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The Continuing Challenge of Preventing Pressure Ulcers
The Joint Commission Journal on Quality and Patient Safety Performance Improvement
The Continuing Challenge of Preventing Pressure Ulcers Janice M. Beitz, Ph.D., R.N., C.S., C.N.O.R., C.W.O.C.N., C.R.N.P., M.A.P.W.C.A.
P
ressure ulcers (PUs) represent a major failure in securing high-quality care and patient safety. They are considered such a serious and complex health care problem that Healthy People 20101 and Healthy People 20202 have included them as an area in need of improvement. Multiple factors are contributing to the urgency with which PU prevention is being addressed. Despite major programs and initiatives on prevention, the incidence and prevalence of PUs have increased substantially (by nearly 80%) in hospitalized patients in the United States in recent decades.3 Concomitantly, American society is aging, and its members are increasingly affected by chronic illnesses. Simply stated, persons who are at greatest risk for pressure ulceration are those who are elderly with multiple co-morbidities.4,5 PUs can generate significant complications, including infection, septicemia, osteomyelitis, pain, amputation and even fatality.4 A more pragmatic issue is financial viability for health care organizations. As of October 1, 2008, the Centers for Medicare & Medicaid Services (CMS) altered reimbursement for care of PUs in acute care settings. CMS now reimburses care at appropriate DRG (diagnosis-related group) levels for Stage III and Stage IV PUs only if they are present on admission.6 If they are undocumented or hospital-acquired, the facility is responsible for the costs. The human factors model focuses on designing systems to ensure safety with the involved people (patients, health care personnel, families) at the center of focus.7 The human factors principles for patient safety are as follows7: ■ Designing for standardization and simplicity ■ Knowing your users ■ Using participatory design-in safety ■ Understanding when and why things go wrong ■ Making it easy for staff to do the right thing ■ Procuring for safety ■ Understanding team work ■ Thinking about how it all fits together ■ Managing change In a recent issue of The Joint Commission Journal on Quality and Patient Safety, Ayello,8 Dahlstrom et al.,9 and Vose et al.10 addressed the challenge of identifying and documenting PUs on
June 2011
admission.6 In the current issue, two articles contribute to an understanding of the challenge of preventing PUs.11,12 Like the earlier articles,8–10 they make a strong case for a multifaceted systems approach. Jankowski and Nadzam11 report on a translational research study in which they scrutinized the implementation of PU prevention strategies at the bedside in four major hospitals—two tertiary-level and two communitytype hospitals—in the eastern United States. The article describes how the facilities, led by project leaders and team members, have invited participation of professional staff; educated staff; and used bundles, protocols, and order sets to standardize care processes. Yet despite all the good work, gaps and barriers in implementation were evident, some of which, from a human factors perspective, were alarming. Three of the four hospitals did not include nursing assistants in the PU teams and did not educate them in an ongoing manner. In addition, patients and families were not routinely educated about wound self-care; risk assessment scores were not communicated among nursing staff; physicians were not involved in their patients’ PU care; and concerned staff had difficulty in obtaining appropriate equipment and supplies, making it harder to provide optimal care. Staff also reported that they did not consider themselves adequately educated on wound care and PU prevention, similar to findings in other recent studies.13,14 Most importantly, feedback about outcomes was limited, so that quality improvement evaluations of bedside practice opportunities were lost. Jankowski and Nadzam provide recommendations for solutions to the identified barriers and gaps. Not surprisingly, many of the recommendations, such as “Observe turning practices to gain specific information about problems with maintaining turning schedules and explore with staff why adherence may be problematic,” and “Avoid creating complicated gatekeeper systems that could cause delays in ordering necessary equipment,” reflect human factors principles.7 Soban et al. scrutinized PU prevention in acute care by using an entirely different process—that is, a systematic review of the literature.12 They attempted to meet three objectives—to describe the kinds of PU intervention strategies used, describe the types of process and outcome measures reported, and examine
Volume 37 Number 6
Copyright 2011 © The Joint Commission
