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ALABAMA PRESSURE ULCER INITIATIVE

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Title: ALABAMA PRESSURE ULCER INITIATIVE


1
ALABAMA PRESSURE ULCER INITIATIVE
  • Pressure Ulcer Reduction and Pressure Ulcer
    Prevention
  • A Statewide Initiative

2
Goals for this Meeting
  • Identify practices your facility can implement to
    improve pressure ulcer prevention and management
  • Recognize barriers that prevent your facility
    from implementing interventions to reduce
    pressure ulcer risk and establish methods to
    overcome these barriers

3
Goals for this Meeting
  • Develop strategies, using data, to monitor and
    improve your facilitys pressure ulcer
    management
  • Identify ways to work with other providers in the
    community to improve pressure ulcer care across
    the continuum

4
Whats the Problem?
  • Prevalence of Stage 2 or greater pressure ulcers
    in
  • Nursing homes 1.2 to 11.2
  • Hospitals 3.0 to 11
  • Home Care 8.7
  • 1.2 to 2.7 of all patients admitted to a
    hospital develop Stage 2 or greater pressure
    ulcer
  • About 60 of pressure ulcers develop in acute
    care hospitals, 20 in nursing homes, and 20 at
    home
  • Reference (Thomas Allman, 1997)

5
Whats the Problem?
  • Increased death rates in elderly who develop
    pressure ulcers
  • Issue of quality of life
  • Represent a cost of 2.2 to 3.6 billion in acute
    care settings
  • References (Thomas Allman, 1997)

6
Whats the Problem in Alabama?
  • The prevalence of pressure ulcers has not
    decreased since the Centers for Medicare and
    Medicaid Services (CMS) published of Residents
    with Pressure Sores in November 2002 on Nursing
    Home Compare website
  • www.medicare.gov
  • Rate November 2002
  • Pressure Ulcers 6.96

7
Whats the Problem in Alabama?
  • January 2004 CMS revised the pressure ulcer
    Quality Measure and stratified into
  • Chronic Residents
  • High risk
  • Low risk
  • Post-Acute or Short Stay Residents

8
Baseline Quality Measures (Quality Measures
November 2004)
9
Pressure Ulcer Steering Committee
  • Initial meeting June 2004
  • Committee members include representatives from
    ADPH, AQAF, ANHA, ombudsman, Alabama Medical
    Directors Association and nursing home providers

10
Pressure Ulcer Steering Committee
  • Committee vision
  • All Alabama nursing homes to have available a
    structured, effective pressure ulcer program for
    their facilities with the result that the number
    and severity of pressure ulcers in Alabama
    nursing homes would decrease

11
Pressure Ulcer Steering Committee
  • Identified barriers to quality pressure ulcer
    management in nursing homes
  • Lack of adequate risk assessment and/or care
    planning based on assessment
  • Inconsistent implementation of appropriate
    interventions
  • Lack of consistent care related to pressure ulcer
    management as residents transfer among health
    care settings

12
Pressure Ulcer Steering Committee
  • Dissemination of Information
  • All nursing homes and surveyors were provided
    with a copy of Guideline for Prevention and
    Management of Pressure Ulcers (Oct. 2004)
  • All nursing homes received a tool entitled
    Pressure Ulcer Facility Checklist to help them
    assess their facilitys pressure ulcer management
    program (Oct. 2004)
  • A supplemental Pressure Ulcer Resource Manual is
    being provided to all nursing homes during
    todays meeting

13
Pressure Ulcer Steering Committee
  • Dissemination of Information
  • Regional workshops for all nursing homes (Nov.
    Dec. 2004)
  • Education sessions for ombudsman, surveyors and
    medical directors (fall and winter 2004)
  • 13 month pressure ulcer collaborative open to all
    nursing homes in the state (Beginning Jan. 2005)

14
Goals for Alabama Pressure Ulcer Initiative
  • Develop
  • Implement
  • Monitor
  • Improve pressure ulcer management for Alabama
    nursing home residents

15
Goals for Alabama Pressure Ulcer Initiative
  • How will we know if we have improved?
  • Statewide Quality Indicator numbers
  • Statewide Quality Measure rates
  • How will you know if your facility has improved?
  • Facility Quality Indicator numbers
  • Facility Quality Measure rates

16
Quality Indicators
  • Each facility will use their quality indicator
    reports from November 1, 2004 as their baseline
  • Using this data each facility will decrease their
    quality indicator numbers for high and low risk
    pressure ulcers by at least 25 each year

17
Quality Measures - Facility
  • Facilities will decrease their Quality Measures
    for chronic high and low risk pressure ulcers by
    25 each year.
  • Facilities will decrease their Quality Measure
    for short-stay residents by 10 each year.
  • AQAF will provide each facility with quarterly
    reports for their pressure ulcer quality
    measures.

