On-Time Pressure Ulcer Healing Facilitator Training Implementation of the Healing Reports: Handouts
AHRQ’s Safety Program for Nursing Homes
Review of Self-Assessment Worksheet
- Script Illustrating Change Team Meeting To Discuss and Complete Self-Assessment Worksheet
- Completed Self-Assessment Worksheet
Review of the Change Team’s Process of Choosing On-Time Reports, Incorporating Them Into Huddles and Clinical Meetings, and Piloting Those Meetings
- Completed Menu of Implementation Strategies Worksheet
- Completed Communication Practices Grid From Healing Self-Assessment Worksheet
- Meeting Descriptions and Suggested Pressure Ulcer Healing Reports
- Implementation Scripted Exercise – Selecting Healing Reports and Meetings in Which To Use Them
Review of Self-Assessment Worksheet
Script Illustrating Change Team Meeting To Discuss and Complete Self-Assessment Worksheet
Program Champion: Hi, everyone, we’re here today to go over our pressure ulcer healing practices and learn how we can improve it further with On-Time. I know everyone is busy, so let’s dive into the Self-Assessment right away. The On-Time Self-Assessment is divided into four sections: Pressure Ulcer Tracking and Assessment, Pressure Ulcer Healing Practices, Investigations/Root Cause Analysis of Delayed Pressure Ulcer Healing, and Communication Practices. Let’s start with Pressure Ulcer Tracking and Assessment. We’ll begin by talking about how we currently monitor pressure ulcer healing.
Nurse Manager A: We assess pressure ulcers at admission and daily. We record onset day, stage, and surface area of each pressure ulcer during wound rounds. We calculate area by hand. We enter the numbers in the database. To see trends, we have to pull reports from different weeks. We identify who is at risk of pressure ulcer based on the Braden Scale but we don't identify risk factors that affect healing. We don't know who is not healing appropriately. I suppose if the surface area were getting bigger or stage was higher, we would consider changing treatment.
Dietitian: I think we try to discuss the residents’ nutritional status and look for changes in eating habits during wound rounds but the documentation that we need to get a complete picture of their status is sometimes not always easy to pull together. That can be really frustrating. We would like to know if there are recent changes in their nutritional status.…
Nurse Manager B: .…or if they are incontinent or less mobile.
Program Champion: How do you decide when to change the treatment? If the pressure ulcer area is not improving, could that signal a problem? Do you collect enough to know if there is a potential infection?
Nurse Manager B: It’s up to the wound nurse to decide if there is a problem but it would be better to have strict criteria for identifying pressure ulcers with healing problems.
Program Champion: Next, let’s talk about whether the number of pressure ulcers is collected for the facility at large and on the unit level and, if so, how often that information is collected.
QAA Coordinator: We collect and track unit- and facility-level pressure ulcer counts monthly.
Program Champion: Sally [QAA Coordinator], do we collect the counts by stage?
QAA Coordinator: We do; the nurse managers all collect that information at the end of each month and provide me with it. I compile the information monthly and present it quarterly to the QAA Committee. We talk about pressure ulcers monthly at the QAA meetings but the statistics that you asked about are trended and presented quarterly. The basic information is in the EMR, but we have to sum it up and put it into tables. It’s quite an effort.
Program Champion: I think that I understand you to be saying that pressure ulcer counts, including by stage, are extracted from the EMR and put into a table monthly at both the unit- and facility- level. Is that right?
QAA Coordinator: Yes, that’s right, Tom [Program Champion].
Program Champion: So the total count of pressure ulcers by stage is updated on a monthly basis? How does the EMR help?
QAA Coordinator: It gives us the residents with pressure ulcers and the stage of their ulcer but that is all.
Program Champion: If you had a report that automatically provided all the calculations and was in a format that met the needs of our team, would that save time and allow you to more meaningfully analyze the information with the QAA Committee?
QAA Coordinator: You bet it would. If the information were compiled into a report for me, it would save me time and I wouldn’t have to worry about errors in my calculations. I could use my time more effectively to analyze the information rather than gather it.
Program Champion: Next, let’s talk about the pressure ulcer healing risk assessment. Specifically, let’s talk about what is included on the assessment. Nancy [Nurse Manager A], why don’t you start us off. Please begin to review your list of what is included in the pressure ulcer healing risk assessment. If you come across a “no” answer, we’ll stop and talk about it.
Nurse Manager A: Okay. We use the Braden Scale to identify persons at risk of pressure ulcers at admission but we don’t measure these risk factors in a way that would give us changes in risk factors during their stay. And this doesn’t help us determine who is at risk for slow healing once they have an ulcer, although some of those risk factors are probably the same. Weekly we identify new pressure ulcers and their stage. As we said, at wound rounds we get the surface area but we calculate it by hand. But we don’t have a quick way to compare area and stage over time. That information is picked up by the EMR.
Program Champion: Well, then we are collecting what we need to calculate surface area (the length and width of the ulcer) on a weekly basis. What we are missing is the calculation of the surface area and a report that we can call up to see the trend over weeks. Would you find that useful?
Nurse Manager A: That sounds great. More information with no more work!
Program Champion: Nancy [Nurse Manager A], tell me about onset date and ulcer days. Does our EMR include this information?
Nurse Manager A: We don’t collect the number of days that the ulcer has been in existence in our assessment. That is what you mean by ulcer days, right?
Program Champion That is correct; ulcer days is the number of days from the date of ulcer onset through the current date. How about the onset date? Is that included on the pressure ulcer assessment?
strong>Nurse Manager A: We collect it but we have to pull it up from the EMR if we need it.
Evening Nursing Supervisor: It seems like we are missing information that is easily accessible. We need information on a weekly basis to identify how risks are changing but we can’t expect to pull the information one piece at a time. We are too busy for that.
Program Champion: It would be great to have all that information in the EMR, but we need to see it in ways that will help us make better decisions about care. It would take a lot of time to record all of this information weekly by hand. The beauty of using the On-Time assessment as part of our EMR is that information regarding the ulcer’s origin will be entered into the assessment initially and then will be automatically populated into the reports along with other important information. This will give us a better picture of the resident’s status related to the pressure ulcer all in one place and allow us to see trends.
Remind us again, Mary [DON], does the weekly pressure ulcer assessment that is done at Wound Rounds include information on undermining and tunneling, the tissue in the wound bed, and wound drainage?
DON: No, we only collect limited information—stage and surface area. It doesn’t include information about the periwound tissue. I see the need for debridement noted next here; our assessment does not include that information, either. We do include information about whether or not the resident has pain.
Program Champion: Is there anything else that is included in the pressure ulcer healing assessment that we haven’t talked about?
DON: I don’t think so.