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The Joint Commission Journal on Quality and Patient Safety the interventions’ effects on outcomes. They found that the PU prevention strategies reported in the final pool of 39 studies (in 38 papers) generally incorporated multifaceted approaches, including education and quality improvement strategies. Implemented changes also included documentation, reminders, and the use of consultants. As reported by Soban and colleagues, the findings suggested that nearly all the projects had a positive effect on PU prevention. However, they note major design issues, creating a generally low general level of evidence. The authors called for future work to address gaps in the understanding of how to achieve improved outcomes and of the role of local conditions in the success or failure of specific intervention strategies. In my own experience as a staff educator, clinical nurse specialist, nurse practitioner, and wound, ostomy and continence nursing clinician, involving patient care assistants and other unlicensed staff is vital to successful wound care and skin protection. The idea that “one and done” for education about wound care is simply erroneous. Quality education must be ongoing, thorough, repeated, and incorporated into caregivers’ thought processes. Indeed, recent Institute of Medicine reports15,16 call for improvement in nursing education and how nursing staff are used in the acute care setting. It is important to track patient care outcomes regarding skin and wound care, especially on “troubled” units, and inform staff about successes and failures. A related challenge is to engage physicians in documenting PUs, as stated elsewhere,8–10 and preventing PUs. The stakes are high in terms of patient safety and possible financial and even legal consequences for PUs to be documented by physicians on admission6 and for proof of care during hospitalization to be clearly evident. An undercurrent in the endeavor of preventing PUs is the issue of expert nurses at the bedside. Although the current economy may be slowing the retirement exit of registered nurses,17 the exodus will occur eventually. A more expert nursing workforce is associated with a decrease in hospital-acquired PUs.18 In addition to incorporating the pragmatic approaches suggested by Jankowski and Nadzam and the best practices identified by Soban et al., hospitals and health care systems will need to retain experienced aging nurses to promote quality and patient safety.19 This retention issue will be an ongoing challenge across the spectrum of care for years to come. In conclusion, the financial and human costs of wound development and care are substantial and will escalate for the foreseeable future unless evidence-based approaches are enacted at the bedside using systems-oriented strategies. J
244
June 2011
Janice M. Beitz, Ph.D., R.N., C.S., C.N.O.R., C.W.O.C.N., C.R.N.P., M.A.P.W.C.A., is Professor of Nursing and Director of the Wound Ostomy Continence Nursing Education Program, La Salle University, Philadelphia, and a wound, ostomy and continence nursing consultant. Please address correspondence to Janice M. Beitz, [email protected].
References 1. U.S. Department of Health & Human Services: Healthy People 2010. http://www.healthypeople.gov/2010/ (last accessed Apr. 20, 2011). 2. U.S. Department of Health & Human Services: Healthy People 2020. http://www.healthypeople.gov/2020/default.aspx (last accessed Apr. 20, 2011). 3. Agency for Healthcare Research and Quality: Pressure Ulcers Increasing Among Hospital Patients. Dec. 3, 2008 (last accessed Apr. 2011). http://www.ahrq.gov/news/nn/nn120308.htm 4. Myers B.: Wound Management Principles and Practice, 2nd ed. Upper Saddle River, NJ: Pearson Education, 2008. 5. Popovich K., Tohm P., Hord T.: Skin and wound care excellence: Integrating best-practice evidence. Healthc Q 13:42-46, Sep. 2010. 6. Centers for Medicare & Medicaid Services (CMS): Hospital-Acquired Conditions (Present on Admission Indicators). https://www.cms.gov/hospitalacqcond/ (last accessed Apr. 20, 2011). 7. Norris B.: Human factors and safe patient care. J Nurs Manage 17:203–211, Mar. 2009. 8. Ayello E.A.: Changing systems, changing cultures: Reducing pressure ulcers in hospitals [editorial]. Jt Comm J Qual Patient Saf 37:120–122, Mar. 2011. 9. Dahlstrom M., et al.: Improving identification and documentation of pressure ulcers at an urban academic hospital. Jt Comm J Qual Patient Saf 37:123–130, Mar. 2011. 10. Vose A., et al.: Establishing a comprehensive networkwide pressure ulcer identification process. Jt Comm J Qual Patient Saf 37:131–137, Mar. 2011. 11. Jankowski I.M., Nadzam D.M.: Identifying gaps, barriers, and solutions in implementing pressure ulcer prevention programs. Jt Comm J Qual Patient Saf 37:253–264, Jun. 2011. 