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«Pressure Ulcers at Ascension Health Pressure ulcers affect approximately 10 percent of hospitalized patients and are associated with significant ...»


Pressure Ulcers at Ascension Health

Pressure ulcers affect approximately 10 percent of hospitalized patients and are associated with

significant patient discomfort, prolonged hospitalization, and increased risk of death. Risk factors

include poor mobility, incontinence, abnormal nutritional status, and altered consciousness.

Variability in pressure ulcer rates across health care settings suggests that opportunities exist to improve outcomes for at-risk patients.1 From the implementation of the pressure ulcer initiative in 2006 to the follow-up in 2011, Ascension Health achieved a 70 percent reduction in facilityacquired pressure ulcer prevalence (including Stage 1) among patients at the network’s 67 acute care hospitals. In 2010, 12 Ascension Health hospitals reported no hospital-acquired pressure ulcers. Results from the system demonstrated a system-wide pressure ulcer rate of 0.86 per 1,000 inpatient days—94 percent lower than the national average.2 Facility-Acquired Pressure Ulcer Prevalence at Ascension Health, 2005-2011 Including Stage 1 Excluding Stage 1 10.0 10.0 Prevalence, % 8.3 Prevalence, % 8.0 8.0 6.4 4.7 6.0 6.0 4.2 4.3 3.3 3.4 2.6 2.8 4.0 2.7 2.4 4.0 2.3 1.9 1.7 2.0 2.0 0.0 0.0 '10 '11 '05 '09 '06 '08 '07 '06 '08 '09 '10 '05 '07 '11 Time Frame: 2004-2011. The alpha site hospital created and piloted a S.K.I.N.® care bundle in 2004 followed by development and dissemination of a system-wide toolkit in 2005. In January 2006, all network facilities adopted the standardized S.K.I.N.® care bundle, which remains in place across all Ascension Health hospitals today.3 Motivation, Sponsor, and Lead Organization: In 2002, Ascension Health created a vision to transform health care delivery and identified pressure ulcer reduction as one of its eight priorities for action to eliminate preventable injuries or deaths through its Journey to Zero quality improvement initiative.

Participating Sites: 67 acute care hospitals in the Ascension Health network.

Key Success Factors Engagement of key leaders: System leaders (such as chief executive, operating, financial, nursing,  and medical officers) set an aggressive goal to eliminate pressure ulcers as part of a broad harm reduction and patient safety improvement initiative.

Incentives: Executive at-risk compensation was linked to the system scorecard goal of preventable  mortality reduction that included patient safety initiatives.

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consensus on one standard of care, the S.K.I.N.® care bundle, for implementation in all facilities.

Performance monitoring: Standard metrics, transparency in the monthly reporting of results,  subsequent tracking, and regular feedback to hospitals allowed initiative leaders to monitor progress.

Nurse champions: Chief Nursing Officers (CNOs) assumed leadership of the initiative, providing  an opportunity for nurses to drive the process to improve patient outcomes.

Multidisciplinary teams: Nurse champions led a team of educators, bedside caregivers, wound  care nurses, pharmacists, and nutritionists to coordinate pressure ulcer reduction practice changes.

More About the Strategies Used At the System Level A system-wide Pressure Ulcer Summit convened internal and external experts to spread  implementation of a standardized S.K.I.N.® care bundle across the network.

More than 100 CNOs, clinical educators, wound experts, front-line nurse managers, and clinical staff nurses participated in a two-day, in-person rapid design meeting to develop a standardized pressure ulcer plan of care. During the meeting, participants evaluated evidence-based best practices and conducted an item-level review of more than 100 standards of care in place across the network. Using real-time voting technology, they unanimously adopted one standard S.K.I.N.® care bundle, and then planned its dissemination.

All network facilities had easy, online access to implementation support tools.

 All facilities had online access to the S.K.I.N.® care bundle and relevant educational materials as well as a pressure ulcer listserv for ongoing communication and peer-to-peer coaching.

Ongoing measurement tracked performance, and timely feedback helped sustain  accountability and commitment among network facilities.

Clinical leaders agreed to a common performance metric, and Ascension Health created a simple web-based data collection tool to minimize the reporting burden on facilities. Facility-level results were available to all hospitals to promote accountability and facilitate peer-to-peer sharing of implementation experiences.

Clinical and financial leaders developed a business case for investment in equipment to  prevent skin breakdown.

Clinical and financial leaders proposed the business case for a system-wide bed replacement plan, which led to a strategic partnership with a health care equipment company and a group purchase of surfaces designed to prevent skin breakdown.

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Nurse educators offered ongoing staff education including instruction at the bedside.

 Brief presentations to clinical staff introduced the S.K.I.N.® care bundle and provided the rationale for the initiative and anticipated results. Multiple educational offerings included bedside teaching, newsletters, self-study modules, posters, pocket cards, and staff huddles. Bedside teaching involved team head-to-toe skin assessments at the patient’s bedside with one expert nurse explaining to two or three novice staff how to conduct the assessment and implement the S.K.I.N.® care bundle. Leadership participation in rounding demonstrated high-level commitment to the initiative.

