8th 9th SOW Transition PowerPoint

1
Skin Care Fair
Jennifer Wieckowski, MSGManager, Nursing
Home Health Services Advisory Group
2
HSAG of California?The Medicare Quality
Improvement Organization (QIO) for California

• The Centers for Medicare Medicaid Services
  (CMS) issues 53 QIO contracts (one for each
  state, D.C., Puerto Rico, and the U.S. Virgin
  Islands)
• Health Services Holdings, Inc. (HSH)?HSAG of
  Californias parent company?holds QIO contracts
  in Arizona, California, and Florida
• Three-year QIO contracts are called Scopes of
  Work (SoWs)?currently in the 9SoW
• August 2008 through July 2011

3
HSAG of Californias Targeted Counties

• 62 Hospitals
• 61 Nursing Homes
• Fresno
• Kern
• Los Angeles
• Orange
• Riverside
• Sacramento
• San Bernardino
• San Diego

4
Part of the 9SoW Vision

• Help hospitals and nursing homesreduce the
  incidence of PrUs.
• PrUs?HOT TOPIC

5
Just to ReviewA Pressure Ulcer is

• Localized injury to the skin and/or underlying
  tissue
• Usually over bony prominences
• Result of pressure, or pressure in combination
  with shear and/or friction.
• So if theres no pressure it isnt a pressure
  ulcer.

5
6
Californias Nursing Home Rankingfor PrUs
7
Fast Facts

• The cost of treating one full-thickness ulcer is
  estimated at 70,000.
• Fifty-four percent of pressure ulcers occur in
  persons 70?89 years of age.
• New regulations and policy changes provide
  external motivation to improve pressure ulcer
  care.
• Quality of life drastically decreases with the
  development of a pressure ulcer.

8
Presentation Objectives

• Identify at-risk pressure points of the body
• Identify common prevention interventions linked
  to the Braden Scale for Predicting PrU Risk
• The importance of hydrating skin
• How to handle fragile skin
• Importance of nutrition
• Review of pressure ulcer staging

9
The Braden Scale Score 6-23
Score of 18 or below indicates riskScore of 10
or below indicates HIGH risk
Mobility
Friction and Sheer
Nutrition
Moisture
Activity
Sensory Perception
10
The Braden Scale Assessment
11
Usual Pressure Ulcer Locations

• Over Bony Prominences
• Occipital
• Ears
• Scapula
• Spinous Processes
• Shoulder
• Elbow
• Iliac Crest
• Sacrum/Coccyx
• Ischial Tuberosity
• Trochanter
• Knee
• Malleolus
• Heel
• Toes

12
Other Common Pressure Ulcer Locations
13
Oh,My Precious Epidermis
Skin the largest organ of the body
14
The Barren Desert Friction Shear
15
The Barren Dessert Example

• Onion elders fragile skin
• Sock bed linen
• Who wants to be the first volunteer?

16
The Barren Dessert Example

• How does applying lotion
• change the results seen
• on the onions skin?

17
The Daily Post

• Protect Dry Skin which can lead to friction
  injuries and skin tears
• Use moisturizers frequently and as often as
  necessary
• Always be on the look-out for skin changes
• Avoid vigorous massage over bony prominences and
  reddened areas.

18
Fragile Handle with CareFriction Shear
19
Who has a tender touch?

• Tomato fragile skin of elderly resident
• Tape band-aid or dressing
• Challenge remove the tape without tearing the
  skin

20
The Daily Post

• Be cautious when changing incontinent products,
  bandages, or even clothes
• Your elders skin is very fragile and can tear
  easily
• Residents can wear long sleeves and pants to add
  a layer of protection.

21
The Barrier ReefMoisture Exercise
22

• Place hands in water.

23
While the hands are soaking.

• What do your hands look like
• after you wash dishes or
• soak in a bath for a long time?

• Moisture from incontinence irritates the skin and
  contributes to pressure ulcers.
• Maintain residents clean and dry after
  incontinent episodes.

24

• What do you expect the
• hands will look like?

25
Barrier Reef ExerciseSee the water beading up on
right hand?
26
The Daily Post

• Moisture barriers can be the first line of
  defense for your resident to stop a pressure
  ulcer before it develops
• Barrier creams and ointments only work if they
  are applied, and applied correctly
• Cleanse skin at the time of soiling.
• Select under pads/briefs that are absorbent and
  provide quick drying surface for the skin.
• Analogy wax application on a car repels water
  when it rains and protects the car surface

27
Youre Tearing Me ApartFriction Shear
28
Friction Shear

• Who is the wild one in the group?
• Wax paper fragile skin
• Wall bed linen

29
The Daily Post

• Simple movements, such as turning or lifting, can
  create friction and shearing, which can injure
  skin.
• How can you reposition residents to reduce
  friction?