12. Soban L.M., et al.: Hospital-based nurse-focused interventions for pressure ulcer prevention. Jt Comm J Qual Patient Saf 37:245–252, Jun. 2011. 13. Beitz J.M., Van Rijswijk L.: A cross-sectional study to validate wound care algorithms for use by registered nurses. Ostomy Wound Manage 56:46-59, Apr. 1, 2010. 14. Beitz J.M., Van Rijswijk, L.: Development and validation of an online interactive, multimedia wound care algorithms program: Outcomes of a pilot study (unpublished manuscript). New York City, Dec. 2010. 15. Institute of Medicine: A Summary of the October 2009 Forum on the Future of Nursing: Acute Care—Workshop Summary. Washington, DC: National Academies Press, 2010. 16. Institute of Medicine: The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press, 2010. 17. Dunton N., et al.: The relationship of nursing workforce characteristics to patient outcomes. Online Journal of Issues in Nursing 12, Sep 2007. http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPe riodicals/OJIN/TableofContents/Volume122007/No3Sept07/NursingWorkforceCharacteristics.aspx (last accessed Apr. 20, 2011). 18. Armstrong D.G., et al.: New opportunities to improve pressure ulcer prevention and treatment: implications of the CMS inpatient hospital care Present on Admission (POA) indicators/hospital-acquired conditions (HAC) policy. A consensus paper from the International Expert Wound Care Advisory Panel. J Wound Ostomy Continence Nurs 35:485–492, Sep.–Oct. 2008. 19. Hill K.S.: Improving quality and patient safety by retaining nursing expertise. Online Journal of Issues in Nursing 15, Sep. 2010. http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ ANAPeriodicals/OJIN/TableofContents/Vol152010/No3-Sept-2010/ Articles-Previously-Topic/Improving-Quality-and-Patient-Safety-.aspx (last accessed Apr. 20, 2011)
Volume 37 Number 6
Copyright 2011 © The Joint Commission
The Continuing Challenge of Preventing Pressure Ulcers Janice M. Beitz, Ph.D., R.N., C.S., C.N.O.R., C.W.O.C.N., C.R.N.P., M.A.P.W.C.A.
P
ressure ulcers (PUs) represent a major failure in securing high-quality care and patient safety. They are considered such a serious and complex health care problem that Healthy People 20101 and Healthy People 20202 have included them as an area in need of improvement. Multiple factors are contributing to the urgency with which PU prevention is being addressed. Despite major programs and initiatives on prevention, the incidence and prevalence of PUs have increased substantially (by nearly 80%) in hospitalized patients in the United States in recent decades.3 Concomitantly, American society is aging, and its members are increasingly affected by chronic illnesses. Simply stated, persons who are at greatest risk for pressure ulceration are those who are elderly with multiple co-morbidities.4,5 PUs can generate significant complications, including infection, septicemia, osteomyelitis, pain, amputation and even fatality.4 A more pragmatic issue is financial viability for health care organizations. As of October 1, 2008, the Centers for Medicare & Medicaid Services (CMS) altered reimbursement for care of PUs in acute care settings. CMS now reimburses care at appropriate DRG (diagnosis-related group) levels for Stage III and Stage IV PUs only if they are present on admission.6 If they are undocumented or hospital-acquired, the facility is responsible for the costs. The human factors model focuses on designing systems to ensure safety with the involved people (patients, health care personnel, families) at the center of focus.7 The human factors principles for patient safety are as follows7: ■ Designing for standardization and simplicity ■ Knowing your users ■ Using participatory design-in safety ■ Understanding when and why things go wrong ■ Making it easy for staff to do the right thing ■ Procuring for safety ■ Understanding team work ■ Thinking about how it all fits together ■ Managing change In a recent issue of The Joint Commission Journal on Quality and Patient Safety, Ayello,8 Dahlstrom et al.,9 and Vose et al.10 addressed the challenge of identifying and documenting PUs on
June 2011
