HOSPITALS ARE challenged to provide increasingly complex care to higher acuity patients while keeping a close eye on the bottom line. As the demand for quality outcomes is increasing, so are financial pressures to avoid "no pay" events. In October 2008, the U.S. Centers for Medicare and Medicaid Services (CMS) began denying reimbursement for treatment of certain conditions considered avoidable, such as hospital-acquired stage III and stage IV pressure ulcers that "could reasonably have been prevented through the application of evidence-based guidelines."1
Nurses, who are direct caregivers, are increasingly responsible for meeting these challenges, often without an increase in resources. They need effective communication, streamlined workflow processes, and optimal human resources to be successful.
Martha Jefferson Hospital, a 176-bed not-for-profit Magnet®-designated community hospital, has improved quality outcomes by using unlicensed assistive personnel (UAP) to champion pressure ulcer prevention (PUP) strategies. This article describes this initiative and technology improvements that support these strategies.
Lunches lead to learning
Recognizing the contribution that UAP make to patient care, our department of nursing education began sponsoring a program called Uniquely Yours in January 2006. The purpose was to recognize UAP for their hard work and optimize their promotion of patient safety and quality. Held once each month, Uniquely Yours luncheons provide an opportunity for UAP from across the organization to gather, learn, and discuss issues of concern.
At the first Uniquely Yours luncheon, the nurse educator discussed PUP and the important role UAP play in noticing subtle changes in skin condition, and gave all UAP a pocket guide with tips for preventing pressure ulcers. She also led a discussion about potential barriers to implementing skin care strategies and followed up with each nursing unit to ensure that proper equipment and resources were available to implement PUP strategies.
Several months later, the nurse educator returned to Uniquely Yours to inform the UAP about guidelines for PUP set forth by the National Pressure Ulcer Advisory Panel (NPUAP) and the Wound, Ostomy and Continence Nurses Society.2,3 These include elevating heels, repositioning, keeping patients clean and dry, and optimizing nutrition.
Creative teaching strategies included a game of charades with participants acting out prevention strategies. The nurse educator then made sure that UAP had access to prevention tools (such as pillows, heel lift boots, and nonmedicated skin care products within their scope of practice).
Our UAP are educated on the importance of communicating skin changes to the patient's primary nurse and collaborating with the nurse to determine the best PUP strategies for the patient. To engage UAP in ongoing awareness of PUP and to facilitate communication about skin changes, we implemented skin care report cards, using carbon-copy tools. Our UAP fill out a diagram to indicate areas of concern requiring assessment by the nurse, add their name and the patient's name, and give it to the primary nurse. The duplicate goes into a box for a monthly prize drawing.
Our PUP education led to a feeling of empowerment among the UAP, who saw the impact of their prevention strategies. They started seeking guidance directly from the nurse educator when they believed that patients needed further interventions and made sure that their contributions were documented.
Around then, the NPUAP changed the staging guidelines for pressure ulcers, and the CMS's no pay events were looming. We identified a need for enhanced electronic documentation to ensure that PUP activities were recorded and any pressure ulcers were staged and documented consistently.
We formed a "rapid cycle" pressure ulcer team to help us quickly produce results on this critical initiative. For more about this process, see http://www.ashp.org/s_ashp/docs/files/QII_RapidCycleImprov.pdf. We developed electronic pressure ulcer documentation screens that were suitable for use by both disciplines. In this documentation, the nurse completes the Braden scale on admission, then every 24 hours and as required by any change in the patient's condition.4
If the Braden scale score indicates a patient is at risk, a PUP intervention form is automatically posted to the nurse and the UAP computer-generated task list every 2 hours. The PUP intervention form includes PUP strategies for each level of risk based on the Braden score. This triggers a reminder to provide and document all recommended PUP measures performed.
Once these interventions have been performed and documented, the task disappears from both lists, and then reappears 2 hours later, until the patient is discharged or is no longer at risk. Either discipline can access the PUP form anytime between the scheduled tasks to ensure that new or additional preventive measures are documented.
The changes to the electronic medical record went live in December 2008 following education and training on all units. Intermittent follow-up is done at Uniquely Yours luncheons.
In addition, the nurse educator receives a daily electronic report showing the location of any patients with low Braden scores or pressure ulcers. This lets the educator follow up immediately to discuss individualized PUP strategies for patients.
The report also enables her to collaborate with the primary nurses to ensure that any patients admitted with skin breakdown are receiving optimal treatment and that care is being documented correctly.
Outcomes measure up
As a result of these initiatives, the incidence of patients with hospital-acquired pressure ulcers at our facility is consistently below the Magnet® mean on all medical-surgical units and the ICU as reported to the National Database for Nursing Quality Indicators (NDNQI). Pressure ulcer incidence is tracked daily and reported at the unit and hospital level to raise awareness around prevention and to celebrate ongoing quality outcomes. Our hospital's UAP turnover rate is consistently lower than that of comparison hospitals as measured by NDNQI.
Since the implemention of these initiatives on our inpatient units, we've also established PUP strategies in our ED. We've made enhancements to our electronic record in the ED to document prevention strategies and have added a Braden scale assessment to identify patients at risk for skin breakdown. ED technicians now also attend our Uniquely Yours programs, which is helping to hardwire UAP initiatives across the continuum of care.
Using our UAP to champion PUP has been a win-win for our hospital—and for our patients, the ultimate beneficiaries.