30
Ideas to Reduce Friction

• Use lifting devices and draw sheets to lift
  rather than drag residents.
• Keep head of bed at, or below, 30 degrees to
  prevent sliding and shear injuries.
• Use devices, such as pillows and cushions, to
  keep bony prominences from direct contact.
• Reposition bed bound patients every two hours.
• Reposition chair bound patients every one hour.
• Keep in mind that tissue tolerance is unique to
  each patient.

31
Treasure Hunt

• Nutrition

32
Treasure Huntthe picture on the right is view
from glasses with petroleum
Seeing through the residents eyes
33
The Daily Post

• Physical limitations can be a factor in poor
  nutritional intake.
• Assist patients with eating as necessary.
• Understand how residents may feel about their
  limitations.
• Notify the nurse if there is a decline or change
  in a patients eating habits.

34
The Princess and the Pea
35
Is There a Princess in the Chair?

• What can be done to wheelchairs and beds
• to reduce pressure and make the
• resident more comfortable?

36
The Daily Post

• Use support surfaces on beds and chairs to reduce
  pressure.
• Use pillows or devices to raise heels off the
  bed.
• Make sure your support surface is not worn out
  and needing replacement.

37
Dorothys Shoes
Pressure and Blisters and Objects Oh MY!
38
The Daily Post

• Limited sensory perception, the ability to sense
  and react to pressure, is a risk factor for
  pressure ulcers.
• Always be on the lookout for anything that could
  create pressure on skin, and dont forget to
  check feet.
• Diabetics can lose the sensation in their feet
  and may not feel pressure injuries to feet.
• Make sure residents shoes and slippers fit
  properly, and are not worn out.

39
Mom, Shes Squeezin Me!
40
The Daily Post

• Tissue damage can occur within a short period of
  time with high-intensity pressure.
• Actions that minimize pressure, such as using
  pillows and wedges between bony prominences, will
  help prevent pressure ulcers.

41
The Braden Scale Score 6-23
Score of 18 or below indicates riskScore of 10
or below indicates HIGH risk
Mobility
Friction and Sheer
Nutrition
Moisture
Activity
Sensory Perception
42
The Braden Scale Assessment
43
Terrors of the Deep
44
Terrors of the Deep
Stage 1
Stage 2
Stage 3
Stage 4
45
Stage I Pressure Ulcer

• Defined area of persistent redness (does not
  blanche) in lightly pigmented skin
• May appear with persistent red, blue, or purple
  hues in persons with darker skin tones
• No open area

• Compared to surrounding skin, ulcer may also be
• Warmer or cooler
• Firm or boggy
• Painful or itchy

45
46
Stage II Pressure Ulcer

• Partial thickness skin loss involving epidermis,
  dermis or both.

• Presents as a shiny or dry shallow open ulcer
  with a red pink wound bed, without slough or
  bruising.

• May also present as an intact or open/ruptured
  serum-filled blister. Bruising indicates
  suspected deep tissue injury

46
47
Stage III Pressure Ulcer

• Full thickness skin loss (epidermis dermis
  missing)
• Deep crater with damage or necrosis of
  subcutaneous tissue
• Bone, tendon, muscle are not exposed

• May extend down to but not through underlying
  fascia
• Slough may be present but doesnt obscure depth
  of tissue loss.
• Depth of ulcer varies by anatomical location,
  e.g. bridge of the nose, ear, occiput and
  malleolus will be very shallow stage IIIs

47
48
Stage III
49
Stage IV Pressure Ulcer

• Full thickness skin loss with extensive
  destruction, tissue necrosis, or damage to
  muscle, bone or supporting structures.
• Undermining and sinus tracts (tunnels) may be
  associated with Stage IV ulcers.

• Wound is deep
• Visible or palpable bone
• Undermining and tunneling
• May or may not have exposed tendon, slough or
  eschar
• Do not label ulcers with necrotic tissues (eschar
  or slough) as Stage IV, label them as unstageable

49
50
Stage IV
51
The Daily Post

• Stage IV Pressure sores take the longest to heal.
• In some patients, Stage IV can develop in a
  matter of hours for example, if left on the
  wrong surface too long.

52
Suspected Deep Tissue Injury

• Pressure related wound that begins in subdermal
  tissue
• Initially appears purple, maroon or blue on
  intact skin or blood-filled blister due to damage
  of underlying soft tissue from pressure and/or
  shear.
• Tissue may be painful, firm, mushy, boggy, warmer
  or cooler
• Evolution may include a thin blister over a dark
  wound bed
• May become covered by thin eschar

• May rapidly expose layers of tissue even with
  optimal treatment
• Do not stage as stage I
• Consult with physician or DON to get correct MDS
  staging

52
53
SuspectedDeep Tissue Injury

• Evolution may include a thin blister over a dark
  wound bed. The wound may further evolve and
  become covered by thin eschar. Evolution may be
  rapid exposing additional layers of tissue even
  with optimal treatment.