Nursing leaders monitored performance and provided feedback to nursing staff.

 Nursing directors, nurse managers, clinical resource coordinators, and unit champions attended weekly “S.K.I.N.” meetings to review hospital-acquired pressure ulcer events. The nursing leadership’s support of staff attendance at these meetings (including permitting staff to leave the floor and encouraging coverage arrangements) conveyed the importance of the initiative to staff.

Meetings focused solely on pressure ulcer reduction and served to maintain accountability while providing a forum for idea exchange and problem solving. Feedback to staff enhanced commitment and pride in performance improvements.

Nurse leaders expanded pressure ulcer reduction efforts to include product evaluation and  engagement of patients and families.

In addition to conducting patient risk assessments and implementing the S.K.I.N.® care bundle, nursing staff began evaluating products and surfaces for risk of skin breakdown and providing input into product purchasing decisions. Nurses also engaged patients and families to increase awareness of the importance of repositioning and nutrition in preventing pressure ulcers.

Challenges Faced and Lessons Learned Achieving network-wide pressure ulcer reduction has required adaptation of S.K.I.N.® care  bundle implementation to accommodate hospitals of diverse size and type.

The Ascension Health network includes a diverse set of acute care facilities ranging from small rural hospitals to large urban hospitals. The network spans 20 states and the District of Columbia.

Transparent reporting of hospitals’ performance data has allowed facilities to track their relative performance and high-performing hospitals have assisted low performers with identifying and resolving barriers to improvement.

Sustaining improvement requires different strategies than those used to achieve initial  reductions in pressure ulcers.

After achieving compliance with the S.K.I.N.® care bundle, facility leaders have continued to review all hospital-acquired pressure ulcer cases to identify both root and common causes and strategies to address them. System leaders continue to evaluate trends to target low-performing facilities for additional support.

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by demonstrating improved patient outcomes.

Staff education raised awareness of the preventability of facility-acquired pressure ulcers. Nurse leaders worked to shift staff expectations from “critically ill patients will leave the organization alive” to “critically ill patients will leave the organization alive and without a pressure ulcer.” Establishing the pressure ulcer reduction effort as a nursing-led initiative empowered nurses to drive improvement in patient outcomes. Rounding together helped establish peer accountability and a sense of shared responsibility for pressure ulcer reduction.

Nursing staff appreciate knowing that some pressure ulcers may not be preventable.

 Ascension conducted a literature review and a small study that suggested that a small number of critically ill patients with hypotension or organ failure will develop pressure ulcers despite skin care that meets every component of the bundle.4 Making nurses aware of this avoids the development of frustration and doubt about the S.K.I.N.® care bundle’s effectiveness.

Pressure ulcer rates initially spiked after implementing the pressure ulcer reduction  intervention.

In the early stage of the pressure ulcer intervention, a rise in prevalence was attributed to an increase in reporting. Nursing leaders worked to manage expectations and maintain staff commitment to the long-term reduction goal by recognizing the benefits from increased compliance with the standard of care.

Compliance with the S.K.I.N.® care bundle requires availability of appropriate products.

 Early on, lack of appropriate products prevented nurses from complying with all components of the S.K.I.N.® care bundle. Nursing leaders began working with system executives, supply chain staff, and finance staff to inform product decisions and build a business case for investment in pressure reduction surfaces/products to meet their pressure ulcer reduction goal. This system-wide mattress and frame replacement strategy provided an opportunity to align practice with technology.

Kaltenthaler, E., M.D. Whitfield, S.J. Walters, et al. “UK, USA and Canada: How Do Their Pressure Ulcer Prevalence and Incidence Data Compare?” Journal of Wound Care, vol. 10, 2001, pp. 530–535.

Pryor, David, Ann Hendrich, Robert J. Henkel, James K. Beckmann, and Anthony R. Tersigni. “The Quality ‘Journey’ at Ascension Health: How We’ve Prevented at Least 1,500 Avoidable Deaths a Year—and Aim to Do Even Better.” Health Affairs, vol. 30, no. 4, 2011, pp. 604-611.

The bundle was given the mnemonic “SKIN,” which stands for Surface selection (the mattresses and cushions on which patients lay or sit), Keep turning patients or keep them moving, Incontinence management, and Nutrition and hydration (Gibbons, Wanda, Helana T. Shanks, Pam Kleinhelter, and Polly Jones. “Eliminating Facility-Acquired Pressure Ulcers at Ascension Health.” Joint Commission Journal on Quality and Patient Safety, vol. 32, no. 9, Sept. 2006, pp. 488-496; Shanks, Helana T., Pam Kleinhelter, and John Baker. “Skin Failure: a Retrospective Review of Patients with Hospital-Acquired Pressure Ulcers.” WCET Journal, vol. 29, no. 1, January/March 2009, pp. 6-10).

Shanks, Helana T., Pam Kleinhelter, and John Baker. “Skin Failure: a Retrospective Review of Patients with Hospital-Acquired Pressure Ulcers.” WCET Journal, vol. 29, no. 1, January/March 2009, pp. 6-10).

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