18
Quality Measures-Statewide
19
Facility Culture
  • How does your facility look at pressure ulcers?
  • Assuming that all pressure ulcers are avoidable
    can possibly change how your staff looks at
    pressure ulcers.

20
Pressure Ulcers
  • Localized areas of tissue destruction that
    develop when soft tissue is compressed between a
    bony prominence and an external surface for a
    prolonged period of time (WOCN,2003)
  • A pressure ulcer is an injury usually caused by
    unrelieved pressure that damages the underlying
    tissue (RAI manual 3-162)

21
Stage I
  • A defined area of persistent redness (does not
    blanch) in lightly pigmented skin
  • May appear with persistent red, blue, or purple
    hues in persons with darker skin tones  (NPUAP
    2002)
  • Area may also be
  • Warmer or cooler
  • Firm or boggy
  • Painful or itchy
  • No open skin area

22
Stage II
  • Partial thickness skin loss involving
    epidermis, dermis, or both. The ulcer is
    superficial and presents clinically as an
    abrasion, blister, or shallow crater.

23
Stage III
  • Full thickness skin loss
  • Damage or necrosis of subcutaneous tissue
  • May extend down to but not through underlying
    fascia
  • A deep crater with or without undermining

24
Stage IV
  • Full thickness skin loss with extensive
    destruction, tissue necrosis or damage to muscle,
    bone, or supporting structures (e.g. tendon,
    joint capsule, etc.)
  • Often associated with tunneling or undermining

25
Unstageable
  • Pressure ulcers which have slough tissue or
    eschar present are considered unstageable.
  • Pressure ulcers cannot be staged accurately until
    the eschar or slough tissue is removed.
  • On the MDS (Minimum Data Set) pressure ulcers
    with eschar or slough are coded as Stage 4.

26
Deep Tissue Injury
  • Purple, blue, black discoloration, not open,
    often seen on the heels
  • On MDS must be coded as Stage 1

27
Staging Correctly
  • Incorrect staging can result in
  • Inaccurate MDS coding
  • Incorrect treatment plan
  • Incorrect documentation

28
Form 672
  • F 115 with pressure sores
  • The number or residents with ischemic ulcerations
    and/or necrosis tissues overlying a bony
    prominence (exclude stage I)
  • Any M1b,c or d gt0 or M2agt1
  • Code for the first assessment after latest
    admission or readmission

29
Form 672
  • F116 Of the total number or residents with
    pressure ulcers excluding Stage I
  • The number who had pressure sores on admission or
    who were readmitted with a pressure sore (exclude
    stage I)
  • Code when criteria for F115 is met and A8a 1 or
    A8b 1 or 5

30
Form 672
  • The facility may use the MDS data to start the
    672 form, but must verify all information, and in
    some cases, re-code the item responses to meet
    the intent of the 672 to represent current
    resident status.
  • Since the census is designed to be a
    representation of the facility during the survey,
    it does not directly correspond to the MDS in
    every item.
  • The information also refers to only certified
    beds (as opposed to licensure only beds).

