at or below a specific number, having a body mass index above or below a certain level, or a history of previous PrU. Although the available literature continues to refine what is most likely to improve PrU rates and lead to reductions, a recent review article revealed the need for ongoing publications in this area (Niederhauser et al., 2012). Niederhauser et al. (2012) reviewed 24 studies looking at facility PrU reduction programs. Among the gaps identified in the literature was a lack of program effectiveness being measured by statistical significance. While they found most studies reported PrU prevalence rates before and after program changes, seven of the articles did not provide enough details to give meaningful value to the results and P values were “rarely reported” in any of the publications (Chicano & Drolshagen, 2009; Courtney, Ruppman, & Cooper, 2006; Gibbons, Shanks, Kleinhelter, & Jones, 2006; LeMaster, 2007; Stoelting et al., 2007; Young, Ernsting, Kehoe, & Holmes, 2010; Young, Evans, & Davis, 2003). In addition, it was noted in this review that specific facilities need specific interventions and that certain changes may in fact be detrimental. They conclude their article with a call for more facilities to publish their results. Another recent review article highlights the need for process change details so that others can replicate those changes (Soban et al., 2011). In this work, the implementation and effect of a PrU reduction program, in a long-term acute care (LTAC) hospital will be described. Methods The Facility The location of this project was an 82-bed LTAC in an urban eastern U.S. city. Their average census was 60 patients with an average length of stay of 25 days during the period examined. Although diagnosis and case mix were not measured precisely, it was determined that 49% of their patients are insured by Medicaid, 34% by Medicare, and 17% by private insurance. Interestingly, 80% of their patients have wounds of various etiologies on admission. These trends were consistent throughout the time period of the project.
225
LTACH Pressure Ulcer Prevention Program
While PrU prevention and monitoring were important to this facility, they did not have a comprehensive plan in place. During a conference in 2009, the facility chief nursing officer (CNO) was introduced to representatives from Medline Inc. and learned about a program they developed for healthcare facilities to track and manage PrU rates. Medline calls this the Medline Pressure Ulcer Prevention Program (mPUPP). A more detailed description of this program has been previously described (Young, Chakravarthy, & Mirkia, 2012). Implementation of mPUPP This was a quality improvement project initiated by hospital administration and the data collected were those normally collected by the facility for ongoing monitoring. Because of this methodology, IRB approval was not sought before implementation. During the Fall of 2010, the CNO and select clinical providers including their certified wound ostomy and continence nurse, their nurse educator, the nurse managers, their supply chain manager, some of their physicians, the surgical director, and the quality/risk manager met to review the facility PrU rates and practices in light of mPUPP recommendations and available services. These meetings culminated in a plan, which began execution in the fall of that year. Plan components were grouped into three main categories. The first component was staff education regarding PrU prevention best practice. Second, a wound care team was created which would be consulted for the care of patients with specific triggers identifying them as having or being at risk for PrU development. Third, was the continued collection of data to monitor progress with the addition of more frequent reporting and discussion of that data with the wound care team and care providers in general. Each of the plan categories for PrU reduction was informed by or supported by mPUPP in specific ways. Beginning in October of 2010, the provider education component was completed by all facility staff. This provider education was administered through a web-based education portal created for the mPUPP within Medline University (MedlineU). MedlineU is a free online resource for education about different aspects of health care and best practice. The portion for mPUPP has an evaluation tool, or test, that is taken pre- and postcompletion of the education module with which it is paired. Psychometric properties of the test on MedlineU have not been established. In addition to MedlineU, facility
