By Debra Wood, RN, contributor
Long before the Centers for Medicare & Medicaid Services (CMS) decided to stop reimbursing for care associated with hospital-acquired pressure ulcers and certain other adverse events, Northwest Community Hospital in Arlington Heights, Illinois, began working on a comprehensive plan to reduce the incidence of decubitus ulcers.
“We were ahead of our time,” said Diane Davis-Zeek, MS, APN, NP-C, CWOCN, a wound, ostomy and continence nurse consultant and nurse practitioner at Northwest Community. “When this came about in October [2008] with the reimbursement, we were ready for it.
Davis-Zeek had previously worked in long-term care and home care, where CMS first focused on pressure ulcer prevention and she expected the agency would soon target acute care facilities, which it did.
A 2004 study drawing data from the New Mexico Medicaid fee-for-service program estimated that each pressure ulcer cost hospitals approximately $15,760 in 1998. Other research has pegged the costs to be much higher. It’s more difficult to heal than it is to prevent one from developing in the first place, Davis-Zeek explained.
Preventing decubiti not only saves money, it’s better for patients.
“Pressure ulcers are painful,” Davis-Zeek said. “It also puts the patient at risk for infection.”
Northwest Community’s quality improvement council first noted the hospital’s pressure ulcer rate started falling below national benchmarks more than four years ago. The hospital decided to form a Skin Protection Task Force to tackle the problem, implemented a series of practice changes and brought the rate from 16 percent down to between 2 percent and 5 percent. Davis-Zeek presented the hospital’s initiative at the 2007 Institute for Healthcare Improvement annual forum on quality improvement.
The task force researched best practices, national guidelines and compared Northwest Community’s policies and procedures to established evidence. It found the products the facility used were not the most effective, policies needed changing and staff required additional education in skin care.
Nurses now complete the Braden scale for predicting pressure ulcer risk on admission with any significant condition change, and every Monday, Wednesday and Friday. Guidelines are changing and Northwest has already begun updating policies to reflect that change to daily risk assessments on regular units and every 12 hours in critical care.
Northwest Community nicknamed its skin care resource team the Skintastics. Nurses and patient care technicians on the team serve as resource people to help implement new measures and conduct quarterly prevalence surveys. A skin care notebook stays on the unit for quick reference about how to use all of the new skin-care products: 3M Advanced Care Products; Prevalon heel protectors; Ehob waffle mattress overlays and chair cushions, which the patient takes home; and Sage bathing and barrier protection products.
“I can’t say some of the products we have chosen and the measures we’ve undertaken have been the cheapest alternatives,” Davis-Zeek said. “You have to look at the whole picture…sometimes you have to spend a little to save a lot down the road.”
Administration support is key to the initiative’s success and investing in products and people pays off, she said. The hospital’s annual cost of caring for heel pressure ulcers prior to implementation was $1.99 million. Pressure-relieving boots cost about $88,000, to stock the entire facility, resulting in a net savings of $1.9 million.
Sage Products, which develops and manufactures innovative products for the professional and retail health care industries, introduced the boots about two years ago after years of research. Jim Layer, Sage vice president of new product development, encourages nurses to ask vendors for evidence that their products are intuitive to use in the practice setting and will work to prevent pressure ulcers.
“Anything short of that and you are gambling,” said Layer, adding that nurses also should work with purchasing to make sure the product aligns with established processes and procedures.
Knowing that continuously wet skin increases the damaging effects of pressure, friction and shear, the Northwest Community nurses have also focused on incontinence management. For patients with considerable diarrhea, nurses may apply a fecal pouch. Rather than diapering patients, nurses place Attends Supersorb pads under the patient.
“It does not hold the moisture next to the patient’s skin,” Davis-Zeek said. “It allows air flow. When it gets wet, it gels and wicks away moisture, so the patient isn’t lying on a big, wadded up wet thing.”
Turning clocks—images of clocks posted on the wall—help remind staff to reposition patients. Dieticians consult whenever a patient develops a wound or a patient is at risk.
It’s always a work in progress,” Davis-Zeek said. “We are trying for zero.”
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