31
Form 802
  • 23 Pressure Sores/Ulcers
  • If the resident has a stage 2, 3 or 4 pressure
    sore (s), check this column
  • If M2a is greater than 1, then 802 23 is
    checked
  • Facilities can use the MDS as a worksheet but
    the information must represent current resident
    status during the survey

32
Skin Inspections
  • Performed by licensed or non-licensed staff
  • All individuals at risk for pressure ulcers
    should have a systematic skin inspection at least
    once a day. (AHCPR, 1998)
  • Assess all bony prominences of at-risk
    individuals at least on a daily basis
  • (Bergstrom Braden, 1992)

33
Skin Inspections
  • Clothes, shoes, heel and elbow protectors,
    orthotic devices, restraints, and protective wear
    should be removed for skin and bony prominence
    inspection
  • Vulnerable pressure points for bed or chair-
    bound individuals
  • Supine position Occiput, sacrum, heels
  • Sitting position Ischial tuberosities, coccyx
  • Side-lying position Trochanters
  • (WOCN, 2003)

34
Skin Inspections
  • Can be performed by the nursing assistant during
    daily routine care
  • Facility needs a process in place for
    communicating skin changes

35
Skin Assessments
  • Performed by licensed staff
  • Perform skin assessment before resident leaves
    your facility (if resident condition allows)
  • Perform skin assessment upon return to your
    facility (ex. ER, dialysis)

36
Identifying Risk Factors
  • More than just assigning a number

37
Risk Assessments
  • Bed-and chair-bound individuals or those with
    impaired ability to reposition should be assessed
    for additional factors that increase risk for
    developing pressure ulcers
  • A systematic risk assessment can be accomplished
    by using a validated risk assessment tool such as
    the Braden or Norton scale
  • (AHCPR,1998)

38
Risk Assessments
  • No matter which risk assessment tool is used,
    performing a risk assessment is more than just
    assigning a number to the resident.
  • Risk assessment involves identifying the risk
    factors and then working to minimize those
    specific deficits.

39
Risk Assessments
  • Braden
  • 6 subscales sensory perception, moisture,
    activity, mobility, nutrition friction/shear
  • Each subscale is rated on a scale of 1-4 except
    friction/shear which is 1-3
  • The maximum possible score is 23
  • Lower scores reflect higher risk
  • Risk for pressure ulcer 16 or less

40
Risk Assessments
  • Norton
  • 5 parameters physical condition, mental state,
    activity, mobility, incontinence
  • Each parameter is rated on scale of 1-4
  • Scores can range from 5-20
  • Lower scales reflect higher risk
  • Risk for pressure ulcer 16 or less

41
Risk Assessments
42
Impact of Risk Assessments
  • Use of Braden scale and resulting prevention
    efforts reduced incidence of new pressure ulcers
    by 60.
  • Severity of pressure ulcers and cost of care
    decreased as well.
  • (Braden Bergstrom, 1992)

43
Identifying Risk Factors
  • Assessing residents for risk should be done in a
    systematic fashion.
  • Does your facility have a process in place to
    assess residents for changes in risk factors
    during an acute illness or exacerbation?
  • Ex. resident develops pneumonia

44
Mobility Decline
  • Requires a wheelchair
  • Bedfast
  • Requires assistance with transfers

45
Pressure, Friction Shearing
  • Head of bed greater than 30 degrees
  • Improper transfer techniques
  • Bone on bone contact
  • Prolonged sitting or laying in one position
  • Sliding down in a chair or wheelchair
  • Impaired bed mobility
  • Moisture

46
Pressure, Friction Shearing
  • Abrasive forces such as starch, bleach or
    detergents in clothing or linen
  • Disposable briefs/pads
  • Misuse of gait belt
  • Dry skin
  • Improper fitting splints or immobilzers

47
Incontinence
  • Bladder incontinence
  • Bowel incontinence
  • Diarrhea

48
Nutritional Deficiencies
  • Weight loss (5-30days, 7.5-3 months, 10 - 180
    days)
  • Malnutrition
  • Dehydration
  • Requires assistance with eating
  • Leaves less than 75 of meals uneaten
  • Decreased albumin
  • Obese
  • Decreased body weight less than desirable

49
Impaired Skin Integrity
  • Dry skin
  • Moist skin
  • Edema
  • Skin desensitized
  • Fragile skin

50
Use of Devices
  • Oxygen tubing
  • Restraints
  • Splints
  • Ace Bandages
  • Cast
  • Foley Catheters
  • Multipodus boots
  • Wheelchairs/Gerichairs
  • Compression Stockings

51
Diagnosis/Treatments/Meds
  • Peripheral Vascular Disease
  • Paraplegia/Quadriplegia
  • Stroke
  • Decreased Mental Status
  • Diabetes
  • Diuretics
  • Steroids
  • Chemotherapy
  • Radiation

52
History of Pressure Ulcer
  • At best, the tensile strength of scar tissue is
    never more than 80 of the tensile strength in
    non-wounded tissue. (Cuono, 1985)
  • Recurrence rates for adults have been reported at
    13-56 (Relander Palmer, 1998 Schryvers,
    Stranc, Nance, 2000) with 21 developing a new
    ulcer at a different site. (Schryvers et. al.)

