Healthcare Agency

Original Article

Inpatient Pressure Ulcer Prevalence in an Acute Care Hospital Using Evidence-Based Practice M. Elizabeth Beal, MSN, RN, CWON • Kimberly Smith, MSN, RN, CWON

Keywords

Pressure ulcer prevention,

prevalence rate, hospital-acquired,

evidence-based practice,

acute care

ABSTRACT Background: A national goal was set in 2004 for decreasing hospital-acquired pressure ulcers (HAPUs). A mean to achieve that goal was initiated in 2005 with long-term care facilities. Acute care facilities, with encouragement from the Centers for Medicare and Medicaid Services, took action.

Aims: Pressure ulcer prevention efforts at MaineGeneral Medical Center (MGMC), a 192-bed acute care hospital in Augusta, Maine, sought to reduce HAPU prevalence from a mean of 7.8% in 2005.

Methods: A retrospective study over a 10-year period, from 2005 through 2014, tracked HAPUs and evidence-based practice (EBP) initiatives to decrease the annual mean prevalence rate.

Results: The annual mean HAPU prevalence rate of 7.8% in 2005 decreased to 1.4% in 2011, then maintaining this level through 2014 at MGMC. Evidence-based practices for pressure ulcer prevention were implemented using data collection tools from the National Database of Nursing Quality Indicators; guidelines from the National Pressure Ulcer Advisory Panel; and procedural guidance tools from the 5 Million Lives Campaign and the Agency for Healthcare Research and Quality.

Conclusions: Accurate data collection methods and evidence-based guidelines are vital to im- proving care; yet planning with annual review, fostering an EBP culture, by-in of stakeholders, and education, are the means to long-term consistent implementation of pressure ulcer prevention measures.

Linking Evidence to Action: Keys to decreasing and maintaining the rate were based on effec- tive scientific evidence for prevention of pressure ulcers: assessment tools, education, planning guidance, documentation, and evidence-based practice guidelines.

BACKGROUND The National Council on Disability Government Performance and Results Act (National Council on Disability, 2005) set a national goal to reduce long-term care facility pressure ulcer prevalence rates. The Centers for Medicare and Medicaid Ser- vices (CMS, 2004) was directed by this act to create a means to achieve that goal (Lyder & van Rijswijk, 2005). In response, the Institute for Healthcare Improvement (IHI; 2006) began the Protecting 5 Million Lives From Harm campaign, build- ing on its 100,000 Lives campaign started in 2004, to help hospitals engage in preventing pressure ulcers. In 2006, the Agency for Healthcare Research and Quality (2014) developed the Pressure Ulcer Prevention Toolkit citing the National Pres- sure Ulcer Advisory Panel (NPUAP, 2014) as a resource for pressure ulcer best practice.

Pressure ulcer prevention efforts at MaineGeneral Medi- cal Center (MGMC), a 192-bed acute care hospital in Augusta, Maine, has been successful in reducing hospital-acquired pres-

sure ulcers (HAPU) prevalence in patients from an annual mean of 7.8% in 2005, to 1.4% in 2014 (see Figure S1, avail- able with the online version of this article), using measurement tools from the National Database of Nursing Quality Indicators (NDNQI; Press Ganey Associates, 2015). HAPUs are any stage of pressure ulcer assessed on a patient after 24 hours of being in the hospital that was not documented upon admission. This ar- ticle will discuss the successful process used by MGMC to reach and maintain the decrease in annual mean hospital-acquired pressure ulcer prevalence rate through evidence-based prac- tices (EBP).

AIMS AND METHODS This is a retrospective study addressing the impact of various implementations to decrease hospital-acquired pressure ulcers (see Figure S2, available with the online version of this article). Over the 10 years included in this discussion the same certified wound, ostomy nurse (CWON) directed the implementations.

112 Worldviews on Evidence-Based Nursing, 2016; 13:2, 112–117. C© 2016 Sigma Theta Tau International

Original Article Four medical-surgical RNs were members of the process for this period of time. Other “skin champions,” Wound Treatment Associates (WTAs), and wound committee members changed as staff terminated their employment, or transferred to other departments. Records were kept from 2005 on plans of action, data collected from chart reviews and studies, and the educa- tional plans, as well as copies of trainings. The prevalence rate is determined through the NDNQI prevalence study, conducted quarterly, by determining the number of HAPUs documented in the hospital on the day of the study. The number of HA- PUs is then divided by the number of patients assessed in the hospital that day. The mean prevalence rate of the combined quarterly studies is the annual mean prevalence rate.

