A Framework of Quality Improvement Interventions to Implement Evidence-Based Practices for Pressure Ulcer Prevention

Padula, William V. PhD, MS; Mishra, Manish K. MD, MPH; Makic, Mary Beth F. PhD, RN; Valuck, Robert J. PhD, RPh

Advances in Skin & Wound Care:
doi: 10.1097/01.ASW.0000450703.87099.5b
Features: Clinical Management Extra

PURPOSE: To enhance the learner’s competence with knowledge about a framework of quality improvement (QI) interventions to implement evidence-based practices for pressure ulcer (PrU) prevention.

TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.

OBJECTIVES: After participating in this educational activity, the participant should be better able to:

1. Summarize the process of creating and initiating the best-practice framework of QI for PrU prevention.

2. Identify the domains and QI interventions for the best-practice framework of QI for PrU prevention.

ABSTRACT: Pressure ulcer (PrU) prevention is a priority issue in US hospitals. The National Pressure Ulcer Advisory Panel endorses an evidence-based practice (EBP) protocol to help prevent PrUs. Effective implementation of EBPs requires systematic change of existing care units. Quality improvement interventions offer a mechanism of change to existing structures in order to effectively implement EBPs for PrU prevention. The best-practice framework developed by Nelson et al is a useful model of quality improvement interventions that targets process improvement in 4 domains: leadership, staff, information and information technology, and performance and improvement. At 2 academic medical centers, the best-practice framework was shown to physicians, nurses, and health services researchers. Their insight was used to modify the best-practice framework as a reference tool for quality improvement interventions in PrU prevention. The revised framework includes 25 elements across 4 domains. Many of these elements support EBPs for PrU prevention, such as updates in PrU staging and risk assessment. The best-practice framework offers a reference point to initiating a bundle of quality improvement interventions in support of EBPs. Hospitals and clinicians tasked with quality improvement efforts can use this framework to problem-solve PrU prevention and other critical issues.

Author Information

William V. Padula, PhD, MS • Postdoctoral Fellow • Department of Medicine, University of Chicago • Chicago, Illinois

Manish K. Mishra, MD, MPH • Fellow • Geisel School of Medicine, Dartmouth College • Hanover, New Hampshire

Mary Beth F. Makic, PhD, RN • Research Nurse Scientist, Critical Care • University of Colorado Hospital • Aurora, Colorado

Robert J. Valuck, PhD, RPh • Professor • Department of Clinical Pharmacy, University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences • Aurora, Colorado

Acknowledgments: The authors thank the following people who participated in the pilot to revise the best-practice framework for pressure ulcer prevention: Dr Heidi Wald, Dr Kavita Nair, Dr Jonathan Campbell, Dr Anne Libby, Dr Heather Anderson, Dr Vahram Ghushchyan, Carol Ruscin, Connie Chambers, Dr Paul Cooke, Paula Gipp, Dr Dan Matlock, Dr Lisa Price, Ethan Cumbler, Dr Paul Batalden, Dr Mark Splaine, Mary Catherine Rawls, Mary Jo Slattery, and Carmelita Beidler.

All authors, staff, faculty, and planners, including spouses/partners (if any), in any position to control the content of this CME activity have disclosed that they have no financial relationships with, or financial interests in, any commercial companies pertaining to this educational activity.

To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least 13 of the 18 questions correctly.

This continuing educational activity will expire for physicians on June 30, 2015.

Article Outline
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Pressure ulcer (PrU) prevention is a key concern in all hospitals, especially in critical care and postoperative units throughout North America and Europe. According to Black et al,1 PrUs are mostly preventable if clinicians actively implement evidence-based practices (EBPs) for PrU prevention. The National Pressure Ulcer Advisory Panel (NPUAP) endorses an evidence-based prevention protocol that includes 5 elements: risk assessment with a valid instrument (eg, the Braden Scale for Predicting Pressure Sore Risk© or the Norton Scale); frequent patient repositioning; managing nutrition, moisture, and incontinence; using modern support surfaces (eg, beds and overlays); and continual nursing education about prevention.2 This protocol was published in 2003, and coincidentally, since the mid-2000s, hospital-acquired PrU rates in the United States have fallen significantly from approximately 7% to 4.5% as of 2012.3,4

The NPUAP protocol guided clinicians on hospital-level initiatives for preventing PrUs. However, underlying factors likely facilitated PrU prevention. In 2008, the US Centers for Medicare “ Medicaid Services enacted nonpayment policy for priority hospital-acquired conditions (HACs) including PrUs.5 This policy institutionalized EBPs for PrU prevention since the burden of these costly HACs was transferred to hospitals.6 Considering multiple studies that find PrU prevention cost-effective compared with treatment,7,8 hospitals reacted appropriately by emphasizing implementation of EBPs.9

According to Gonzales et al,10 standardizing EBPs comes after many iterations of organizational change to hospital systems. In the early 2000s, hospital systems were susceptible to “workaround culture,”11 so in order to incorporate EBPs clinicians had to actively redesign the systems that they supported.12 Therefore, quality improvement (QI) theory offers a solution to systematic redesign. Quality improvement interventions are a set of system tools that enable interaction between stakeholders in each domain of healthcare to achieve specific aims.13 Therefore, adoption of QI interventions supports effective implementation of EBPs to achieve desired outcomes, such as hospital-acquired PrU prevention.