226
D. L. Young et al.
in-service meetings were held to discuss the mPUPP program and implementation for all facility staff. In addition, in October 2010, the wound care team, previously identified, was put into practice and its members and role was made known throughout the facility. Specific triggers for the wound care team involvement were implemented. These triggers included a Braden Score below 15, wound(s) on admission, patient weight being low or high, impaired nutritional status, impaired mobility, incontinence, or physician orders for specialty beds. All of these triggers were driven by the nursing admission assessment. This team’s function was supported by mPUPP through the products available from Medline Industries Inc. A unified product line including micronutrient-based skin cleansers,1 moisturizers,1 barrier creams,1 wound dressings, and incontinence management dry pads2 were implemented. Previous research demonstrated that the use of these micronutrient-based skincare products1 protects and nourishes fragile skin at risk of becoming damaged skin that may manifest itself as PrUs (Groom, Shannon, Chakravarthy, & Fleck, 2010; Shannon, Brown, & Chakravarthy, 2012; Shannon et al., 2009). Research and review articles also indicate a correlation between occurrence of incontinence associated dermatitis (IAD), incontinence, and the occurrence of PrUs (Groom et al., 2010; Shannon et al., 2009, 2012). Medline representatives visited the facility to consult with the administration and skin/wound care team to identify the products that would best support the goals of this facility. The third component of the plan was the data the facility planned to continue collecting. The relevant data they tracked included: the total number of wound care team assessments, the number of wound care team assessments completed within 72 hours, the total number of wounds, the total number of PrUs, the total number of nosocomial PrUs as well as the rate per 1,000 patient days, the number of debridements performed, and the total number of wounds that closed during a patients admission. These data were collected as monthly totals from January of 2010 to November of 2011. A follow-up check for sustainability was done in 2012 on nosocomial PrUs. One of the services provided by mPUPP is assistance with data collection and interpretation. mPUPP representatives called monthly to remind facilities to measure PrU prevalence and then collect that data to generate reports that track progress and financial impact of the changes. At this facility, the local Medline representative assisted with training and coordination of activities. © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 224–234
LTACH Pressure Ulcer Prevention Program
D. L. Young et al.
Table 1 Personnel time and salary costs for implementing mPUPP
Personnel Administration Nurse Educator Wound Care Team Nurses Patient Care Technicians
Total Hours People (Hours/Person)
Total Cost Cost Per Person
24 6 (4) 8 1 (8) 8 2 (4) 630 84 (7.5) 225.5 41 (5.5)
$1,200 $200 $360 n/a $252 $108/$144 $22,050 $262.5 $3,157 $77
In addition, the facility tracked the labor cost of implementation of the mPUPP. Among administrative personnel, six individuals spent an estimated 4 hours each of dedicated time to implement mPUPP. The facility hired a contract nurse educator for 8 hours to help provide in servicing to clinical staff. There were two clinicians comprising the facility “wound care team” that each spent 4 hours helping to implement the changes associated with mPUPP. Clinical staff training was done for nurses and patient care technicians (PCT) with 84 nurses receiving 7.5 hours of inservicing and 41 PCTs receiving 5.5 hours of inservicing. Both nurses and PCTs took the mPUPP pretest and posttest which took approximately 45 minutes each (Table 1). Change is often difficult and facility wide changes such as these were not without challenges to overcome. Before the program, the facility had over 30 products that could be ordered for services ranging from routine perineal care to chemical debridement of wounds. Before the program, there were two different types of adult briefs available. Nurses and physicians had become accustomed to these products and there was significant education and training that had to occur for the transition to a single product line. The time to complete the education on product and process changes, as well as that for the modules that are part of MedlineU, presented a scheduling challenge. This was met by offering both computer- and classroom-based instruction as well as offering training during lunch breaks. One interesting challenge was that some staff feared that MedlineU test results would lead to disciplinary action. This resulted in delays in staff attending the first pretesting sessions. The CNO and nurse mangers overcame this by openly promoting the program and rewarding staff that participated with small gifts. © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 224–234