Program Champion: Okay, before we move on to the next section of the Self-Assessment and talk about pressure ulcer healing practices, let me tell you all a bit more about the On-Time pressure ulcer assessment. I have reviewed the assessment tool and have contacted our EMR vendor to facilitate activation of the On-Time assessment in the system in conjunction with the implementation of the program. The assessment has been developed with the input of a team of clinical experts and includes elements of the Bates-Jensen Wound Assessment Tool (or BWAT). The BWAT score (which will be calculated based on assessment information that you enter into the EMR) provides the team with enough information to assess pressure ulcer healing and you will be able to identify wounds suspected of infection. Then the reports will give us information that identifies which pressure ulcers are at risk for delayed healing and risk information and treatment history to help decide how to change treatment if needed.
We have been thinking about bringing in a wound consultant who uses the PUSH tool to monitor healing but only on a monthly basis. I am not sure that is enough. It would give us a score that incorporates surface area, drainage, and tissue damage. It would help us identify suspected infections and give us a better picture of the status of the pressure ulcer.
DON: I don’t think that will be enough. The newest guidelines suggest that if the surface area doesn’t decline over a 2-week period that is a red flag. We need to pay attention to the new guidelines and be able to make care changes as soon as we have an indication of a problem. I think we need to work at consistent information on a weekly basis so that we can stay ahead of infections and healing problems.
QAA Coordinator: I remember when we formulated our policy and procedure that Dr. Schwartz, our Medical Director, had a very specific set of criteria that he wanted us to include as triggers indicating that the pressure ulcer may need to be reevaluated. I am not sure where those criteria came from.
Nurse Manager C: All of our physicians document when a resident’s pressure ulcer will likely not heal due to the resident’s condition, for instance, when the resident is terminally ill and has extremely poor nutrition. I don’t think that we consider if healing may be delayed in all of our residents with pressure ulcers and I don’t think that we have specific criteria for ulcers that are not healing in an expected timeframe.
Nurse Manager A: I agree with Josh [Nurse Manager C]. We only address those residents who we think have ulcers that will never heal due to the resident’s overall status. We don’t consider this for all residents with pressure ulcers.
Program Champion: It sounds like we have found another opportunity to enhance practices related to pressure ulcer assessment and healing practices.
Nurse Manager A: We don’t have specific guidance on pressure ulcer debridement but Curtis [Rehab Director] is trained in debridement and goes on wound rounds. He always offers his opinion on whether debridement may be needed when necrotic tissue is present.
Rehab Director: That’s right, I do. We also discuss treatments as a team during wound rounds. Our protocol includes guidance related to dressing categories based on the wound characteristics but there are often at least a few options for a resident’s pressure ulcer treatment. It’s much more than the wound characteristics that need to be considered when selecting a dressing. We also consider all that we know about the individual resident who has the pressure ulcer. It would be great to have reports about the residents’ treatments and risk factors available during wound rounds.
Nursing Assistant: The members of the team always look to us for what we know about a resident’s bowel and bladder status, mobility, and behavior when deciding on a dressing. They need to know if there is a possibility for problems like soilage or loosening of the dressing and we are able to give insights that the rest of the team may not have but we often don’t have time to verify or check the records.
Dietitian: Our protocol includes dietitian assessment whenever there is a new or worsening pressure ulcer to consider if the resident’s nutritional needs (including calories, protein, and more) are being met.
Rehab Director: We always consider if particular support surfaces are needed for pressure ulcer prevention for each resident. This is a routine part of the therapist’s screening of the resident on admission, on a quarterly basis, and with any change in condition. We also consider this for residents with healing problems when they are brought to our attention.
Nursing Assistant: We have cushions, mattresses, and other support surfaces included on the care cards that we use and we are really careful to make sure the residents all have what they need or we let the charge nurse know right away. The need to do this was stressed during the pressure ulcer prevention and healing education that we had a couple of months back.
DON: Guidance on wound cleansing, assessment for pain related to pressure ulcers, topical agents, and adjunctive treatments are also included in the protocol.
Nurse Manager C: It sounds like we have a lot of information included in our protocols but it would be worthwhile to identify a current, evidence-based guideline to review and ensure that our protocols are up to date.
Program Champion: I agree; that is definitely on our to-do list as a result of this Self-Assessment. I plan on meeting with Mary [DON] and Dr. Schwartz, our Medical Director, to discuss this further. We need to begin by determining which guideline we will use. Then I can begin to coordinate that review process.
Next, let’s move on to the third section of the Self-Assessment where there are several questions related to investigations of pressure ulcers with delayed healing. Does your facility’s team investigate delayed healing pressure ulcers according to the facility policy or guidelines?
Nurse Manager B: We do talk about residents who have pressure ulcers that are not healing or that have signs of infection but I am not sure we collect enough information about the pressure ulcer treatment history and other risk factors to determine if we consistently identify all or even the right people.
Nurse Manager C: I agree, Jane [Nurse Manager B], it’s difficult to assemble the residents’ history.
QAA Coordinator: I agree. We definitely review new or worsening pressure ulcers using a root cause framework as part of our QAA investigations. However, I don’t think that we clearly define delayed healing and therefore are not identifying all the ulcers that are not healing appropriately. It is difficult to assemble the treatment history and understand other health issues that we need to know to make adjustments to the resident’s care plan, so we probably are not doing as well as we could. Without that information, it’s difficult to find system problems or even identify care problems or where staff need to better follow through.
Program Champion: Based on the input of the nurse managers and Sally [QAA Coordinator], it seems that there is the potential to make some significant enhancements related to investigations and root cause analysis of pressure ulcers with delayed healing. What I am hearing is that there are investigations of new and worsening pressure ulcers as part of QAA but ulcers with delayed healing are not clearly defined, and they may not be investigated in a structured way. I am not sure we are finding all the ulcers that have signs of infection, either. Do the rest of you agree with the Nurse Managers and Sally [QAA Coordinator]?
Team: Yes.
DON: I think we have the next item on our to-do list. We need to better identify pressure ulcers with delayed healing and determine how we will investigate them.
Program Champion: As we move through the healing reports together, you will see how On-Time is going to enhance your team’s ability to identify and investigate pressure ulcers with delayed healing.
DON: That sounds great. I think this brings us to the last section of the Self-Assessment: Communication Practices.
Program Champion: Correct; let’s review the different meetings in which the team discusses pressure ulcer healing. Why don’t we walk through this list of meetings included in the Self-Assessment? As I read the name of the meeting, I welcome the rest of you to comment on who chairs it, who is invited and in attendance, and the frequency of the meeting. Of course, we don’t have all the meetings that are listed. Okay, the first meeting listed is the care plan meeting. The nurse manager for each unit leads these meetings.
