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