Results A mean monthly value for each of the seven measured variables was calculated for the 10 months before implementation of mPUPP and the 13 months following full mPUPP implementation. November of 2010 was considered the first month with full program implementation. These pre- and post-mPUPP means were compared using SPSS 18.0 for Mac (SPSS, Inc., Chicago, IL, USA) with a t test where an a priori alpha level of 0.05 was selected to indicate significant difference between the values (Table 2). There was a significant reduction in nosocomial PrU when comparing preprogram (mean = 5.9, SD = 2.56) to postprogram (mean = 0.2, SD = 0.422) monthly means, p < .0005 (see Figure 1). For the other six variables measured (the total number of wound care team assessments, the number of wound care team assessments completed within 72 hours, the total number of wounds, the total number of PrUs, the number of debridements performed, the total number of wounds that healed during a patients admission), there were no statistical differences (see Table 2). Excluding nosocomial PrUs, monthly values for all data showed variability that did not appear to trend in any meaningful way over the study period (see Figures 2 and 3). Nosocomial PrUs per 1,000 patient days during the study period are reported in Table 3. With regard to sustainability, nosocomial PrU data from the 3rd quarter of 2012 revealed two PrUs in July, but none in any other month that quarter. In the preceding two quarters of 2012, there were only two other nosocomial PrUs. This yielded a rate of 0.2 nosocomial PrUs per 1,000 patient days in the first 3 quarters of 2012 (Figure 4). Statistical process control charts are helpful to show the stability of a process. They help an organization to recognize the need for change if the outcome desired from a process is not stable when taking into account variation normal to the process in question (Mohammed, Worthington, & Woodall, 2008; Padula, Mishra, Makic, & Sullivan, 2011). For this study, nosocomial PrUs are the most concerning outcome from the studied process, the PUPP. A u-chart was prepared using QI Macros for Excel (KnowWare International, Inc., http:// www.qimacros.com/about-knowware/) to highlight the rate of nosocomial PrU per patient day at the facility (Figure 5). The total estimated labor cost of implementation included the time of training and administration at this facility and totaled $27,019. Labor costs for implementation among administrative personnel was approximately
227
LTACH Pressure Ulcer Prevention Program
D. L. Young et al.
Table 2 Statistical comparison of pre- (January 2010–October 2010) and post- (November 2010–November 2011) program variables. All values are monthly mean counts of that condition or activity with the exception of “WCT assmt within 72hrs” which is the percent of WCT assessments completed within 72 hours of referral
Comparison of Pre- and Postprogram Monthly Mean For: WCT assmt within 72hrs All wounds PrUs Nosocomial PrUs Debridements WCT Assessments Closed Wounds
Preprogram Means SD
Postprogram Means SD
100.00% 0.000 232.90 43.67 143.89 38.27 5.90 2.56 32.00 26.88 283.90 50.66 8.40 4.53
99.56% 0.936 293.80 104.92 155.11 71.64 0.20 0.422 49.60 25.22 256.60 90.43 6.40 3.41
t statistic
p-value
t (9) = 1.50
.168
t (9) =
2.03
.073
t (8) =
0.469
.652
t (9) = 7.64
A Single Long-Term Acute Care Hospital Experience with a Pressure Ulcer Prevention Program Daniel L. Young1, PT, DPT, Cathy Borris-Hale2, MHA, BSN, RN, Margaret Falconio-West3, BSN, RN, APN/CNS, CWOCN, DAPWCA & Debashish Chakravarthy3, PhD, FAPWCA 1 Department of Physical Therapy, School of Allied Health Sciences, University of Nevada, Las Vegas, NV, USA 2 Specialty Hospital of Washington-Hadley, SW Washington, DC, USA 3 Medline Industries, Inc., Mundelein, IL, USA
Keywords
Abstract
Pressure ulcer; hospital-acquired; nosocomial; quality improvement; pressure ulcer prevention program. Correspondence Daniel L. Young, Department of Physical Therapy, School of Allied Health Sciences, University of Nevada, Las Vegas, 4505 S. Maryland Parkway Box 453029, Las Vegas, NV 89154-3029. E-mail: [email protected] Accepted July 4, 2014. doi: 10.1002/rnj.178
Purpose: The occurrence of pressure ulcers (PrUs) challenges care facilities. Few studies report PrU reduction efforts in long-term acute care (LTAC). This study described the PrU reduction efforts of a single, LTAC facility using the Medline Pressure Ulcer Prevention Program (mPUPP). Design: This study was a quasi-experimental, quality improvement project, with pre- and postmeasurement design. Methods: Outcomes were tracked for 24 months. The mPUPP was implemented in month 11. Education for caregivers was provided through an interactive web-based suite. In addition, all Patient Care Technicians attended a 4-week 1-hour inservice. New skin care products were implemented. The facility also implemented an algorithm for treatment of wounds. Findings: There was a significant reduction in the mean monthly hospitalacquired PrU (nPrU) rate when preprogram is compared to postprogram. Conclusions: Sustainable nPrU reduction can be achieved with mPUPP. Clinical Relevance: LTAC hospitals could expect to reduce nPrU with education and incentive of caregivers.