admission.6 In the current issue, two articles contribute to an understanding of the challenge of preventing PUs.11,12 Like the earlier articles,8–10 they make a strong case for a multifaceted systems approach. Jankowski and Nadzam11 report on a translational research study in which they scrutinized the implementation of PU prevention strategies at the bedside in four major hospitals—two tertiary-level and two communitytype hospitals—in the eastern United States. The article describes how the facilities, led by project leaders and team members, have invited participation of professional staff; educated staff; and used bundles, protocols, and order sets to standardize care processes. Yet despite all the good work, gaps and barriers in implementation were evident, some of which, from a human factors perspective, were alarming. Three of the four hospitals did not include nursing assistants in the PU teams and did not educate them in an ongoing manner. In addition, patients and families were not routinely educated about wound self-care; risk assessment scores were not communicated among nursing staff; physicians were not involved in their patients’ PU care; and concerned staff had difficulty in obtaining appropriate equipment and supplies, making it harder to provide optimal care. Staff also reported that they did not consider themselves adequately educated on wound care and PU prevention, similar to findings in other recent studies.13,14 Most importantly, feedback about outcomes was limited, so that quality improvement evaluations of bedside practice opportunities were lost. Jankowski and Nadzam provide recommendations for solutions to the identified barriers and gaps. Not surprisingly, many of the recommendations, such as “Observe turning practices to gain specific information about problems with maintaining turning schedules and explore with staff why adherence may be problematic,” and “Avoid creating complicated gatekeeper systems that could cause delays in ordering necessary equipment,” reflect human factors principles.7 Soban et al. scrutinized PU prevention in acute care by using an entirely different process—that is, a systematic review of the literature.12 They attempted to meet three objectives—to describe the kinds of PU intervention strategies used, describe the types of process and outcome measures reported, and examine
Volume 37 Number 6
Copyright 2011 © The Joint Commission
243
The Joint Commission Journal on Quality and Patient Safety the interventions’ effects on outcomes. They found that the PU prevention strategies reported in the final pool of 39 studies (in 38 papers) generally incorporated multifaceted approaches, including education and quality improvement strategies. Implemented changes also included documentation, reminders, and the use of consultants. As reported by Soban and colleagues, the findings suggested that nearly all the projects had a positive effect on PU prevention. However, they note major design issues, creating a generally low general level of evidence. The authors called for future work to address gaps in the understanding of how to achieve improved outcomes and of the role of local conditions in the success or failure of specific intervention strategies. In my own experience as a staff educator, clinical nurse specialist, nurse practitioner, and wound, ostomy and continence nursing clinician, involving patient care assistants and other unlicensed staff is vital to successful wound care and skin protection. The idea that “one and done” for education about wound care is simply erroneous. Quality education must be ongoing, thorough, repeated, and incorporated into caregivers’ thought processes. Indeed, recent Institute of Medicine reports15,16 call for improvement in nursing education and how nursing staff are used in the acute care setting. It is important to track patient care outcomes regarding skin and wound care, especially on “troubled” units, and inform staff about successes and failures. A related challenge is to engage physicians in documenting PUs, as stated elsewhere,8–10 and preventing PUs. The stakes are high in terms of patient safety and possible financial and even legal consequences for PUs to be documented by physicians on admission6 and for proof of care during hospitalization to be clearly evident. An undercurrent in the endeavor of preventing PUs is the issue of expert nurses at the bedside. Although the current economy may be slowing the retirement exit of registered nurses,17 the exodus will occur eventually. A more expert nursing workforce is associated with a decrease in hospital-acquired PUs.18 In addition to incorporating the pragmatic approaches suggested by Jankowski and Nadzam and the best practices identified by Soban et al., hospitals and health care systems will need to retain experienced aging nurses to promote quality and patient safety.19 This retention issue will be an ongoing challenge across the spectrum of care for years to come. In conclusion, the financial and human costs of wound development and care are substantial and will escalate for the foreseeable future unless evidence-based approaches are enacted at the bedside using systems-oriented strategies. J
244
June 2011
Janice M. Beitz, Ph.D., R.N., C.S., C.N.O.R., C.W.O.C.N., C.R.N.P., M.A.P.W.C.A., is Professor of Nursing and Director of the Wound Ostomy Continence Nursing Education Program, La Salle University, Philadelphia, and a wound, ostomy and continence nursing consultant. Please address correspondence to Janice M. Beitz, [email protected].
