Work together to eliminate pressure ulcers

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Prevention tactics from successful New Jersey association

With the help of the New Jersey Hospital Association’s (NJHA) Pressure Ulcer Collaborative, the incidence rate of pressure ulcers has been reduced by 70% at participating facilities. Doing so required patience, a willingness to learn and work with others, and an attitude of excitement about standard practices.

“The interventions were not high-tech or expensive, they just required energy for basic clinical practice,” says Aline Holmes, RN, APNC, senior vice president of clinical affairs for the NJHA. Holmes and Theresa Edelstein, MPH, LNHA, vice president of continuing care services at the NJHA, headed up the pressure ulcer collaborative.

Beginning in September 2005, the collaborative extended an invitation to more than 700 healthcare facilities in New Jersey, ranging from hospitals to nursing homes to assisted living facilities. Initially, 125 facilities signed up to be a part of the collaborative, and that number grew during the second year. Being a part of the collaborative meant every three to four months facilities had to attend two-day educational programs that featured nationally known expert speakers. The programs also gave those who attended a chance to network with each other.

“The learning sessions were critical both for the didactic kinds of presentations from experts, but also from the peer-to-peer learning that went on,” Holmes says. Edelstein and Holmes credit chair Elizabeth Ayello, PhD, RN, a nationally known pressure ulcer expert, with helping find great faculty speakers and learning topics.

In addition, each facility had to use a special data collection tool and submit data on a monthly basis to the NJHA. Data were collected between September 2005 and May 2007. The participants also had access to information such as password-protected senior leader reports and a member listserv.

Think positive

The effort resulted in the following achievements:

A 70% reduction in the incidence of new pressure ulcers, which means there was a 70% drop in the number of pressure ulcers developed while in the care of a facility

Forty-eight organizations achieved a 0% incidence rate for three months, meaning no new pressure ulcers were found

The average incidence rate of new pressure ulcers prior to the pressure ulcer collaborative was 18%

Holmes believes the positive results of the collaborative’s efforts were remarkable for simple reasons.

“[They] resulted from the implementation of what most people would call fairly basic clinical practice: comprehensive skin assessment within eight hours of admission or at the first home health visit, good solid identification of risk factors using the Braden scale within eight hours of admission or at the first home health visit, and implementation of preventive strategies in a timely fashion once you’ve identified someone as being at risk,” says Holmes.

These results were achieved by focusing on the bundle of interventions listed above by Holmes, and each bundle was tested on a pilot population, she says.

The preventive strategies highlighted by the collaborative include using pressure redistribution surfaces and positioning devices, implementing positioning schedules, ensuring good nutritional assessment and intervention, and hydration.

“It’s interesting; sometimes in the focus on getting someone well because of something else that’s wrong with them, sometimes these things tend to fall off the radar and get either inadvertently forgotten or given a little less attention, and then you have a problem,” says Holmes. 

Working together

Another part of the collaborative that Edelstein and Holmes feel was vital to its success was the formation of partnerships within the group. Each facility was required to be in a partnership with one or two providers that did not offer the same type of care. For example, a hospital had to partner with a long-term care facility.

“We required them to be part of a partnership so that they were meeting not only internally but externally with their partners and discussing and deciding how they were going to work together across settings,” Holmes says.

Sending along information about a patient’s prior pressure ulcer care helps with the continuity of treatment, a point the collaborative tried to emphasize.

Edelstein and Holmes say this partnership piece of the collaboration helped enforce the idea that pressure ulcer care should not be limited to one part of the care continuum. It’s everyone’s responsibility and ultimately will mean a greater quality of care delivered to the patient and less money and frustration spent by each individual healthcare team. It also helped foster new relationships among the different healthcare teams.

The most successful partnerships got a chance to present to the rest of the attendees so the others could learn and get ideas for their own partnerships.

Continual progress

Although the collaborative’s two years officially ended in July 2007, the NJHA has not completely shut down the project.“We’re kind of in a quiet stage right now,” Holmes says. 

“We recognized that sustainability is a big challenge. It is with any quality initiative,” Edelstein explains. “So while, yes, we are in a quiet stage, we have committed to certain things.”

First, the listserv and Web site have remained open, and there is activity on them every day, says Holmes. 

Second, the NJHA still accepts and seeks out data, although submitting them is no longer mandatory. 

Third, Holmes and Edelstein have been brainstorming for a checkup conference call at the end of this year for those facilities that participated. 

And last, the NJHA is thinking of hosting a daylong educational conference for facilities that did not take part in the collaborative but are interested in starting their own program. 

This will feature presentations by faculties from those facilities that did participate.

Holmes and Edelstein advise any facilities or health collaboratives wanting to take part in similar efforts to realize it is not something that can be done in a short period of time.

“It takes a while to effect change in the way people practice,” Edelstein says. “You have to have a lot of patience and a sense of humor, because depending on where an organization is with performance improvement, or if they haven’t had a focus on skin care before, it will take longer than a facility that has already started.”

“By this time next year, we’ll be looking at the next phase of the collaborative, and we need to begin to pick the brains of some clinical people to decide what the next pieces are,” Edelstein says. “Do we want to look at things like ‘How do medications affect the condition of a patient’s skin?’ Our heads are kind of all over the place with ideas, but we know one thing for sure—we want to build on what we started.” 

The following are tips for success:

Have patience when taking on a project like this; it is not one that can be finished in a few months. Caregivers want to do the best for their patients, and changing practice is often part of that process.

Be willing to invest money in recognition and awards for star facilities. The pressure ulcer collaborative went public by giving out posters, pins, and plaques to facilities that stood out in their prevention efforts. As a result, patients and visitors to those facilities could see these on display. 

Check out the Institute for Healthcare Improvement Web site. It has a wealth of information about how to help lower the incidence rate of pressure ulcers.