Introduction Pressure ulcers (PrUs) are a persistent problem in health care. PrUs are wounds that develop when pressure and shear are applied to the tissues. We have increasing knowledge about the negative clinical and economic impacts of these ulcers. In fact, of the 1–2 million people with a PrU each year, 60,000 will die from complications related to that PrU annually (Russo, Steiner, & Spector, 2006; Thomas, Goode, Tarquine, & Allman, 1996). This increased attention may also be due in part to the growing body of knowledge surrounding their costs. In the United States, it is estimated that PrU-related care costs exceed $11 billion annually, with each ulcer contributing between $500 and $70,000 (Beckrich & Aronovitch, 1999; Brem et al., 2010; Russo et al., 2006).
224
What may be the greatest reason for the increased attention is the knowledge that these ulcers are largely preventable (Cuddigan, Berlowitz & Ayello, 2001; NPUAP, 2001; Van Gaal et al., 2009). Thus, the greatest efforts to address the problems of morbidity, mortality, and costs for PrUs should lie in their prevention. It is important to distinguish between efforts to better identify PrUs and efforts to reduce or prevent PrUs. Prevention efforts involve identification and reduction of risk factors, while identification efforts focus on classification of an existing PrU. This article will focus on the former. Health care facilities’ efforts to implement change measures targeted at PrU reductions have been incentivized in different ways. Since 2008, Medicare has made an additional payment available to hospitals caring for © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 224–234
LTACH Pressure Ulcer Prevention Program
D. L. Young et al.
patients with a more severe PrU if that ulcer was present when the patient was admitted to the facility; however, if the ulcer developed while the person was already in the hospital (hospital-acquired or nosocomial), the payment is not available. National goals, such as those in Healthy People 2020, combined with nomenclature that PrUs are “quality of care indicators” are also strong incentives to reduce nosocomial PrUs (Ayello, 2011; Bergquist-Beringer et al., 2009; Kuhn & Coulter, 1992; Van Gaal et al., 2009; Vose et al., 2011). Background The literature and evidence base on nosocomial PrU reduction efforts has gradually increased in volume (Bale, Tebble, Jones, & Price, 2004; Bales & Padwojski, 2009; Beitz, 2011; Campbell, Woodbury, & Houghton, 2010; Horn et al., 2010; Jankowski & Nadzam, 2011; Lyman, 2009; Reddy, Gill, & Rochon, 2006; Shannon, Coombs, & Chakravarthy, 2009; Shekelle et al., 2013; Soban, Hempel, Munjas, Miles, & Rubenstein, 2011; Walsh et al., 2012). From this literature, several themes have emerged that can guide future efforts. First, these studies indicate that success is enhanced when a facility begins with a specific plan in place (Niederhauser et al., 2012). Being proactive and informed from the beginning will focus efforts and help move all of the stakeholders in the desired direction together. Next, the literature suggests that success is more likely when facilities are following best practices for prevention of PrUs (Niederhauser et al., 2012). Among the Agency for Healthcare Research and Quality (AHRQ) PrU prevention guidelines, six have been highlighted as particularly critical (Saliba et al., 2003): 1. Assessment of PrU risk on admission, 2. Reassessments of PrU risk regularly during admission, 3. Systematic skin inspection particularly of bony prominences at least once a day, 4. Nutritional support or supplement if needed, 5. Repositioning every 2 hours for immobile patients, 6. Pressure-reducing device when in bed for at-risk patients. The third theme for successful PrU reduction programs is employee education. A surprising lack of knowledge exists among healthcare workers regarding PrU risk factors and correct identification (Kottner, Raeder, Halfens, & Dassen, 2009; Stausberg, Lehmann, Kr€ oger, Maier, & Niebel, 2007; Stausberg & Kiefer, 2009; Young, Estocado, Landers, & Black, 2011). A fourth theme is ongoing monitoring and reporting of the PrU reduction program. © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 224–234
