MDS Alert

Are your staff or residents' families unwittingly undermining this common pressure-ulcer prevention strategy?

The MDS 3.0 Section M will do a better job than its predecessor in tracking how well your facility is preventing and healing pressure ulcers. And one nursing facility has a number of hard-earned "lessons learned" about how to implement and keep a skin care quality improvement initiative on the right track.

"We don't have the textbook case of ... perfect forever after," said Ellen Parish, VP of quality for Isabella Geriatric Center (New York, N.Y.), who presented on the initiative at the November 2009 American Association of Homes & Services for the Aging annual meeting. In a recent update on the facility's progress, Parish says the facility continues to work on maintaining its initial success  rates. "It's a battle" -- one Parish says she thinks a lot of facilities grapple with.

At the outset of the initiative, Isabella decided to target two areas: pressure ulcers that occurred after the resident came to the facility, and non-healing decubiti.

Address Various Facets of Prevention, Wound Care Here's a sampling of strategies the center uses as the result of its quality initiative and subsequent fine-tuning.

1. A multi-disciplinary wound-care team. The facility brought its interdisciplinary team, which had been primarily doing wound-related documentation reviews, "closer to the bedside," Parish relayed. And the facility hired a certified wound consultant who is a physical therapist to include in the pressure-ulcer rounds. In addition, the people providing care participated in the rounding process, including the resident's primary CNA and the charge nurse for the shift.

Also: The facility brought a wound-care physician specialist on as a consultant to write recommendations for wound care for the residents' primary physicians.

2. Computerized tools to identify and track pressure ulcers and healing. The facility adopted a pressure ulcer tracking tool provided by IPRO, the state quality improvement organization (see page 118 for a sample report generated by the tool, which is an Excel file). The tool, which uses the National Pressure Ulcer Advisory Panel's pressure ulcer staging definitions, is free to any facility that wants to use it nationwide.

Isabella center rolled out the tracking tool on the six units with the highest number of pressure ulcers. Staff completes the tool weekly. The tool provides immediate feedback that you can discuss with the staff to identify trends on a unit, Parish relayed.

Using the tracking tool is "kind of labor-intensive" up front because you have to enter the information for all residents with pressure ulcers, Parish told AAHSA conferees. "But once you set it up, it's just a weekly update of same, improved, changed, discharged. Then every month, you do a monthly close-out and it generates the sheet for the next month."

The program carries all of the basic information (resident name, site of wound, stage of wound, date of onset) forward in the new file for the next month, relays David Johnson, NHA, senior QI specialist at IPRO, who developed the tracking form. You can also review any previous month's data.

Isabella also implemented a new form that CNAs use to document any skin changes each shift. The CNAs also report the skin changes to the charge nurse. That information would be logged on a 24-hour-report, and follow-up would be provided, Parish said.

Outcome: The facility found that staff members were catching pressure ulcers at stage 1, which are much easier to heal than more advanced stages.

3. A problem-solving approach for tackling nosocomial pressure ulcers. The team talks to the resident's care staff to understand in a non-punitive "problem-solving way" what might have contributed to the skin change, Parish relayed. Then staff thinks through what to do next and revises the plan of care, using person-centered approaches.

Tip: If the team doesn't see improvement in a wound within a week's time, they review the care plan and try some new ways to "move that pressure ulcer along to a healing state," said Parish.

4. T he ability to monitor and respond to statistical trends. Isabella uses a free statistical trending report file from IPRO to allow the facility to keep tabs on its track record. "To use this file, you manually enter the information from the monthly pressure ulcer tracking form summary tab," which requires about five minutes of time each month, says Johnson. Using the file, the facility can monitor whether it has an increased number of in-house pressure ulcers, and the average number of days required to heal pressure ulcers.

"You can drill down to virtually anything you want, including units and caregiver assignments," Johnson says.

Using the information allows you to target inservice training to a particular unit or type of care issue. The tool can also identify successes to help the rest of the facility implement what has created those successes, adds Johnson.

Resource: You can review sample statistical trending and pressure ulcer tracking reports at http://jeny.ipro.org/showthread.php?t=2369.

4. E ducation related to products. The facility educated staff on the differences between surfaces and how to use them correctly, Parish says. As part of several daylong symposia, vendors came in to exhibit their pressure-relieving products, allowing staff to test them, sit on the surfaces, and become more familiar with them "in a setting removed from the bedside,"

Parish said in her presentation.

A problem: The quality improvement team noticed that staff or even family members were sometimes inflating specialty surfaces more because they perceived the surfaces weren't firm enough for their residents. And in some cases, the increased inflation, which should be geared to a person's weight, etc., caused skin breakdown. In addition, family members were sitting on the bed in some cases and deflating the mattress. "So we would think we had a special surface redistributing pressure but it wasn't working well because someone sat on the bed and caused a deflation."

Solution: The facility provides "one-on-one education" to alert staff and families "to the importance of not changing settings of equipment or sitting on the residents' beds, as this could alter the integrity of the equipment," Parish reports.