53
Prevention
  • Individualizing Interventions

54
Mobility Decline
  • Individualized turning schedule
  • Repositioning (bed every 2 hours, chair every 1
    hour)
  • Appropriate support surfaces
  • If able, encourage ambulation
  • Check for appropriate size of wheelchair
  • Restorative program
  • Physical therapy evaluation
  • Consider use of lift
  • Assess for appropriate positioning devices

55
Incontinence
  • Individualized incontinence care
  • Toileting program
  • Assess for appropriate brief type
  • Consider use of catheter (stage 3 or 4 with
    contamination as an issue)
  • Moisture barrier
  • Assess need for incontinence pouch
  • Increase hydration
  • Assess the frequency of incontinence care related
    to briefs used
  • Evaluate medications
  • Consider occupational therapy evaluation

56
Nutritional Deficiencies
  • Consider protein supplement
  • Hydration pass
  • Assist with meals as needed
  • Consider nutritional supplement
  • Dietary evaluation
  • Assess dental health
  • Weekly weights
  • Consider high protein, high calorie foods
  • Offer food substitutes
  • Assess for food and drug interactions
  • Consider Park, Walk Dine Program
  • Consider use of assigned seating charts and
    feeding assignments

57
Previous History of Pressure Ulcer
  • Apply skin protectant to the site of the previous
    pressure ulcer
  • Apply hydrocolloid to the site of the previous
    pressure ulcer
  • Pressure reduction/relief cushion in chair
  • Pressure reduction/relief mattress
  • Assess nutritional status

58
Impaired Skin Integrity
  • Avoid hot water
  • Use a mild cleansing agent
  • Use moisturizers
  • Avoid massage over bony prominences
  • Skin inspection daily
  • Bathing schedule
  • Assess hydration and plan delivery of fluid needs
  • Elevate extremity
  • Check footwear
  • Avoid constricting clothing
  • Apply protective clothing

59
Use of Devices
  • Assess skin under the device (if allowed by MD)
  • Pad oxygen tubing
  • Assess for least restrictive device
  • Assess for proper application of splint or ace
    bandage
  • Maintenance schedule for checking equipment
  • Release restraint and reposition resident
    (individualized)
  • Consider use of hydrocolloid dressing over the
    ears

60
Pain
  • Turn and reposition off the ulcer
  • Use appropriate support surfaces for the bed and
    chair
  • Refer to the pain clinic as needed
  • Assess for pain prior to and during pressure
    ulcer treatment
  • Monitor for effectiveness of pain medications
  • Consider therapy evaluation
  • Consider use of routine pain medications prior to
    pressure ulcer treatment

61
Diagnosis/Treatments/Meds
  • MD evaluation as needed
  • Medications as ordered
  • Therapy evaluation as needed
  • Monitor labs
  • Pharmacy evaluation
  • Dietary evaluation
  • Assess each resident on an individual basis
    regarding their disease process

62
Pressure, Friction Shearing
  • Head of bed lower than 30 degrees
  • Use trapeze bar
  • Float heels
  • Avoid positioning directly on the trochanter
  • Use gait belts
  • Assess proper fit of shoes
  • Assess proper alignment in bed and chair
  • Consider use of slide sheets
  • Assess for appropriate transfer techniques
  • Appropriate support surfaces
  • Prevent bone on bone contact
  • Consider therapy consult
  • Consider use of heel and/or elbow protectors

63
Inconsistent Implementation
  • Barriers to Prevention

64
Failure to Identify Residents Nutritional State
  • Nutritional assessment should be performed on
    entry to a new health care setting and whenever
    there is a change in an individuals condition
    that may increase the risk of malnutrition