People will quickly forget the goals for PrU reduction if not reminded and encouraged with measures of success. The fifth theme is having skin care specialists available and identified. While a base level of knowledge for all caregivers is necessary, individuals with advanced knowledge and focused purpose enhance success. The final theme from the literature for successful PrU reduction programs is having specific triggers for action. Some examples include PrU risk scale scores being at or below a specific number, having a body mass index above or below a certain level, or a history of previous PrU. Although the available literature continues to refine what is most likely to improve PrU rates and lead to reductions, a recent review article revealed the need for ongoing publications in this area (Niederhauser et al., 2012). Niederhauser et al. (2012) reviewed 24 studies looking at facility PrU reduction programs. Among the gaps identified in the literature was a lack of program effectiveness being measured by statistical significance. While they found most studies reported PrU prevalence rates before and after program changes, seven of the articles did not provide enough details to give meaningful value to the results and P values were “rarely reported” in any of the publications (Chicano & Drolshagen, 2009; Courtney, Ruppman, & Cooper, 2006; Gibbons, Shanks, Kleinhelter, & Jones, 2006; LeMaster, 2007; Stoelting et al., 2007; Young, Ernsting, Kehoe, & Holmes, 2010; Young, Evans, & Davis, 2003). In addition, it was noted in this review that specific facilities need specific interventions and that certain changes may in fact be detrimental. They conclude their article with a call for more facilities to publish their results. Another recent review article highlights the need for process change details so that others can replicate those changes (Soban et al., 2011). In this work, the implementation and effect of a PrU reduction program, in a long-term acute care (LTAC) hospital will be described. Methods The Facility The location of this project was an 82-bed LTAC in an urban eastern U.S. city. Their average census was 60 patients with an average length of stay of 25 days during the period examined. Although diagnosis and case mix were not measured precisely, it was determined that 49% of their patients are insured by Medicaid, 34% by Medicare, and 17% by private insurance. Interestingly, 80% of their patients have wounds of various etiologies on admission. These trends were consistent throughout the time period of the project.
225
LTACH Pressure Ulcer Prevention Program
While PrU prevention and monitoring were important to this facility, they did not have a comprehensive plan in place. During a conference in 2009, the facility chief nursing officer (CNO) was introduced to representatives from Medline Inc. and learned about a program they developed for healthcare facilities to track and manage PrU rates. Medline calls this the Medline Pressure Ulcer Prevention Program (mPUPP). A more detailed description of this program has been previously described (Young, Chakravarthy, & Mirkia, 2012). Implementation of mPUPP This was a quality improvement project initiated by hospital administration and the data collected were those normally collected by the facility for ongoing monitoring. Because of this methodology, IRB approval was not sought before implementation. During the Fall of 2010, the CNO and select clinical providers including their certified wound ostomy and continence nurse, their nurse educator, the nurse managers, their supply chain manager, some of their physicians, the surgical director, and the quality/risk manager met to review the facility PrU rates and practices in light of mPUPP recommendations and available services. These meetings culminated in a plan, which began execution in the fall of that year. Plan components were grouped into three main categories. The first component was staff education regarding PrU prevention best practice. Second, a wound care team was created which would be consulted for the care of patients with specific triggers identifying them as having or being at risk for PrU development. Third, was the continued collection of data to monitor progress with the addition of more frequent reporting and discussion of that data with the wound care team and care providers in general. Each of the plan categories for PrU reduction was informed by or supported by mPUPP in specific ways. Beginning in October of 2010, the provider education component was completed by all facility staff. This provider education was administered through a web-based education portal created for the mPUPP within Medline University (MedlineU). MedlineU is a free online resource for education about different aspects of health care and best practice. The portion for mPUPP has an evaluation tool, or test, that is taken pre- and postcompletion of the education module with which it is paired. Psychometric properties of the test on MedlineU have not been established. In addition to MedlineU, facility