The best-practice framework of QI developed by Nelson et al13 is a useful model of QI interventions that targets process improvement in 4 domains: leadership, staff, information and information technology (IT), and performance and improvement.13 Each domain is structured with individual QI interventions designed to activate stakeholder participation in the adoption of EBPs, such as hospital leadership, clinicians, and patients (Figure 1).

 Based on the understanding that QI supports EBPs, there is an interest in knowing what QI intervention(s) can be used in a bundle with the PrU prevention protocol to increase adherence to elements of the protocol and reduce PrU incidence. The hypothesis of this report is that the best-practice framework can be modified from its generalizable form for application in PrU prevention. By reading this article, clinicians and hospital staff tasked with QI efforts can use this framework to problem-solve PrU prevention and other critical issues.

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Nelson et al’s13 presentation of the best-practice framework in Quality by Design is a general approach to QI. To target an important issue arising in hospital critical care, the purpose of this study was to modify the best-practice framework for clinicians to reference in PrU prevention efforts. This study began by conducting qualitative interviews with experts in PrU prevention and QI.14 The best-practice framework was shown to 7 physician experts in critical care, preventive medicine, and QI, as well as 5 nursing experts in critical care and wound care, and 6 health services researchers at 2 US academic medical centers. These experts offered insight into how the best-practice framework should be altered as a reference tool for QI strategies in PrU prevention.

The revised framework includes 25 elements across 4 domains (Table 1). Leadership interventions are meant to offer inclusion of hospital administration that govern the supply of resources (eg, financial, personnel, material) to be applied toward new priorities such as PrU prevention. Staff interventions support the dissemination of EBPs for use in hospitalized patients in areas of surgery, critical care, and general internal medicine. Performance and improvement interventions are designed to modify existing clinical microsystems to directly incorporate new EBPs. Many of the performance-improvement elements support direct improvements to the NPUAP protocol, such as updates in PrU staging and risk assessment.15,16 Other interventions such as a risk-assessment tool embedded in electronic health record systems support the novel use of IT to implement EBPs hospital-wide.

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The best-practice framework by Nelson et al13 is a valuable resource of QI interventions that can be reapplied to PrU prevention throughout various hospital settings, as found during qualitative interviews with QI and prevention experts. Clinicians should reference the organized findings of this study to systematically change clinical processes for the adoption of EBPs in critical care, postoperative care, and general internal medicine. This framework has the potential to be applied to other HACs in addition to PrUs that impact patient utilization of critical care services, such as catheter-associated urinary tract infections, surgical-site infections, ventilator-associated pneumonia, and falls. Reapplication of the framework should begin with the process of modification as prescribed by clinical content experts for the priority area of interest (eg, clinical “champions”) and follow with support from leadership and involved staff.

The adoption of this QI framework begins with leadership. Clinical champions such as wound care experts in the case of PrU prevention should use the leadership QI interventions to gain support from hospital administrators and QI leaders for their cause. Following leadership support, champions should disseminate an understanding of the QI strategy to other staff that can help achieve successful outcomes using the team approach.17 Performance and improvement interventions offer tools that are directly applicable to systematic improvement of the problem, divisible by the application to critical care or elsewhere. Finally, IT provides a novel interface through which system tools are enabled hospital-wide for more efficient implementation of EBPs, such as the NPUAP protocol.18

This study was limited by multiple factors, including a small cohort that was interviewed to modify the best-practice framework. The generalizability of these findings may be of limited application outside academic medical centers as well. Academic medical centers typically have the resources to research effective implementation of EBPs. Other types of hospitals may be further behind on the spectrum, such as requiring a better understanding of what EBPs are, before investigating approaches implementation.

Ultimately, this best-practice framework is useful for clinicians tasked with improving outcomes in the hospital with EBPs. A QI initiative is operable only if it gains thorough support from all domains of the hospital system, including leadership, staff, IT, and performance and improvement. The best-practice framework for QI developed by Nelson et al13 is not only considered for PrU prevention, but can also be continuously reiterated for other HACs that have associated EBPs for prevention, such as catheter-associated urinary tract infections, falls, and surgical-site infections.19 A simple, yet effective approach to altering the best-practice framework for other conditions can be modeled after the approach of this study to achieve development of a reference tool for QI interventions.