Nurse Manager A: Right, and who attends depends on the resident. For instance, Jamie, the Occupational Therapist, would come to the care plan meeting if a resident is on an OT program, but usually not for a resident not on a program, unless the person is a new admission. The resident or a family member is always invited and encouraged to come, in addition to the nurse manager, the primary care nursing assistant, and the dietitian. Also, a social worker and an activities staff member for the unit the resident lives on always attend care plan meetings. A care plan meeting is held for each resident upon admission, quarterly, and with a significant change in status assessment. This meeting may discuss pressure ulcer healing if there is a pressure ulcer and there has been an identified problem.
Program Champion: The next meeting on the list is the shift report or brief with the nursing assistants. This is generally with the charge nurse and nursing assistants working on a particular unit on a particular shift.
Nursing Assistant: The dietitian joins the charge nurse and nursing assistants for at least one shift report a week on each unit to discuss the nutritional and weight status of the residents on the unit. Then, once a week we meet with Curtis [Rehab Director] to talk about residents who have had falls and changes related to resident mobility. Beverly (the Director of Social Services) and Fran (the Activities Director) join us once a week as well so that we can talk about any concerns that we have about our residents related to those areas. We usually focus on residents with changes in care plans.
Program Champion: Next, report or brief with the department heads is listed. This happens at 9 a.m. on every business day. Dr. Schwartz, the Medical Director, attends this meeting on occasions when he’s available, so I think that this covers the meeting with medical staff or medical director listed as well. Mary [DON] chairs this meeting and all department heads attend, as do the nurse managers. Pressure ulcer healing rarely comes up.
Nursing Assistant: We don’t attend those meetings, but we always hear about anything pertinent to our residents that is discussed during the meeting.
Program Champion: Next on the list is the QAPI or quality improvement meeting.
QA Coordinator: We meet monthly. I chair those meetings and our entire QAA Committee attends, including everyone here plus Dr. Schwartz (our Medical Director), Tim (our Administrator), Chrissy (our Wound Nurse), Beverly (the Director of Social Services), Fran (the Activities Director), and two additional nursing assistants so that there is one nursing assistant from each of the three units. Pressure ulcers are always on the agenda; sometimes we have QAA projects related more to prevention. I am not sure we have ever focused on pressure ulcer treatments or healing.
Program Champion: Weekly skin rounds are next. I lead those rounds and am joined by Kim [Dietitian] and the nurse manager for each unit. The nursing assistant assigned to the resident being seen on rounds joins us while we see that specific resident. Physician rounds are noted next; since the nurse managers coordinate the physician rounds and join the physician on the rounds, they are in the best position to speak to this.
Nurse Manager B: Rounds for routine physician visits are scheduled on my unit on Monday and Thursday, the routine visits on Nancy’s [Nurse Manager A’s] unit occur on Tuesday and Friday, and for Josh [Nurse Manager C], the routine visits are on Wednesday and Friday. The physician or physicians making rounds on a given day also visit the other units as needed for urgent issues while they are here. On Saturday and Sunday, the weekend supervisor works with the charge nurses to contact the physicians as needed by phone.
Nurse Manager C: So it is usually the nurse manager and a physician who make rounds together but sometimes another nurse on the unit works with the physician on a given day.
Nurse Manager A: I think most of the time, it is the nurse manager who makes rounds with the physicians.
Nurse Manager B: I agree.
Program Champion: We often schedule briefs held with dietary, social services, and rehab that occur with the nursing assistants and charge nurses. Are there other briefs that we should note here? We haven’t focused on residents with pressure ulcer healing issues, but we could.
DON: I can’t think of any meetings that we missed, either.
Program Champion: Okay, but I want you to think about ways that we may improve our treatment of pressure ulcers and identify residents who are having problems with healing and what meetings would make sense to include a discussion of pressure ulcer healing.
Program Champion: I have the dates for the trainings that were included in the Self-Assessment. Nurses were trained in measuring pressure ulcers in March of this year. At the same time, they were trained in triggers that indicate a pressure ulcer may need to be reevaluated. Based on the discussion regarding delayed healing earlier in this meeting, I think we have the opportunity to enhance our practices and our training related to this issue. Every June we have a mandatory skills training fair for all nurses; documentation, including pressure ulcer risk assessment, is included in that training, so that would be the most recent training on that topic, but it did not include treatment of pressure ulcers or identifying residents who have problem with pressure ulcer healing.
To wrap up the meeting, let's quickly r-cap what we've heard today:
- Monitoring pressure ulcer healing is currently happening weekly but we do not have consistent ways of identifying problems with pressure ulcer healing.
- Preparing for wound rounds is time consuming and frustrating. Streamlining processes to prepare for rounds is a priority for the team, and we need to more easily assemble information on the resident's treatment history, nutritional status, bowel and bladder status, and ADL changes during rounds.
- Calculating pressure ulcer surface area is something that the team currently does but the EMR should help show trends. We also can improve what we assess to help us better identify probable infections. We have a protocol or procedure to guide pressure ulcer care but the team wasn't aware of which guideline, if any, they were based on.
- Practices related to determining pressure ulcers with delayed healing need to be reviewed as do the practices related to investigations and root cause analysis of those ulcers.
- We have an EMR, but it does not generate clinical reports that include information that we need to facilitate care decisionmaking or QAA. Therefore, we are spending a lot of time assembling information rather than using that time to make adjustments to resident care plans and actually providing resident care.
- We may be able to use On-Time reports to improve would rounds and we may be able to bring these reports into other meetings, huddles, or briefs to get broader input and improve our ability to treat these ulcers and prevent further deteriorations.
Does that accurately sum it up? [Team members nod.]
At a few points during our discussion, I mentioned how the On-Time reports can help us in our practices related to pressure ulcer healing. I think the On-Time reports could be very helpful in addressing the opportunities for enhancement that we identified. They can provide timely information on ulcer healing to enhance care planning. Our Facilitator will work with us to identify the reports we want to adopt and how to integrate the use of the reports into existing meetings. If we decide a new meeting would be needed to communicate the information, she will us through the processes related to creating that meeting as well. That will be the focus of our next session. And the Facilitator will attend to try to help us.
Thanks for a great discussion, team.