65
Failure to Identify Residents Nutritional State
  • History of involuntary weight loss or gain
  • Current and usual weight
  • Nutritional intake versus needs, including
    protein, calorie, and fluid needs
  • Appetite
  • Dental health
  • Cultural and lifestyle influences
  • Oral and GI health including chewing and
    swallowing, ability to feed self
  • Medical/surgical history or interventions that
    influence nutrition
  • Drug/nutrient interaction
  • Psychosocial factors affecting food intake
  • Food preferences

66
Inconsistent Rehab/Restorative Referrals
  • Evaluate your facilitys process for referring
    residents to your restorative program or rehab

67
Failure to Follow Treatment Guidelines
  • Current practice guidelines have been researched
    and tested
  • Each facility has been sent a copy of the current
    treatment guidelines from the Wound Ostomy and
    Continence Nurses Society
  • Additional information can be obtained from the
    AMDA and AHCPR guidelines

68
Resident and/or Family Non-Compliance
  • The facility should determine exactly what the
    resident and/or family is refusing and why. To
    the extent the facility is able it should
    address the residents concerns.

69
Resident and/or Family Non-Compliance
  • The facility should
  • Assess if the resident or family member can give
    informed consent to refuse treatment
  • Assess the reasons for the refusal or non-
    compliance
  • Clarify and educate the resident and/or family as
    to the consequences of the refusal
  • Offer alternative treatments
  • Continue to provide all other services

70
Resident and/or Family Non-Compliance
  • Clearly document in the clinical record the
    assessment, education and what, if any,
    alternative treatments were offered to the
    resident.
  • Periodically re-evaluate the non- compliance and
    document additional assessment, education, and
    alternatives, which take place.

71
Increased Cost to the Resident or Facility
  • Use good clinical judgment when determining
    treatment options for residents.

72
Paperwork Requirements Compete With
Treatment/Monitoring
  • Evaluate facility processes to determine if
    duplicate documentation is being done.
  • Possibly consider use of flow sheets
  • Electronic charting systems

73
Paperwork Requirements Compete With
Treatment/monitoring
  • Evaluate documentation to determine if it is
    consistent with other interdisciplinary
    documentation and facility policy
  • For MDS completion, make sure you are looking at
    the correct look back period

74
Inadequate Communication Systems
  • Facility should have a process in place to assure
    that adequate communication is occurring between,
    staff, physicians, resident and family

75
Inadequate Communication Systems
  • Evaluate your facilitys communication practices
  • Is information passed through official channels,
    or is the grapevine the best source of
    information?
  • Do supervisors say one thing, and mean another?
  • What hidden communication rules are in your
    organization?

76
Inadequate Communication Systems
  • Communication
  • Increases awareness of situations
  • Enables planning and discussion
  • Facilitates flow of information

77
Lack of Education
  • Educational programs are part of the foundation
    for preventing and treating pressure ulcers.
  • Education programs should be structured,
    organized, and comprehensive and directed at all
    levels of health care providers, patients, and
    family or caregivers.

78
Lack of Education
  • Consider making pressure ulcer management part of
    your orientation program
  • Ex. use video AQAF provided to facilities
  • Consider having quarterly pressure ulcer
    education
  • Consider use of competencies
  • Ex. Evaluate staff completing pressure ulcer
    treatments to make sure they are using clean
    technique

79
Lack of Education Areas to address in your
pressure ulcer education program
  • Etiology of risk factors
  • Principles of wound healing
  • Bowel bladder management
  • Positioning support surfaces
  • Skin care
  • Skin inspections
  • Monitoring
  • Staging
  • Prevention
  • Nutrition
  • Wound care
  • documentation

80
Supply System Inadequate to Meet Resident/Staff
Needs
  • Evaluate facility processes to determine if
    appropriate supplies are in stock
  • Consider developing protocols so that staff
    consistently uses the same supplies

81
Lack of Policies and/or Procedures
  • Policies and Procedures
  • Provide a framework for practice within the
    organization
  • Directs the course of action for the organization
    within a specific area
  • Can outline goals related to a program.