DISCUSSION In order for CMS to make progress toward a decrease in HAPUs, regional and state multidisciplinary health task forces were initiated. The Maine Department of Health and Human Services established a pressure ulcer task force in 2005 (Maine Healthcare Association, n.d.), that included MGMC and CWONs. A literature review from this task force cited two national studies emphasizing the need for action. One was published in the Journal of Wound, Ostomy & Continence Nursing (Whittington, Patrick, & Roberts, 2000), and the other in Advances in Skin & Wound Care (Whittington & Briones, 2004). This sparked the development of a wound committee at MGMC guided by the CWONs and consisting of nurse representatives from medical surgical units, critical care (CCU), operating room (OR), rehabilitation, and float pool. The NDNQI study of HAPUs was started in November 2005, re- sulting in a prevalence of 7.8%. After learning the national rate was 7% (Cuddigan, Berlowitz, & Ayello, 2001), one of the first actions was to recommend nurse training in pressure ulcer prevention (PUP).

Responding in 2006 the CWONs developed a voluntary self- study program with testing on pressure ulcer staging and pre- vention based on the National Pressure Ulcer Advisory Panel (NPUAP) guidelines (Press Ganey Associates, 2015). Those who completed this program were skin-care champions on their units and conducted the NDNQI survey each quarter. Data was collected on each patient on each unit with a bedside skin assessment completed by the “skin-champions,” followed by a chart review with specific categories such as various pres- sure ulcer risk factors, and whether pressure ulcer plans of care were in place. Inter-rater reliability was increased by the CWON assessing patients who were deemed by the skin-care champion to have a hospital-acquired pressure ulcer.

A 2006 year-end goal of 5% for HAPU prevalence was set. MaineGeneral’s objectives were created based on data collected from the NDNQI study and chart reviews. To increase the Braden score (Braden & Bergstrom, 1998) skin breakdown risk assessment completion upon admission from 85% to 100%, and to increase compliance with implementation of the pressure ulcer prevention NPUAP guidelines from 15% to 100% and increase documentation of interventions from 15%

to 100%. To reach these objectives, in-services were provided on compliance issues and best practice based on NPUAP guidelines (2014); performance of monthly chart audits in between the study dates; and the CWONs made regular visits to each unit and assessed the electronic medical record (EMR) for ease and accuracy of wound documentation. Despite these actions, the annual mean rate of HAPU prevalence at the end of 2006 was 8%.

In 2007, a qualitative survey on one unit of 11 registered nurses (RN) and 5 nursing unit assistants (NUA) was con- ducted to determine attitudes and understanding of pressure ulcer prevention (PUP). This showed the greatest perceived ob- stacles to prevention interventions were lack of time and poor communication. Lack of knowledge and inadequate equipment were also cited. After education via in-services and staff meet- ings on best practice, skin-care champions encouragement at the bedside, and monitoring through chart reviews and the prevalence study, the annual mean prevalence rate decreased minimally in 2007 to 6.9%. At that time it was predicted that when nurses were given the knowledge, they would automat- ically turn it into practice. This prediction was not realized in the study rate. According to a national retrospective study in the northeast region of the United States, the annual mean prevalence rate for 2007 was 4.6% (Lyder et al., 2012).

In 2008, the 5 Million Lives Getting Started Kit: Prevent Pressure Ulcers How to Guide (IHI, 2006) was used to support and incorporate EBP. In particular, small tests of change were conducted, using the plan-do-study-act cycle with one medical surgical unit as a test case. For instance, the unit RNs posted a paper clock on the wall in the patient’s room, to remind staff of the need to turn the patient every 2 hours. It was learned that at first the clock helped, but then it was ignored, blending in with the other items of importance. Next, a yellow card was used. The cared was attached to the outside of the door jam signifying the patient was at high-risk for pressure ulcers to prompt more frequent assessment. This was successful, as staff said it was easy to see and a reminder to go into the room to turn the patient more frequently.

At the same time, other hospital EBP initiatives began. For example, the OR established a policy for PUP using gel pads and memory foam, developed a four-person transfer process to minimize skin shearing, and initiated skin assessments before and after a patient was in the prone position. Case studies on positioning and the Braden scale were presented at staff meet- ings on the medical surgical units. An algorithm was devel- oped by the CWONs for pressure redistribution surfaces, such as when to use a chair air cushion or a low-air-loss mattress. Distribution started of a monthly PUP newsletter highlight- ing skin tips of the month. By the end of 2008, the Agency for Healthcare Research and Quality tool kit (2014), and guidelines from the NPUAP (2014), effectively impacted the planning and implementation process in regards to five areas: patient as- sessment including the Braden score, management of excess skin moisture, optimization of patient nutrition, skin hydra- tion, and pressure minimization. In December of 2008, the