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This qualitative study provides an off-the-shelf catalogue of QI interventions that wound care teams can utilize for preventing hospital-acquired PrUs and possibly other HACs. For further consideration, the field would benefit from comparative effectiveness research about QI interventions and strategies for hospital-acquired PrU prevention toward which hospitals can focus their efforts.

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* Pressure ulcer prevention guidelines are evidence-based and should be implemented as prescribed.

* Quality improvement interventions are adopted in support of implementing EBPs.

* Quality improvement is not a replacement for EBPs.

* Quality improvement efforts require thorough strategy components based on this framework.

* Hand-picking 1 or 2 QI interventions that are not complementary is not a sustainable practice.

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1. Black JM, Edsberg LE, Baharestani MM, et al.National Pressure Ulcer Advisory Panel. Pressure ulcers: avoidable or unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference. Ostomy Wound Manage 2011; 57 (2): 24–37.
2. Ratliff CR, Bryant DE. Guidelines for the Prevention and Management of Pressure Ulcers. WOCN Clinical Practice Guideline No. 2. Glenview, IL: Wound, Ostomy, and Continence Nurses Society; 2003: 52.
3. Whittington K, Briones R. National Prevalence and Incidence Study: 6-year sequential acute care data. Adv Skin Wound Care 2004; 17: 490–4.
4. Lyder CH, Wang Y, Metersky M, et al. Hospital-acquired pressure ulcers: results from the national Medicare Patient Safety Monitoring System study. J Am Geriatr Soc 2012; 60: 1603–8.
5. Kurtzman E, Buerhaus PI. New Medicare payment rules: danger or opportunity for nursing? Am J Nurs 2008; 108 (6): 30–35.
6. Welton JM. Implications of Medicare reimbursement changes related to inpatient nursing care quality. J Nurs Adm 2008; 38: 325–30.
7. Padula WV, Mishra MK, Makic MB, Sullivan PW. Improving the quality of pressure ulcer care with prevention: a cost-effectiveness analysis. Med Care 2011; 49: 385–92.
8. Pham B, Stern A, Chen W, et al. Preventing pressure ulcers in long-term care: a cost-effectiveness analysis. Arch Intern Med 2011; 171: 1839–47.
9. Makic MB, VonRueden KT, Rauen CA, Chadwick J. Evidence-based practice habits: putting more sacred cows out to pasture. Crit Care Nurs 2011; 31 (2): 38–61.
10. Gonzales R, Handley MA, Ackerman S, O’Sullivan PS. A framework for training health professionals in implementation and dissemination science. Acad Med 2012; 87: 271–8.
11. Edmondson AC. Learning from failure in health care: frequent opportunities, pervasive barriers. Qual Saf Health Care 2004; 13 (Suppl 2): ii3–9.
12. Nelson WA, Gardent PB, Shulman E, Splaine ME. Preventing ethics conflicts and improving healthcare quality through system redesign. Qual Saf Health Care 2010; 19: 526–30.
13. Nelson EC, Batalden PB, Godfrey MM. Quality by design. San Francisco, CA: Jossey-Bass; 2007.
14. Padula WV, Mishra MK, Makic MB, et al. Implementation of quality improvement interventions for pressure ulcer prevention in university health system consortium hospitals. Value Health 2013; 16 (3): A208.
15. Black JMNational Pressure Ulcer Advisory Panel. Moving toward consensus on deep tissue injury and pressure ulcer staging. Adv Skin Wound Care 2005; 18: 415–6, 418, 420-1.
16. Bergstrom N, Braden BJ, Laguzza A, Holman A. The Braden Scale for predicting pressure sore risk. Nurs Res 1987; 36: 205–10.
17. Schaffer A. Fighting bedsores with a team approach. new York Times 2008. http://www.nytimes.com/2008/02/19/health/19sore.html?pagewanted=all“_r=0. Last accessed April 7, 2014.
18. Padula WV, Mishra MK, Weaver CD, Yilmaz T, Splaine ME. Building information for systematic improvement of the prevention of hospital-acquired pressure ulcers with statistical process control charts and regression. BMJ Qual Saf 2012; 21: 473–80.
19. Wald HL, Kramer AM. Nonpayment for harms resulting from medical care: catheter-associated urinary tract infections. JAMA 2007; 298: 2782–4.

pressure ulcers; evidence-based practices; Centers for Medicare “ Medicaid Services policy; quality improvement

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