Completed Self-Assessment Worksheet
Facility Name: Sunny Tree NH
Date Completed: 07/01/16
Completed By: Change Team
Section 1: Pressure Ulcer Tracking and Assessment
1. What tools, if any, does your facility use to monitor pressure ulcer healing? Check all that apply.
| Individual Patient/Resident Level | Facility Level | |
|---|---|---|
| Advancing Excellence Pressure Ulcer Tracking Tool | ||
| Facility-developed forms/database | ✓ | ✓ |
| Corporate-directed forms/database | ||
| Paper records/log | ✓ | ✓ |
| PUSH – Pressure Ulcer Scale for Healing Tool | ||
| BWAT – Bates-Jenson Wound Assessment Tool | ||
| None of the above | ||
| Other (specify) |
2. How often does your facility reassess pressure ulcers?
- |___| Daily
- |___| At every dressing change
- ✓ Weekly
- ✓ Other (specify): ___ we identify new pressure ulcer daily and at admission _____________
3. Does your facility collect the following information?
| Facility at Large | Unit Level | |||
|---|---|---|---|---|
| a. Total count of ulcers | ✓Yes | No | Yes | No |
| b. Count of ulcers by stage | ✓Yes | No | Yes | No |
4. How often is the information updated?
- Total count of pressure ulcers is updated:
|___| Daily
|___| Weekly
|___| Every 2 weeks
✓ Monthly
|___| Quarterly - Total count of pressure ulcers by stage is updated:
|___| Daily
|___| Weekly
|___| Every 2 weeks
✓ Monthly
|___| Quarterly
5. Does your assessment of pressure ulcers include the following items:
| Yes | No | |
|---|---|---|
|
✓ ✓ ✓ ✓ ✓ |___| ✓ |___| ✓ ✓ |___| |___| |___| |___| |___| |___| ✓ |___| |___| |
|___| |___| |___| |___| |___| ✓ |___| ✓ |___| |___| ✓ ✓ ✓ ✓ ✓ ✓ |___| |___| |___| |
Section 2: Pressure Ulcer Healing Practices
1. Does your facility have a protocol for monitoring the progress of pressure ulcer healing?
Yes |___| No ✓ If no, explain:
Weekly look at pressure ulcers; don't have specific triggers for identifying slow healing ulcers. We track surface are and stage over time.
2. What guidelines are used in your facility protocol regarding evaluating pressure ulcer healing? Check all that apply.
- |___| AMDA – The Society for Post-Acute and Long-Term Care Medicine's Pressure Ulcer Guidelines
- |___| National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance's Prevention and Treatment of Pressure Ulcers Guidelines
- |___| Wound, Ostomy, and Continence Nurses Society (WOCN) Pressure Ulcer Guidelines
- |___| Other (specify): ___________________________________________________
- ✓ None of the above
3. Does your facility's protocol include criteria for identifying residents whose pressure ulcers may not heal in a reasonable timeframe due to resident comorbidities and/or wound characteristics (i.e., identification of residents who are at risk for delayed healing before delayed healing is evident)?
Yes |___| No ✓
4. Does your facility's protocol include criteria for identifying ulcers that are not healing in an expected timeframe?
Yes |___| No ✓
If yes, what are the criteria?
5. Does your facility protocol provide guidance on:
| Yes | No | Comments | |
|---|---|---|---|
| How to identify potential pressure ulcer infection? | ✓ | ||
| Pressure ulcer debridement? | ✓ | ||
| Selection of dressings based on wound characteristics? | ✓ | ||
| Use of nutritional supplements for residents with pressure ulcers? | ✓ | ||
| Use of support surfaces for bed and chairs/wheelchairs? | ✓ | ||
| Wound cleansing? | ✓ | ||
| Assessing the resident for pain? | ✓ | ||
| Appropriate use of topical wound agents? | ✓ | ||
| Appropriate use of adjunctive treatments? | ✓ |
Section 3: Investigations/Root Cause Analysis of Delayed Pressure Ulcer Healing
1. Does your facility investigate delayed healing pressure ulcers according to your facility's policies and guidelines?
Yes |___| No ✓ Not Sure |___|
2. Does your facility investigate delayed pressure ulcer healing via a root cause analysis framework?
Yes |___| No |___| Not Sure ✓ If no, skip to Section 4.
3. Does the investigation include a review of changes to the resident's clinical status that may have warranted a change in pressure ulcer care approaches?
Yes ✓ No |___| If no, skip to Question 5.
4. Which of the following changes to the resident's clinical status would be considered when determining if a change in pressure ulcer care approaches is needed? Check all that apply.
- ✓ Change in condition
- ✓ Weight loss
- ✓ Change in meal intake
- ✓ Change in fluid intake
- ✓ Change in mobility
- ✓ Change in continence
- |___| Change in ability to communicate pain
5. Based on review of risk factors for poor healing, what interventions would be investigated to ensure that healing was being addressed appropriately? Check all that apply.
- ✓ Nutritional interventions to meet the resident's hydration, protein, calorie, vitamin, and mineral needs
- ✓ Incontinence prevention and/or management
- ✓ Management of medical device-related pressure
- ✓ Pressure redistribution (e.g., support surfaces) and offloading (e.g., specialized footware)
- ✓ Friction and sheer reduction
- ✓ Turning and repositioning procedures
- ✓ Treatment changes per frequency designated by protocol or provider
- ✓ Indicators for debridement
- ✓ Assessment for appropriate bed and chair support surfaces
- ✓ Skin assessments per frequency designated by protocol or provider
- ✓ Dressing protocols
- ✓ Infection prevention and assessment
- |___| Other (specify): ______________________________________________________
Section 4: Communication Practices
1. Review the following list of meetings. For every meeting that occurs at your facility, indicate how often it occurs, who leads the meeting, and who attends. Also indicate if the meeting includes any discussion of pressure ulcer healing.
| Meeting | Meeting Chair/Leader Name and Discipline | Staff Invited and In Attendance (A = Always, V = Varies, As Needed) | Frequency of Meeting (Weekly, Biweekly, Monthly, Quarterly, Change in Condition, As Needed) | Is Pressure Ulcer Healing Discussed? (Y = yes, N = No) |
|---|---|---|---|---|
| a. Care plan review | Nurse Manager on each unit | Nursing – A Nursing Assistants – A Social Services – A Activities – A Rehab – V Dietitian – A |
On admission, quarterly, and with significant change in condition | Y – when relevant |
| b. Shift report or "brief" with CNAs | Charge Nurse | Nursing Assistants – A Dietitian – once/week Rehab – once/week Social Services – once/week Activities – once/week |
Every change of shift | Y – when relevant |
| c. Report or brief with Department Heads | DON | Department heads – A Nurse Managers – A Medical Director – V |
Daily at 9 a.m. (weekdays, nonholidays) | Pressure ulcer healing rarely discussed |
| d. Medical Staff/Medical Director | NA | NA | NA | NA |
| e. QAPI or quality improvement review | QA Coordinator | Administrator – A Nurse Managers – A Nursing Supervisor – A Wound Nurse- A Dietitian – A DON – A Rehab Director – A Nursing Assistants (one from each unit) – A Infection Control Nurse – A Social Services Director – A Activities Director – A Medical Director –V |
Monthly | N - Pressure ulcer healing is not a QAPI initiative |
| f. Skin or Wound Meeting | Program Champion (Wound Nurse) | Dietitian – A Rehab – A Nursing Assistants – A |
Weekly | Y |
| g. MD/APRN Rounds | Nurse Managers | Physicians – A | Weekly | N |
| h. Report or brief with Dietary Department | Nurse Managers | Dietitian – A Nursing Assistant – V |
Weekly | N |
| i. Report or brief with Social Services Department | Nurse Managers | Activities Director – A Social Services Director – A Nursing Assistant – V |
Weekly | N |
| j. Report or brief with Therapy Department | Nurse Managers | Rehab – A Nursing Assistant - A |
Weekly | N |
| k. Report or brief with "Other" | N/A | N/A | N/A | N/A |
| l. Other |
QAPI = Quality Assessment and Performance Improvement; APRN = advanced practice registered nurse.
