Title: ALABAMA PRESSURE ULCER INITIATIVE
1ALABAMA PRESSURE ULCER INITIATIVE
- Pressure Ulcer Reduction and Pressure Ulcer
Prevention - A Statewide Initiative
2Goals 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
3Goals 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
4Whats 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)
5Whats 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)
6Whats 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
7Whats 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
8Baseline Quality Measures (Quality Measures
November 2004)
9Pressure Ulcer Steering Committee
- Initial meeting June 2004
- Committee members include representatives from
ADPH, AQAF, ANHA, ombudsman, Alabama Medical
Directors Association and nursing home providers
10Pressure 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
11Pressure 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
12Pressure 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
13Pressure 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)
14Goals for Alabama Pressure Ulcer Initiative
- Develop
- Implement
- Monitor
- Improve pressure ulcer management for Alabama
nursing home residents
15Goals 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
16Quality 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
17Quality 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.
18Quality Measures-Statewide
19Facility 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.
20Pressure 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)
21Stage 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
22Stage II
- Partial thickness skin loss involving
epidermis, dermis, or both. The ulcer is
superficial and presents clinically as an
abrasion, blister, or shallow crater.
23Stage 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
24Stage 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
25Unstageable
- 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.
26Deep Tissue Injury
- Purple, blue, black discoloration, not open,
often seen on the heels - On MDS must be coded as Stage 1
27Staging 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
29Form 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
30Form 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).
31Form 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
32Skin 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)
33Skin 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)
34Skin Inspections
- Can be performed by the nursing assistant during
daily routine care - Facility needs a process in place for
communicating skin changes
35Skin 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)
36Identifying Risk Factors
- More than just assigning a number
37Risk 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)
38Risk 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.
39Risk 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
40Risk 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
41Risk Assessments
42Impact 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)
43Identifying 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
44Mobility Decline
- Requires a wheelchair
- Bedfast
- Requires assistance with transfers
45Pressure, 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
46Pressure, 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
47Incontinence
- Bladder incontinence
- Bowel incontinence
- Diarrhea
48Nutritional 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
49Impaired Skin Integrity
- Dry skin
- Moist skin
- Edema
- Skin desensitized
- Fragile skin
50Use of Devices
- Oxygen tubing
- Restraints
- Splints
- Ace Bandages
- Cast
- Foley Catheters
- Multipodus boots
- Wheelchairs/Gerichairs
- Compression Stockings
51Diagnosis/Treatments/Meds
- Peripheral Vascular Disease
- Paraplegia/Quadriplegia
- Stroke
- Decreased Mental Status
- Diabetes
- Diuretics
- Steroids
- Chemotherapy
- Radiation
52History 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.)
53Prevention
- Individualizing Interventions
54Mobility 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
55Incontinence
- 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
56Nutritional 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
57Previous 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
58Impaired 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
59Use 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
60Pain
- 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
61Diagnosis/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
62Pressure, 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
63Inconsistent Implementation
64Failure 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
65Failure 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
66Inconsistent Rehab/Restorative Referrals
- Evaluate your facilitys process for referring
residents to your restorative program or rehab
67Failure 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
68Resident 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.
69Resident 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
70Resident 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.
71Increased Cost to the Resident or Facility
- Use good clinical judgment when determining
treatment options for residents.
72Paperwork 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
73Paperwork 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
74Inadequate Communication Systems
- Facility should have a process in place to assure
that adequate communication is occurring between,
staff, physicians, resident and family
75Inadequate 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?
76Inadequate Communication Systems
- Communication
- Increases awareness of situations
- Enables planning and discussion
- Facilitates flow of information
77Lack 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.
78Lack 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
79Lack 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
80Supply 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
81Lack 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.
82Lack 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
83Lack 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
84Problems 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
85Lack 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
86Tracking Pressure Ulcers
87MDS 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
88Incorrect MDS Coding
- Improper RUG (resource utilization group)
classification - Incorrect QMs (quality measures)
- Incorrect QIs (quality indicators)
89Care Planning
- Care planning for residents should be
individualized - Risk factors should be care planned
90Documentation
- 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
91Documentation
- 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
92Documentation
- 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
93Documentation
- 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.
94RegulationsThat 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
95Pressure 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.
96Continuation of Care
- Working together for a common goal
97Continuation of Care
- Establish relationships with other providers to
improve communication and continuation of
resident care - Ex. dialysis units, home health, hospice,
hospitals
98Continuation 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
99Continuation 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
100Continuation 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
101Continuation of Care
- Home Health
- Identify at risk residents
- Provide contact list
- Provide list of educational needs
102Continuation of Care
- Community/Family Education
- Involvement of ombudsman
- Host community educational sessions
- Family Council
103Continuation 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.
104Continuation 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
105Pressure 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
106Pressure 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
107Quality 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.
108Quality 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
109Medical Directors Role
- Serve on your pressure ulcer team
- Assist in developing policies and protocols
- Assist in education of other attending physicians
at your facility
110Pressure 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.
111Pressure 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
112CMS Broadcast
- Survey Certification Online Course Delivery
System - www.cms.internetstreaming.com
- CMS Long Term Care Journal Pressure Ulcer Care
Vol. 1
113Websites
- 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)
114Websites
- 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)
115For 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