References 1. U.S. Department of Health & Human Services: Healthy People 2010. http://www.healthypeople.gov/2010/ (last accessed Apr. 20, 2011). 2. U.S. Department of Health & Human Services: Healthy People 2020. http://www.healthypeople.gov/2020/default.aspx (last accessed Apr. 20, 2011). 3. Agency for Healthcare Research and Quality: Pressure Ulcers Increasing Among Hospital Patients. Dec. 3, 2008 (last accessed Apr. 2011). http://www.ahrq.gov/news/nn/nn120308.htm 4. Myers B.: Wound Management Principles and Practice, 2nd ed. Upper Saddle River, NJ: Pearson Education, 2008. 5. Popovich K., Tohm P., Hord T.: Skin and wound care excellence: Integrating best-practice evidence. Healthc Q 13:42-46, Sep. 2010. 6. Centers for Medicare & Medicaid Services (CMS): Hospital-Acquired Conditions (Present on Admission Indicators). https://www.cms.gov/hospitalacqcond/ (last accessed Apr. 20, 2011). 7. Norris B.: Human factors and safe patient care. J Nurs Manage 17:203–211, Mar. 2009. 8. Ayello E.A.: Changing systems, changing cultures: Reducing pressure ulcers in hospitals [editorial]. Jt Comm J Qual Patient Saf 37:120–122, Mar. 2011. 9. Dahlstrom M., et al.: Improving identification and documentation of pressure ulcers at an urban academic hospital. Jt Comm J Qual Patient Saf 37:123–130, Mar. 2011. 10. Vose A., et al.: Establishing a comprehensive networkwide pressure ulcer identification process. Jt Comm J Qual Patient Saf 37:131–137, Mar. 2011. 11. Jankowski I.M., Nadzam D.M.: Identifying gaps, barriers, and solutions in implementing pressure ulcer prevention programs. Jt Comm J Qual Patient Saf 37:253–264, Jun. 2011. 12. Soban L.M., et al.: Hospital-based nurse-focused interventions for pressure ulcer prevention. Jt Comm J Qual Patient Saf 37:245–252, Jun. 2011. 13. Beitz J.M., Van Rijswijk L.: A cross-sectional study to validate wound care algorithms for use by registered nurses. Ostomy Wound Manage 56:46-59, Apr. 1, 2010. 14. Beitz J.M., Van Rijswijk, L.: Development and validation of an online interactive, multimedia wound care algorithms program: Outcomes of a pilot study (unpublished manuscript). New York City, Dec. 2010. 15. Institute of Medicine: A Summary of the October 2009 Forum on the Future of Nursing: Acute Care—Workshop Summary. Washington, DC: National Academies Press, 2010. 16. Institute of Medicine: The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press, 2010. 17. Dunton N., et al.: The relationship of nursing workforce characteristics to patient outcomes. Online Journal of Issues in Nursing 12, Sep 2007. http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPe riodicals/OJIN/TableofContents/Volume122007/No3Sept07/NursingWorkforceCharacteristics.aspx (last accessed Apr. 20, 2011). 18. Armstrong D.G., et al.: New opportunities to improve pressure ulcer prevention and treatment: implications of the CMS inpatient hospital care Present on Admission (POA) indicators/hospital-acquired conditions (HAC) policy. A consensus paper from the International Expert Wound Care Advisory Panel. J Wound Ostomy Continence Nurs 35:485–492, Sep.–Oct. 2008. 19. Hill K.S.: Improving quality and patient safety by retaining nursing expertise. Online Journal of Issues in Nursing 15, Sep. 2010. http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ ANAPeriodicals/OJIN/TableofContents/Vol152010/No3-Sept-2010/ Articles-Previously-Topic/Improving-Quality-and-Patient-Safety-.aspx (last accessed Apr. 20, 2011)
Volume 37 Number 6
Copyright 2011 © The Joint Commission