54
Unstageable Pressure Ulcer

• Full thickness tissue loss
• Base of ulcer covered by slough (yellow, tan,
  gray, green or brown) and/or eschar (tan, brown
  or black) in the wound bed
• True depth, and therefore stage, cannot be
  determined.
• Stable (dry, adherent, intact without erythema or
  fluctuance) eschar on the heels serves as "the
  body's natural (biological) cover" and should not
  be removed.
• On MDS, code as stage IV

54
55
Interventions to Prevent Breakdown

• Braden or Norton Risk Assessment
• Reposition, increase mobility, manage moisture,
  nutrition, pressure reduction/relief devices.
• Low airloss or other mattresses do not
  substitute for turning schedules!
• All eyes open multidisciplinary approach
• Involve all levels of staff, the resident
  family
• Relentless monitoring of the skin
• Turning and fluids q 2 hours
• Floating heels on pillow, heel protectors
• Any in-house pressure ulcer undergoes a mini
  root cause analysis to determine preventability

56
The truth of the matter is that you always know
the right thing to do. The hard part is doing
it. Norman Schwarzkopf
56
57
Speed Limit Example

• Who always drives the 65mph speed limit?
• Who drives 65 or less?
• Who drives 65-74?
• Who drives 75?

58
Room for Improvement in Healthcare

• We know 65 is the speed limit, but we recklessly
  disregard the rule because we know 65-74 is still
  safe.
• In healthcare, providers rarely do things
  perfectly. They work mid-range outside of
  perfection.

59
Why Do Errors OccurSome Obstacles

• Workload fluctuations
• Interruptions
• Fatigue
• Multi-tasking
• Failure to follow up
• Poor handoffs
• Ineffective communication
• Not following protocol

• Excessive professional courtesy
• Halo effect
• Passenger syndrome
• Hidden agenda
• High-risk phase
• Strength of an idea
• Task (target) fixation

60
Communication
61
The Joint Commission
Targets for Teamwork
62
Communication Challenges

• Language barrier
• Distractions
• Physical proximity
• Personalities
• Workload
• Varying communication styles
• Conflict
• Lack of information verification
• Shift change

GreatOpportunity for Quality and Safety
63
Teamwork Is All Around Us
64
Why Teamwork?

• Reduce clinical errors
• Improve resident outcomes
• Improve process outcomes
• Increase resident/family satisfaction
• Increase staff satisfaction
• Reduce malpractice claims

65
Communication
Assumptions Fatigue Distractions HIPAA
66
Check-Back is
67
Handoff

• The transfer of information (along with authority
  and responsibility) during transitions in care
  across the continuum to include an opportunity
  to ask questions, clarify, and confirm

68
Brief
Clear
Timely
69
This may be the end of our session, but this is
the beginning of your journey to better skin care.

This material was produced by Louisiana Health
Care Review, Inc. (LHCR), the Medicare Quality
Improvement Organization for Louisiana, 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.
LA9SoW2B109-N2024
70
Helpful Web Sites

• Quality Improvement Tools
• http//www.qualitynet.org
• Health Services Advisory Group (HSAG)
• http//www.hsag.com
• National Pressure Ulcer Advisory Panel (NPUAP)
• http//www.npuap.org

71
Questions?
72
Contact Information

• Jennifer Wieckowski
• jwieckowski_at_hsag.com
• Cell 818-427-4378
• Phone [phone]
• Fax [phone]

73
References

• National Pressure Ulcer Advisory Panel (NPUAP)
  http//www.npuap.org
• PCOC YRMC http//www.yrmc.org/education/pressureul
  cer/pressureulcer.pdf
• Reddy M, Gill SS, Rochon PA. JAMA 2006 296
  974-984 (slide 9)
• The FACES scale may be reproduced for
  clinical/research use as it appears in the
  following publications
• Hockenberry MJ, Wilson D Wongs Nursing Care of
  Infants and Children, ed 8, St. Louis, 2007,
  Mosby.
• Hockenberry MJ, Wilson D Wongs Essentials of
  Pediatric Nursing, ed 8, St. Louis, 2005, Mosby.
• Wilson D, Hockenberry MJ Wongs Clinical Manual
  of Pediatric Nursing, ed 7, St. Louis, 2008,
  Mosby.
• The FLACC A behavioral scale for scoring
  postoperative pain in young children, by S Merkel
  and others, 1997, Pediatr Nurse 23(3), p.
  293-297.

74
Over 1 million drug-related injuries occur every
year in health care settings. The Institute of
Medicine estimates that at least a quarter of
these injuries are preventable. To find out how
to prevent medication errors, go to
http//www.hsag.com/ca_drugsafety/.
www.hsag.com This material was prepared by Health
Services Advisory Group Inc., the Medicare
Quality Improvement Organization for California,
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. Publication No. CA-9SOW-XC-022109-01