82
Lack of Policies and/or Procedures
  • Developing policies and procedures
  • Use, clean, concise, simple language
  • Make policies and procedures readily available to
    employees
  • Tie the procedures to the policies
  • Include direct care staff in the development of
    polices and procedures

83
Lack of Policies and/or Procedures
  • Developing policies and procedures
  • Dont include information that could be quickly
    outdated or changed such as name brands
  • Spell out terms
  • Identify who is responsible for carrying out the
    policy and who is responsible for overall
    compliance of the policy

84
Problems with Policies and Procedures
  • Not readily available to staff
  • Too complicated to understand
  • No policy or procedure for a task
  • Not updated to meet current research/standards
  • Steps are left out
  • Not communicated to physicians
  • Lack of staff to carry them out
  • Lack of monitoring
  • Failure to communicate changes to staff
  • Lack of process for developing policies and
    procedures

85
Lack of Appropriate Monitoring Systems
  • Facility needs a process in place to assure
    pressure ulcer prevention strategies are being
    monitored for compliance
  • Even though dressings are not changed daily staff
    needs to monitor daily to assure dressings are
    intact and the surrounding area has not changed
  • Collect data to determine compliance with your
    pressure ulcer program
  • Inspect what you expect

86
Tracking Pressure Ulcers
87
MDS Coding
  • Pressure Ulcers must be coded on the MDS in terms
    of what is seen during the look back period ( RAI
    manual 3-159)
  • Deep tissue injury stage 1
  • A blister caused by an excessively snug brief
    stage II
  • A pressure ulcer with slough tissue or eschar
    stage IV

88
Incorrect MDS Coding
  • Improper RUG (resource utilization group)
    classification
  • Incorrect QMs (quality measures)
  • Incorrect QIs (quality indicators)

89
Care Planning
  • Care planning for residents should be
    individualized
  • Risk factors should be care planned

90
Documentation
  • All assessments of risk should be documented
  • Results of skin inspection should be documented
  • Interventions should be documented
  • Reassess pressure ulcers at least weekly
  • (AHCPR,1998)
  • Assessment of intact dressings

91
Documentation
  • Provide detailed documentation of skin changes
  • In documentation
  • Be careful using the word hip when it is the
    trochanter
  • Give specifics when describing areas on the ankle
  • Separate the coccyx from the sacrum
  • Make sure you document the correct side of the
    body

92
Documentation
  • Assess and monitor pressure ulcer(s) at each
    dressing change and reassess and measure at least
    weekly
  • (WOCN,2003)
  • If a resident has more than one pressure ulcer
    this should be consistently and clearly
    documented in the record.
  • Consider using a diagram of a body to label the
    different pressure ulcer areas

93
Documentation
  • Consider use of tools or forms to do your
    documentation. (ex. PUSH tool, flow sheets)
  • Make sure to include education provided to the
    resident and family in your documentation.
  • Make sure to include family notification in your
    documentation.

94
RegulationsThat could be cited in relationship
to your pressure ulcer program
  • F157 Notification of Changes
  • F314 Pressure Ulcers
  • F309 Quality of Care
  • F310 Quality of Care
  • F272 Comprehensive Assessment
  • F279 Comprehensive care plans
  • F282 Qualified persons to deliver care
  • F325 Nutrition
  • F327 Hydration

95
Pressure Ulcer Team
  • Team in the facility that looks at opportunities
    for improvement in facilities pressure ulcer
    program.
  • Include a nursing assistant on the team
  • Use The Facility Checklist to determine areas
    for improvement in your facility.

96
Continuation of Care
  • Working together for a common goal

97
Continuation of Care
  • Establish relationships with other providers to
    improve communication and continuation of
    resident care
  • Ex. dialysis units, home health, hospice,
    hospitals

98
Continuation of Care
  • Hospitals
  • Hold a meeting between the nursing home and
    hospital
  • Redesign your transfer form to include more
    information on pressure ulcers
  • Hold in-services for both nursing home and
    hospital staff

99
Continuation of Care
  • Hospitals
  • Exchange contact information
  • Follow up with the hospital within 24 hours of
    your residents being admitted to provide
    additional information
  • Build a rapport between the nursing home staff,
    social worker and case managers at the hospital

100
Continuation of Care
  • Dialysis
  • Educate nursing home staff on ESRD (end stage
    renal disease)
  • Share contact information
  • Send a bag with resident, consider including
    incontinence products, new med or order changes,
    a snack
  • Establish routine(ex. monthly) communication

101
Continuation of Care
  • Home Health
  • Identify at risk residents
  • Provide contact list
  • Provide list of educational needs

102
Continuation of Care
  • Community/Family Education
  • Involvement of ombudsman
  • Host community educational sessions
  • Family Council

103
Continuation of Care
  • Hospice
  • Involve in care planning
  • Share contact information
  • Educate hospice to nursing home regulations and
    what needs to be communicated to nursing home
    staff about pressure ulcer care and treatment.