226
D. L. Young et al.
in-service meetings were held to discuss the mPUPP program and implementation for all facility staff. In addition, in October 2010, the wound care team, previously identified, was put into practice and its members and role was made known throughout the facility. Specific triggers for the wound care team involvement were implemented. These triggers included a Braden Score below 15, wound(s) on admission, patient weight being low or high, impaired nutritional status, impaired mobility, incontinence, or physician orders for specialty beds. All of these triggers were driven by the nursing admission assessment. This team’s function was supported by mPUPP through the products available from Medline Industries Inc. A unified product line including micronutrient-based skin cleansers,1 moisturizers,1 barrier creams,1 wound dressings, and incontinence management dry pads2 were implemented. Previous research demonstrated that the use of these micronutrient-based skincare products1 protects and nourishes fragile skin at risk of becoming damaged skin that may manifest itself as PrUs (Groom, Shannon, Chakravarthy, & Fleck, 2010; Shannon, Brown, & Chakravarthy, 2012; Shannon et al., 2009). Research and review articles also indicate a correlation between occurrence of incontinence associated dermatitis (IAD), incontinence, and the occurrence of PrUs (Groom et al., 2010; Shannon et al., 2009, 2012). Medline representatives visited the facility to consult with the administration and skin/wound care team to identify the products that would best support the goals of this facility. The third component of the plan was the data the facility planned to continue collecting. The relevant data they tracked included: the total number of wound care team assessments, the number of wound care team assessments completed within 72 hours, the total number of wounds, the total number of PrUs, the total number of nosocomial PrUs as well as the rate per 1,000 patient days, the number of debridements performed, and the total number of wounds that closed during a patients admission. These data were collected as monthly totals from January of 2010 to November of 2011. A follow-up check for sustainability was done in 2012 on nosocomial PrUs. One of the services provided by mPUPP is assistance with data collection and interpretation. mPUPP representatives called monthly to remind facilities to measure PrU prevalence and then collect that data to generate reports that track progress and financial impact of the changes. At this facility, the local Medline representative assisted with training and coordination of activities. © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 224–234