2. Training
Indicate the date of the most recent training provided for the following:
| Topic | Participants | Date |
|---|---|---|
| Measuring pressure ulcers accurately | Nurses | 3/5/16 |
| Recognizing signs of delayed healing in pressure ulcers | Nurses | |
| Pressure ulcer assessment documentation | Nurses | 6/15/16 |
Review of the Change Team's Process of Choosing On-Time Reports, Incorporating Them Into Huddles and Clinical Meetings, and Piloting Those Meetings
Completed Menu of Implementation Strategies Worksheet - For Use With Implementation Scripted Exercise
| Pressure Ulcer Healing Menu of Implementation Strategies | ||
|---|---|---|
| Existing | New | |
| On-Time Existing Pressure Ulcer Report | ||
| Care plan meetings | ✓ | |
| MDS assessment documentation | ✓ | |
| Nurse shift change report | ✓ | |
| Nursing assistant shift report | ✓ | |
| Quality improvement review | ✓ | |
| Rehab Department internal review | ✓ | |
| Skin rounds | ✓ | |
| Weekly nutrition risk huddle | ✓ | |
| Weekly nutrition risk huddle for Nursing and Rehab | ✓ | |
| Weekly risk meeting | ✓ | |
| Weekly wound review meeting | ✓ | |
| On-Time Ulcers At Risk for Delayed Healing Report | ||
| Care plan meetings | ✓ | |
| Dietary Department internal review | ✓ | |
| MDS assessment documentation | ✓ | |
| Nurse shift change report | ✓ | |
| Rehab Department internal review | ✓ | |
| Quality improvement review | ✓ | |
| Risk management meeting | ✓ | |
| Root cause analysis for new pressure ulcers or ulcers at risk for delayed healing | With Quality Improvement Review | |
| Skin rounds | ✓ | |
| Weekly nutrition risk huddle | ✓ | |
| Weekly risk huddle for Nursing and Rehab | ✓ | |
| Weekly wound review meeting | Combined | |
| Weekly wound rounds | ||
| Weekly risk meeting | ✓ | |
| On-Time Weekly Wound Rounds Report | ||
| MDS assessment documentation | ✓ | |
| Rehab Department internal review | ✓ | |
| Skin rounds | ✓ | |
| Weekly nutrition risk huddle | ✓ | |
| Weekly wound review meeting | Combined | |
| Weekly wound rounds | ||
| Weekly risk meeting | ✓ | |
| On-Time Weekly Pressure Ulcer Treatment Summary Report | ||
| Rehab department internal review | ✓ | |
| Root cause analysis for new pressure ulcers or ulcers at risk for delayed healing | With Quality Improvement Review | |
| Weekly risk meeting | ✓ | |
| Weekly wound review meeting | Combined | |
| Weekly wound rounds | ||
| Weekly coordinator review with product representatives | ✓ | |
| On-Time Pressure Ulcer Counts by Month | ||
| Root cause analysis for new pressure ulcers or ulcers at risk for delayed healing | With Quality Improvement Review | |
| Risk management meeting | ✓ | |
| Weekly risk meeting | ✓ | |
| Weekly wound review meeting | Combined | |
| Weekly wound rounds | ||
| Wound coordinator internal review or reporting to leadership | ✓ | |
Completed Communication Practices Grid From Healing Self-Assessment Worksheet - For Use With Implementation Scripted Exercise
Section 4: Communication Practices
1. We are interested in how you communicate the pressure ulcer risk and prevention care plans to the interdisciplinary team. Review the following list of meetings. For every meeting that occurs at your facility, indicate how often it occurs, who leads the meeting, and who attends.
| Meeting | Meeting Chair/Leader Name and Discipline | Staff Invited and In Attendance (A = Always, V = Varies, As Needed) | Frequency of Meeting (Weekly, Biweekly, Monthly, Quarterly, Change in Condition, As Needed) | Is Pressure Ulcer Healing Discussed? (Y = yes, N = No) |
|---|---|---|---|---|
| a. Care plan review | Nurse Manager on each unit | Nursing – A Nursing Assistants – A Social Services – A Activities – A Rehab – V Dietitian – A |
Weekly at the facility level; on admission, quarterly, and with a change in condition at the resident level | Yes |
| b. Shift report on "brief" with CNAs | Charge Nurse | Nursing Assistants – A Dietitian – once/week Rehab – once/week Social Services – once/week Activities – once/week |
Every change of shift | No, unless there is a resident-specific concern that is addressed |
| c. Report or brief with Department Heads | DON | Department heads (Administration, Nursing, Activities, Social Service, Rehab, Dietary, Maintenance, and Housekeeping) – A Nurse Managers – A Medical Director – V |
Daily at 9 a.m. (weekdays, nonholidays) | No, unless there is a resident-specific concern that is addressed |
| d. Medical staff/medical director meeting | DON | Medical Director – A Department heads (Administration, Nursing, Activities, Social Service, Rehab, Dietary, Maintenance, and Housekeeping) – V |
As needed | No |
| e. QAPI or quality improvement review | QA Coordinator | Administrator – A Nurse Managers – A Nursing Supervisor – A Dietitian – A DON – A Rehab Director – A Nursing Assistants (one from each unit) – A Infection Control Nurse – A Social Services Director – A Activities Director – A Medical Director – A |
Monthly | Yes |
| f. Skin or Wound review meeting | Program Champion (Wound Nurse) | Dietitian – A Nurse Managers – A Nursing Assistants – A
|
Weekly | Yes, any residents with a pressure ulcer is seen on rounds |
| g. MD/APRN Rounds | Nurse Managers | Physicians – A | Weekly | No, unless a resident has a pressure ulcer |
| h. Report or brief with Dietary Department | Nurse Managers | Dietitian – A Nursing Assistant – A |
Weekly | No, unless a resident has a pressure ulcer. |
| i. Report or brief with Social Services Department | Nurse Managers | Activities Director – A Social Services Director – A Nursing Assistant – V |
Weekly | No, unless a resident has a pressure ulcer. |
| j. Report or brief with Therapy Department | Nurse Managers | Rehab – A Nursing Assistant - A |
Weekly | No, unless a resident has a pressure ulcer. |
| k. Report or brief with "Other" | N/A | N/A | N/A | N/A |
| l. Other | N/A | N/A | N/A | N/A |
Abbreviations Used: CNA = Certified Nursing Assistant; MD/APRN = Medical Doctor/Advanced Practice Registered Nurse; QAPI = Quality Assurance and Performance Improvement.