104
Continuation of Care
  • Hospice
  • Have hospice educate nursing home to the hospice
    program
  • Process in place for communication
  • System in place so nursing home staff knows what
    hospice is providing for the resident

105
Pressure Ulcer QADoes your facility have a
process in place to determine if pressure ulcers
were avoidable or unavoidable?
  • Avoidable-Pressure ulcer development and facility
    failed to do one or more
  • Evaluate clinical condition /or risk factors
  • Defined/implemented interventions CONSISTENT with
    resident needs, goals
  • Recognized standards of practice (AHCPR, AMDA,
    WOCN, current literature)
  • Monitor and evaluate impact of interventions
  • Revise interventions appropriately

106
Pressure Ulcer QA
  • Unavoidable- Resident developed pressure ulcer
    although facility
  • Evaluated clinical condition and risk factors
  • Defined and implemented interventions consistent
    with residents needs, goals
  • Standards of practice
  • Monitored and evaluated impact of interventions
  • Revised approaches appropriately

107
Quality of Care
  • Some persons may have underlying co-morbidity,
    such as arthritis or metastatic cancer, making
    frequent repositioning painful and burdensome. In
    such cases, comfort measures may be the primary
    management goal, rather than pressure ulcer
    prevention or cure.

108
Quality of Care
  • Even though residents may be receiving comfort
    measures only they need to be
  • Evaluated
  • Care individualized
  • Treatment options documented
  • Reassessed periodically
  • End of life does not mean end of care

109
Medical Directors Role
  • Serve on your pressure ulcer team
  • Assist in developing policies and protocols
  • Assist in education of other attending physicians
    at your facility

110
Pressure Ulcer Collaborative
  • A collaborative is a systematic approach to
    healthcare quality improvement in which
    organizations and providers test and measure
    practical innovations, then share their
    experiences in an effort to accelerate learning
    and widespread implementation of best practices.

111
Pressure Ulcer Collaborative
  • Open to all nursing homes in the state of Alabama
  • Will last 13 months
  • Requires facility commitment of a team attending
    4 meetings, facility improvement changes, monthly
    data collection and monthly reports.
  • Information regarding what a collaborative is has
    been placed in your facility packet

112
CMS Broadcast
  • Survey Certification Online Course Delivery
    System
  • www.cms.internetstreaming.com
  • CMS Long Term Care Journal Pressure Ulcer Care
    Vol. 1

113
Websites
  • www.npuap.org National Pressure Ulcer Advisory
    Panel NPUAP (PUSH Tool)
  • www.woundcarehelpline.com/nortonscale.pdf Norton
    Scale
  • www.bradenscale.com Braden scale
  • Batesjen_at_ucla.edu PSST Tool
  • www.wocn.org Wound Ostomy and Continence Nurses
    Society (WOCN)

114
Websites
  • www.medqic.org MEDQIC (click on resources on
    left side of the page)
  • www.medicare.gov Nursing Home Compare
  • www.aqaf.com Alabama Quality Assurance Foundation
  • www.ahcpr.gov Agency for Healthcare Research and
    Quality
  • www.amda.com American Medical Directors
    Association ( click on resource library, then
    assessment tools, model forms and clinical
    resources)

115
For more information contactCarol Hill
chill_at_alqio.sdps.org800-760-4550 ext. 2284
This material was prepared by Alabama Quality
Assurance Foundation, the Medicare Quality
Improvement Organization for Alabama, under
contract with the Centers for Medicare Medicaid
Services (CMS), an agency of the U.S. Department
of Health and Human Services. The contents
presented do not necessarily reflect CMS policy.
7SOW-AL-NHQI-04-18
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