LTACH Pressure Ulcer Prevention Program
D. L. Young et al.
Table 1 Personnel time and salary costs for implementing mPUPP
Personnel Administration Nurse Educator Wound Care Team Nurses Patient Care Technicians
Total Hours People (Hours/Person)
Total Cost Cost Per Person
24 6 (4) 8 1 (8) 8 2 (4) 630 84 (7.5) 225.5 41 (5.5)
$1,200 $200 $360 n/a $252 $108/$144 $22,050 $262.5 $3,157 $77
In addition, the facility tracked the labor cost of implementation of the mPUPP. Among administrative personnel, six individuals spent an estimated 4 hours each of dedicated time to implement mPUPP. The facility hired a contract nurse educator for 8 hours to help provide in servicing to clinical staff. There were two clinicians comprising the facility “wound care team” that each spent 4 hours helping to implement the changes associated with mPUPP. Clinical staff training was done for nurses and patient care technicians (PCT) with 84 nurses receiving 7.5 hours of inservicing and 41 PCTs receiving 5.5 hours of inservicing. Both nurses and PCTs took the mPUPP pretest and posttest which took approximately 45 minutes each (Table 1). Change is often difficult and facility wide changes such as these were not without challenges to overcome. Before the program, the facility had over 30 products that could be ordered for services ranging from routine perineal care to chemical debridement of wounds. Before the program, there were two different types of adult briefs available. Nurses and physicians had become accustomed to these products and there was significant education and training that had to occur for the transition to a single product line. The time to complete the education on product and process changes, as well as that for the modules that are part of MedlineU, presented a scheduling challenge. This was met by offering both computer- and classroom-based instruction as well as offering training during lunch breaks. One interesting challenge was that some staff feared that MedlineU test results would lead to disciplinary action. This resulted in delays in staff attending the first pretesting sessions. The CNO and nurse mangers overcame this by openly promoting the program and rewarding staff that participated with small gifts. © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 224–234
Results A mean monthly value for each of the seven measured variables was calculated for the 10 months before implementation of mPUPP and the 13 months following full mPUPP implementation. November of 2010 was considered the first month with full program implementation. These pre- and post-mPUPP means were compared using SPSS 18.0 for Mac (SPSS, Inc., Chicago, IL, USA) with a t test where an a priori alpha level of 0.05 was selected to indicate significant difference between the values (Table 2). There was a significant reduction in nosocomial PrU when comparing preprogram (mean = 5.9, SD = 2.56) to postprogram (mean = 0.2, SD = 0.422) monthly means, p < .0005 (see Figure 1). For the other six variables measured (the total number of wound care team assessments, the number of wound care team assessments completed within 72 hours, the total number of wounds, the total number of PrUs, the number of debridements performed, the total number of wounds that healed during a patients admission), there were no statistical differences (see Table 2). Excluding nosocomial PrUs, monthly values for all data showed variability that did not appear to trend in any meaningful way over the study period (see Figures 2 and 3). Nosocomial PrUs per 1,000 patient days during the study period are reported in Table 3. With regard to sustainability, nosocomial PrU data from the 3rd quarter of 2012 revealed two PrUs in July, but none in any other month that quarter. In the preceding two quarters of 2012, there were only two other nosocomial PrUs. This yielded a rate of 0.2 nosocomial PrUs per 1,000 patient days in the first 3 quarters of 2012 (Figure 4). Statistical process control charts are helpful to show the stability of a process. They help an organization to recognize the need for change if the outcome desired from a process is not stable when taking into account variation normal to the process in question (Mohammed, Worthington, & Woodall, 2008; Padula, Mishra, Makic, & Sullivan, 2011). For this study, nosocomial PrUs are the most concerning outcome from the studied process, the PUPP. A u-chart was prepared using QI Macros for Excel (KnowWare International, Inc., http:// www.qimacros.com/about-knowware/) to highlight the rate of nosocomial PrU per patient day at the facility (Figure 5). The total estimated labor cost of implementation included the time of training and administration at this facility and totaled $27,019. Labor costs for implementation among administrative personnel was approximately
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Table 2 Statistical comparison of pre- (January 2010–October 2010) and post- (November 2010–November 2011) program variables. All values are monthly mean counts of that condition or activity with the exception of “WCT assmt within 72hrs” which is the percent of WCT assessments completed within 72 hours of referral
Comparison of Pre- and Postprogram Monthly Mean For: WCT assmt within 72hrs All wounds PrUs Nosocomial PrUs Debridements WCT Assessments Closed Wounds
Preprogram Means SD
Postprogram Means SD
100.00% 0.000 232.90 43.67 143.89 38.27 5.90 2.56 32.00 26.88 283.90 50.66 8.40 4.53
99.56% 0.936 293.80 104.92 155.11 71.64 0.20 0.422 49.60 25.22 256.60 90.43 6.40 3.41
t statistic
p-value
t (9) = 1.50
.168
t (9) =
2.03
.073
t (8) =
0.469
.652
t (9) = 7.64