Meeting Descriptions and Suggested Pressure Ulcer Healing Reports - For Use With Implementation Scripted Exercise
| Nursing Home Meetings | Meeting Description | Typical Attendees and Leads | Existing Pressure Ulcer Report | Pressure Ulcers At Risk for Delayed Healing | Weekly Wound Rounds Report | Weekly Pressure Ulcer Treatment Summary Report | Pressure Ulcer Counts by Month |
|---|---|---|---|---|---|---|---|
| Care plan meetings | Weekly review of resident care plans. Reports help care plan change decisions. | Multidisciplinary team. DON or ADON typically leads the meeting. |
X | X | |||
| Nursing assistant shift change Report | CNAs meet at shift change to share summary of residents’ clinical status and residents’ care plan interventions for CNA followup. The charge nurse typically generates the On-Time reports for the new CNA staff at the beginning of the shift to identify residents with changes in risk. Usually done weekly. | Charge nurse/nurse manager and CNAs. Charge nurse or nurse manager typically leads the meeting. |
X | ||||
| Dietary Department internal review | This is a weekly meeting within the Dietary Department. Report supports nutrition plan review and changes. | Dietary Department staff Director of the Dietary Department typically leads the meeting. | X | ||||
| MDS assessment documentation | Reports may be used to support MDS nurse review of resident records and aids MDS assessment documentation. | MDS nurse and other disciplines responsible for MDS assessment documentation, including Dietary and Rehab. | X | X | X | X | |
| Nurse shift change report | Nurses meet at change of shift to review resident clinical and risk status. On-Time Risk reports help identify residents at risk for pressure ulcer development that need attention. | Nurse managers or charge nurses. Nurse managers or charge nurses typically lead the meeting. |
X | X | |||
| Quality improvement review | Department team weekly review of rehab patients or resident in need of rehab. Report data help identify residents with new ADL decline or worsening ulcers and therefore at risk for pressure ulcer development and in potential need of therapy. | Department heads | |||||
| Rehab Department internal review | Department team weekly review of rehab patients or resident in need of rehab. Report data help identify residents with new ADL decline or worsening ulcers and therefore at risk for pressure ulcer development and in potential need of therapy. | Rehab Department staff. Rehab director typically leads the meeting. |
X | X | X | ||
| Root cause analysis for new pressure ulcers | Multidisciplinary team review focusing on persons with new pressure ulcers. Risk and trended reports provide insights into why these persons had a new pressure ulcer. | DON or ADON, nurse manager, wound nurse, QI director DON, QI director, or QI staff leads the meeting. |
X | X | |||
| Skin rounds | Weekly skin rounds to assess resident skin condition. The reports alert staff about residents who may be likely to have a new pressure ulcer forming. | Charge nurse, or wound nurse and CNA A charge nurse or wound nurse typically leads skin rounds. |
X | X | X | X | |
| Weekly nutrition risk huddle | Nurse/Dietitian/CNA weekly huddle to review nutrition status and confirm appropriate interventions are in place for pressure ulcer prevention. Reports identify resident with nutrition risk and the meeting elicits feedback from CNA staff caring for the residents, as well as perspectives of the nurse and dietitian. | Charge nurse, dietitian, and CNA. Other staff may attend such as wound nurse, social services, and MDS nurse. Nurse and a dietitian colead the meeting. |
X | X | |||
| Weekly risk huddle for Nursing and Rehab | Weekly huddle to review residents at risk for pressure ulcer slow healing and in potential need of therapy based on specific risk factors for a resident. | Nurse manager and Rehab director or Rehab therapist. | X | X | |||
| Weekly risk meetings (e.g., pressure ulcer healing risk or nutrition risk) |
Multidisciplinary team review of residents at risk. The purpose of using the reports is to identify persons with risks associated with pressure ulcers, review care plans, and help update interventions. | DON or ADON, nurse manager, wound nurse, dietitian, and Rehab director or Rehab therapist depending on focus of meeting. DON or ADON leads the meeting. |
X | X | |||
| Weekly wound review meetings* | Multidisciplinary team weekly review of residents with pressure ulcers or skin integrity issues. Reports provide information about current and changing risks for pressure ulcer healing and can aid root cause analyses and decisions about ulcer treatments and interventions. | DON or ADON, nurse manager, wound nurse, physician, NP, and QI director. The team conducting wound rounds typically attends this meeting for a more detailed review of the resident chart and current care plan interventions. Physician, dietitian, therapist, and QI staff, who may not attend wound rounds, attend this meeting. DON typically leads the meeting. |
X | X | X | X | |
| Wound rounds | Multidisciplinary team weekly review of residents with pressure ulcers. The team rounds on residents with a pressure ulcer and uses pressure ulcer healing reports to support decisionmaking on pressure ulcer treatments and interventions. | Nurse manager, wound nurse, wound physician, NP, and CNA Physician, wound nurse, or DON typically leads the meeting. |
X | X |
Abbreviations Used: ADON = Assistant Director of Nursing; CNA = Certified Nursing Assistant; DON = Director of Nursing; MDS = Minimum Data Set; NP = Nurse Practitioner; QI = Quality Improvement.
Implementation Scripted Exercise – Selecting Healing Reports and Meetings in Which To Use Them
Scene 1: Change Team Meeting
Program Champion: Good morning and welcome back to the On-Time training. Today we will talk about using Healing Reports in existing huddles, briefs, or meetings to help us better assemble information about residents with pressure ulcers that are not healing properly to help inform care change discussions. We also can discuss adding some briefs or huddles to better discuss these patients' care needs.
Let me summarize what we concluded after using the Self-Assessment of our pressure ulcer healing practices. We decided we could use the On-Time assessment so that we would be able to better identify pressure ulcers showing signs of infection and signs of healing problems. Currently we do not use any formal ways to identify problem ulcers and we think we may be missing problems. We would like to monitor pressure ulcers weekly and would like to have more information available when we discuss the finding from wound rounds, and ideally save us time preparing for rounds. We want help in determining how to change care or prevent the problem in the future. We also are now familiar with the information on the healing reports so that now we can think about using these reports. Lastly, we should be thinking about who we want in these discussions.
Facilitator: I have reviewed your Self-Assessment and I now have a better idea about how the On-Time reports may be able to help you, but it is best to let you have your own discussions. I will be happy to help if you need some clarifications or suggestions. Also remember it will be important once you pilot these reports that what you enter in the EMR will need to be complete and the vendor will need to program the reports correctly for this to work.
Let's begin by looking at the Menu of implementation Strategies Worksheet that Tom [Program champion] completed, which shows a list of possible meetings, briefs, or huddles that you may already do, and it suggests reports that could be used. One or more reports may be useful to focus the discussion on residents with problem ulcers and provide additional information to discuss the care changes that may be needed. These reports may also help departments like Nutrition or Rehab by identifying problems in those areas that may help reduce the risk of further pressure ulcer deterioration.
