On-Time Pressure Ulcer Healing in Long Term Care (Text Version)

Slide Presentation from the AHRQ 2008 Annual Conference

On September 10, 2008, Siobhan Sharkey, M.B.A., made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (1.4 MB; Plugin Software Help).

Slide 1

On-Time Pressure Ulcer (PrU) Healing in Long Term Care

• Track 4: Patient Safety—Improving Quality of Care in Nursing Homes and
  Long-Term Care Settings

• September 10, 2008

• Presented by
  Siobhan Sharkey, M.B.A.

Slide 2

On-Time PrU Healing Objectives

1. Develop standardized pressure ulcer assessment documentation.
2. Develop new reports to support clinical decision making related to pressure ulcer treatment & heal days.
3. Translate data elements and clinical reports to Health Information Technology (IT) requirements.
4. Analyze data to determine treatments that are associated with better outcomes.

Slide 3

Participants

• High risk PrU quality measure >8%
• Total of 25 skilled nursing facilities

Slide 4

Background

Pressure ulcer healing-a measure of quality:

• Centers for Medicare and Medicaid Services' (CMS) ultimate goal—use pressure ulcer healing rates as a publicly reported measure of nursing home quality.
• Debate over how to define 'healing.'
  • Current definition in Minimum Data Set (MDS) 2.0 is reduction of ulcer stage.
  • 'Down-coding'; stage as the measure of pressure ulcer improvement/healing has been shown to be inadequate (Miller, 1994; Berlowitz et al, 1997).
  • CMS plans to include a revised measure of pressure ulcer healing in MDS 3.0.

Slide 5

Background

No easily accessible decision support tools.

• No standardized set of data elements to document weekly skin assessments and treatments.
• No standardized measure of healing.
  • Pressure Ulcer Scale for Healing (PUSH) tool is promoted to measure healing.
  • Research suggests that area (length x width) is a more realistic and feasible measure.
• Existing decision support tools consume large amounts of staff time AND do not assist wound nurses and front-line clinicians to monitor resident and pressure ulcer status and provide treatment based on best practice.

Slide 6

Major Tasks

1. Define standardize data elements related to wound and skin assessment and PrU treatments.
2. Trial by actual users. Develop prototype documentation forms for wound nurse.
3. Define clinical decision making reports. Design, test, and refine reports for clinical decision making related to PrU healing.
4. Establish functional requirements for Health IT.
5. Collaborate with caregivers to implement new processes of care: documentation, use of clinical decision making reports.

Slide 7

Standardized Data Elements: Wound Assessment

• Ulcer Dimensions
• Wound Edges
• Undermining
• Tunneling
• Necrotic Tissue Type
• Necrotic Tissue Amount
• Drainage/ Exudate Type
• Drainage/ Exudate Amount
• Peri Wound Area
• Peri Wound Edema
• Peri Wound Induration
• Granulation
• Epithelialization
• Pain
• Treatments
• Adjunctive Therapies
• Interventions
• Consultation
• Follow up Ulcer Status
• Current Visualization Ulcer Stage
• Resident Disposition

Slide 8

Wound Assessment: Ulcer Information

This slide is an image of a Wound Assessment: Ulcer Information form.

Slide 9

PrU Healing Reports Initial Definition

1. New and Existing Pressure Ulcer Report. Displays list of residents with new and existing ulcers that are being treated.
2. Stagnant or Worsening Ulcers Report. Displays list of residents with ulcers that have either not improved or worsened during previous 14 days.
3. Pressure Ulcer Quality Indicator (QI) Monitoring Report. Tracks pressure ulcer statistics by ulcer stage and occurrence by nursing station; tracks ulcers >30 days.
4. Detailed Report of Pressure Ulcer Wound Assessment and Treatment Information. Report displays longitudinal view over time (4 weeks) by resident for ulcers >30 days.

Slide 10

Defining Clinical Reports Example: QI Monitor

What questions will the report answer for clinicians?
For example:

• How many pressure ulcers were treated this month on nursing Unit A? Unit B? Unit C? Unit D?
• How many ulcers were Stage I? Stage II? Stage III? Stage IV? Unstageable?
• How many ulcers healed?
• How many ulcers developed in-house?
• How many ulcers were treated for >20 days?
• Which nursing unit has the most ulcers of 30 day or longer duration?

Slide 11

Defining Clinical Reports: Example Stagnant Ulcer Report

Gather input from multiple facilities and translate into Health IT requirements. For example:

• Purpose statement:
  • Provide information on ulcers that remain unhealed >20 days: potential reasons for delayed healing, total number of treatments for each ulcer, if the treatment has not changed in 14 days, etc.
• Information from users detailed into Health IT requirements:
  • Display list of residents with pressure ulcers treated for more than 20 days and
    • i) Ulcer surface area is unimproved for two consecutive wound assessments, or
    • ii) Ulcer has worsened since last assessment.
  • Clinical information is captured by 2 sources: i) certified nurse assistant (CNA) daily documentation ii) nurse documentation of wound assessment

Slide 12

On-Time PrU Healing

• Information Technology:
  • Access timely information

Slide includes flow chart connecting images and descriptive captions.

• On-Time
• Step 1:
  • Standardized Wound Assessment documentation:
    • Consolidate documentation
• Step 2:
  • Healing Reports:
    • Monitor progress
    • Identify residents for review
• Step 3:
  • QI Team:
    • Front-line team members use reports in daily work

Slide 13

Facility Implementation Steps

Slide includes images of American Society of Anesthesiologists Web page. Red arrows point from alert image on Web site to the Food and Drug Administration (FDA) data summary.

• Implement standardized assessment facility-wide
• Confirm in-service strategy
• Confirm completeness and accuracy: participate in documentation audit with clinical expert
• Coordinate with project facilitators to confirm Health IT vendor meeting requirements
• Engage multiple disciplines, including rehab, dieticians, quality improvement team
• Establish plan to use reports: link with workflow

Slide 14

Feedback on Documentation Completeness and Accuracy

• Missing area:
  • Incomplete due to hospitalization, resident refusal
• Stage II and 100% wound covered (epithelialization):
  • The nurses are documenting Stg II and 100% covered for intact blister.
• Unstageable & no necrotic tissue:
  • The nurses are documenting this when deep tissue injury (DTI) is suspected.
• Healed or closed?
  • Several facility policies specify that Stage III and IV ulcers are documented as closed until nurse determines completely healed (2-8 weeks after closed).

Slide 15

Engage Clinicians Preliminary Feedback

• Ulcers in database as of August, 2008:
• Total of 538 ulcers

Slide 16

Engage Clinicians Preliminary Feedback

• How does % healed vary across facilities? Why?
• Bar Graph, Scale 0% to 100%—% Healed Initial Stage II Ulcers
  • A—68%
  • B—85%
  • C—62%
  • D—78%
  • E—58%
• Data: 5 facilities with more than 30 initial stage II ulcers

Slide 17

Use of Reports Linked to Wound Management Workflow

• Who is responsible for wound assessments, measurements, and treatment plan?
• Bar Graph, Scale 0% to 100%—Facility Survey Responses (n=21)
  • Nurses on each unit—42%
  • One person dedicated—58%

Slide 18

Use of Reports Linked to Wound Management Workflow

• Do you have a dedicated wound team?
• Bar Graph, Scale 0% to 100%—Facility Survey Responses (n=21)
  • No—38%
  • Yes—62%

Slide 19

Next Steps

• Establish plan to use reports:
  • Link reports with existing and new processes
• Engage multiple disciplines, including rehab, dieticians, quality improvement team