Program Champion: The Menu is intended to give us ideas and think about our options. What we decide to do needs to make sense to us.
Facilitator: The idea is that the discussions that you have should be short and focused and the information provided by the reports should inform those discussions so that the care will be more timely and better informed. This should not be a burden but a help. Of course, any new practice may take longer than you like at first, but as you become more efficient in controlling and focusing discussions, it should end up being short and sweet.
Program Champion: The Menu Worksheet displays possible meetings where a discussion of residents with pressure ulcers might help and suggests reports that may be useful. The list is intended to give us ideas. It's there to help us think about our options.
Facilitator: The worksheet allows you to identify meetings you already have and others that you could add to help improve pressure ulcer healing. The beauty of the On-Time program is that it's not a one-size-fits-all approach. You select ways to use reports that make sense for your facility.
Evening Supervisor: Oh, I see. That makes a lot of sense.
DON: First and foremost, we want to do a better job of identifying residents with pressure ulcers that are not healing as expected. We also want to improve the accuracy and timeliness of the information we have available for monitoring pressure ulcers.
Program Champion: The Pressure Ulcers at Risk for Delayed Healing Report shows only residents with pressure ulcers that are at risk for delayed healing. The report shows the initial surface area and the three most recent measurements. It also shows the BWAT scores, initial and two most recent. These two items would give us valuable information on how the wound is progressing.
DON: The delayed healing report also shows reasons for delayed healing. The criteria that put a resident on this report come from recognized guidelines. It brings together information from the pressure ulcer assessment on surface area, stage, tissue in the wound bed, periwound area, drainage, and pain all in one place. This makes it very easy to see how the pressure ulcer is changing. I would like to use this and the Weekly Wound Rounds Report to prepare for wound rounds.
Just recently, the restorative nursing staff started an incontinence management group. I think the Weekly Wound Rounds Report would be very helpful to them. It shows increases in bowel and bladder incontinence; this report would allow the restorative nursing team to target those residents who are in need of incontinence management and help at the same time to promote pressure ulcer healing.
And we also have our meeting with Curtis, our Rehab Director, to go over the list of residents currently receiving therapy. I think we could use information from the Weekly Wound Rounds Report to target people with pressure ulcers and ADL decline, to see if they could benefit from therapy to increase mobility and promote pressure ulcer healing.
Facilitator: That's perfect. Does anyone else have other ideas for using this report or other reports?
Dietitian: I would definitely like to use the Pressure Ulcer Treatment Summary and the Weekly Wound Rounds Report during nutrition huddles. The Weekly Wound Rounds Report has nutrition risk, nutrition interventions, and weekly average meal intake for all of the residents with pressure ulcers on one unit in one report. This is the type of information that I'd like to be able to review with the nurses and the nursing assistants. When I see decreased meal intake, I like to get more details from the nursing assistants. For example, is there a problem at one particular meal or is it a problem with a particular type of food? I sit in on shift report once a week with the nursing assistants, but if I could review this on a weekly basis in a short meeting with the nurses and nursing assistants, that would really help me make changes in the diet. These residents with pressure ulcers have very significant nutritional needs. I really need to stay on top of any changes. We don't necessarily need another meeting time; we could have a nutrition huddle once a week on each unit right after report when the nursing assistants are already gathered. I bet it would only take a few minutes because the nursing assistants know the residents so well.
Facilitator: That's right, and the process would promote team collaboration about meal intake trends. Your idea about meeting when the nursing assistants are already all assembled is also a great idea to ensure that the nursing assistants' time is efficiently spent. The discussion would incorporate the perspectives of the nurse, nursing assistants, and dietitian. We should definitely talk about using the Weekly Wound Rounds Report at a weekly nutrition huddle and include the nursing assistants. You also mentioned the Treatment Summary Report. How would you use that?
Dietitian: I'd like to use that with the nurse managers to monitor the nutritional interventions and lab values.
Nurse Managers (A and B): Sounds good to me.
Nursing Assistant: Me too. I know that other nursing assistants would love to participate if they can be freed up for a few minutes. And Sandy [Facilitator], you are right that it makes a lot of sense to have a huddle right after our report. We would already be together as a group and we could just move from our report right into the meeting. That would save us time versus having to come back together at another time in the day.
Nurse Manager A: We can make it happen.
QAA Coordinator: The Existing Pressure Ulcers Report and the Pressure Ulcer Counts by Facility and by Unit would be very helpful with my monthly log sheet and for tracking any trends in new or worsening pressure ulcers. These reports will also help us investigate why certain pressure ulcers are not improving as expected.
DON: I agree. These reports will certainly make this important information readily available, which will free us up to spend more time on the floor supervising care!
Program Champion: So, what I’m hearing is that you’d like to use the Weekly Wound Rounds Report and Pressure Ulcers at Risk for Delayed Healing with wound rounds. Kim [Dietitian] would like to review the Pressure Ulcer Treatment Summary and Weekly Wound Rounds with nurses and nursing assistants. Sally [QAA Coordinator] would like to incorporate the use of the Existing Pressure Ulcers Report and the Pressure Ulcer Counts into the facility’s QAPI program. Have I got it right? Do you all agree?
DON: The restorative team could also want to look at ADL decline and increase in incontinence on the Weekly Wound Rounds Report to help identify persons who have recently declined.
Facilitator: That’s right. Thanks. Now what is the best way to get started? Do you want to trial the use of one report or several? Do you want to try using the report or reports on one unit first and see how it goes or do you want to roll it out to the whole building?
DON: What are the pros and cons for each?
Facilitator: Well, trialing one report on one unit will allow you to see how it goes and allows you to adjust the process before moving on to other units or adding other reports. That way you can fix things that aren’t working well before more staff are involved; a true quality improvement or QAPI cycle. But it will take longer this way and a longer period before you notice any difference in your pressure ulcer rates.
Program Champion: I think we should start with one report on one unit and get the process to where we like it. We can always add more reports later, correct?
Facilitator: Of course, you can add more reports later; as I mentioned, this is not a one-size-fits-all program; you, as a team, decide how you want to proceed.
Nurse Manager A: Which unit are you going to pick?
Program Champion: I would suggest starting with the unit with the highest pressure ulcer rate.
DON: That makes sense to me. Nancy, that would be your unit. Are you comfortable with this plan?
Nurse Manager A: Okay, but I don’t particularly like that distinction.
DON: Well, let’s see if the On-Time program can help.
Facilitator: Which report would you like to implement?
Nurse Manager A: Rather than doing just one report, I'd like to pilot the Weekly Wound Rounds Report and the Pressure Ulcers at Risk for Delayed Healing Report. Each week before we start rounds, we meet to discuss which residents we'll be reviewing and verify that we have all the information we'll need. I think that the Weekly Wound Rounds Report would be good to have prior to rounds to provide a neat list of who is going to be seen with some basic pressure ulcer information. During rounds, we record the new measurements and latest characteristics of the pressure ulcers. Once the new information is in the computer, it would be great to run the Pressure Ulcers at Risk for Delayed Healing Report to see if any of the pressure ulcers have not been progressing as expected. Did surface area not get smaller in the last 2 weeks? If there is a resident whose wound is showing up as at risk for delayed healing, we could also run the Pressure Ulcer Treatment Summary and start investigating what's going on with that resident and his or her pressure ulcer. I'd like to add the treatment summary to my reports to pilot. Is that possible?
Facilitator: That sounds like a great idea.
Program Champion: With those three reports we should be able to spot early on any pressure ulcers not progressing and figure out what's been done so far and what needs to be done to get things back on track.
Nurse Manager B: I'd like to try that also. Can we pilot on my unit as well?
Program Champion: I have no objection. So, just to confirm, Nancy and Jane (Nurse Managers) will run the Weekly Wound Rounds Report prior to rounds to help the team get organized. You'll print copies for everyone on the wound rounds team; besides me and the nurse manager, that's the nursing assistants and Kim (Dietitian). After the wound assessment has been updated, you will run the Pressure Ulcers at Risk for Delayed Healing Report and discuss in a followup meeting.
Nurse Manager A: We do wound rounds on Monday mornings. Let's have a meeting Monday afternoon and discuss the new assessment results and whether we should change any treatments or make referrals. Also, let's meet later in the week about the Delayed Healing Report. I don't want too much time to go by before we discuss the new information. Will that work for you, Kim [Dietitian]?
Nurse Manager B: Our rounds are on Tuesdays. How about Tuesday afternoon for our rounds discussion meeting?
Dietitian: Yes, I'm here on Mondays and Tuesdays. What time?
Nurse Manager A: Let's do 1:30. Residents will be finished with lunch and all back from the dining room at that point.
Nurse Manager B: That works for me, Tuesday at 1:30.
Nursing Assistant: I think that will work. We'll need to work around staff lunches, but we can be flexible.
Program Champion: Okay, that sounds fine to me. Nancy and Jane, can you work out the details?
Nurse Manager A: Sure.
Nurse Manager B: Okay.
Nurse Manager A: Let's follow-up after looking at the new Delayed Healing Report.
Facilitator: It looks like we have a plan. We'll trial the use of the Weekly Wound Rounds Report and the Pressure Ulcers at Risk for Delayed Healing Report on Units A and B. The Nurse Managers will run the Weekly Wound Rounds Report and have copies available for the wound care team prior to rounds. In the afternoon of the day wound rounds are done, the wound care team will meet to review the residents with pressure ulcers using the Delayed Healing report and the Treatment Summary. Let's plan to check back in 2 weeks to see how this trial went. We will need feedback from everyone on what worked, what didn't work, and any suggestions for improving the process. Thanks, everybody. For our next meeting, I won't need to be here. I'll call into the conference room.
Scene 2: Change Team Followup Meeting
Program Champion: Thank you all for coming. We're meeting today to hear how the trial of the Weekly Wound Rounds Report, the Pressure Ulcers at Risk for Delayed Healing Report, and the Treatment Summary Report on Nancy and Jane's units went. Sandy [Facilitator] is on the phone.
Facilitator: Hi, everyone. How did it go?
Nurse Manager A: It went pretty well. I was able to print the Weekly Wound Rounds Report before wound rounds and it was really helpful having all that information available. We had our meeting in the afternoon and discovered one pressure ulcer with delayed healing that we were not aware of. The surface area had not decreased over the past 2 weeks. We used the Treatment Summary to look back at previous interventions and called the physician for a change in the dressing order and for additional nutritional support.
Facilitator: Did you run into any problems?
Nurse Manager B: Not really, except that our first meeting was a little too long.
Facilitator: It is not unusual for the first meeting or two to take longer, but once you get the process down the meetings will go much faster. Everyone will know what is expected of them and everyone will be more familiar with the report and which report data to focus on.
Nurse Manager A: That's probably true. The second meeting that we had was a little smoother and shorter.
Facilitator: How about on Unit B? How did it go for you?
Nurse Manager B: We used the Weekly Wound Rounds Report to organize our wound rounds and the Delayed Healing and Treatment Summary in the followup meeting. The first week we didn't see any pressure ulcers with a delay in healing and didn't need to change or add any orders. The second week, however, we did note a change in the character of the drainage from one pressure ulcer. We followed up with the physician and did some testing for infection.
Facilitator: Did you have any problems?
Nurse Manager B: Other than the meeting running a little long, no, we didn't have any problems. I would like to invite Curtis [Rehab Director], though, as there were questions around positioning and surface supports that we would like his input on.
Nurse Manager A: One other thing, I forgot to mention, the second week we asked some nursing assistants who weren't able to make it for the meeting to attend briefly to provide input on their residents that had pressure ulcers.
DON: Nancy [Nurse Manager A], it is important for the nursing assistants to attend these meetings; it is up to leadership to see that they can attend and important to demonstrate that we are supporting this program. And remember that I am here to help you. Do you remember what happened that day with your nursing assistants?
Nurse Manager A: No, I don't remember what happened, but I'm not so sure it's really necessary to have the nursing assistants at the meeting with the wound nurse and dietitian. I talk to Kim [Dietitian] all the time. The nursing assistants report their concerns to me; I pass them along to Kim, when appropriate.
Facilitator: How is your in-house pressure ulcer rate on this unit? Is it still high?
Nurse Manager A: Unfortunately, yes.
Facilitator: Kim, what do you think? Is the information that you get directly from the nursing assistants valuable? How do you feel about having them attend the post wound round meeting?
Dietitian: I would like to see them continue to attend. Healing pressure ulcers is a real challenge and really requires a team approach. Nutrition is so critical for healing. Including the nursing assistants gives me first-hand knowledge of the resident's intake at each meal and snack and their preferences. The presence and input of the aides at these meetings is invaluable as far as I'm concerned. It's just so much more efficient for me to interact with them directly than by relaying messages through the nurse managers. I realize they're busy, but if we can keep the meetings short and focused, I think it will be worth it.
Nurse Manager A: I agree. Their input is extremely valuable. Scheduling around their lunch breaks is a challenge. I'll try having the huddles at this time for a few more weeks; if it doesn't work out, I'll find another day and time that is convenient for everyone.
Facilitator: Sounds like we should try this for a few more weeks before we make a decision to expand to other units and more reports. Does everyone agree?
All: Yes.
Facilitator: Okay, we are in agreement about that.
Facilitator: Good discussion, team. Making these changes takes flexibility on everyone's part and I appreciate your efforts. Keep up the good work. I think you'll find that this will pay off for you and especially for your residents.
