1. “Saving The Skin: pressure ulcer prevention in the ICU”
Barbara Logue RN, BSN, CCRN
Cynthia Copeland RN, BSN, CCRN
Cardiothoracic ICU (56ICU)
Barnes-Jewish Hospital
October 2014

2. Cynthia and I have been bedside nurses in the Cardiothoracic ICU at Barnes Jewish Hospital for over 10 years. We also function in the role of unit-bases wound liaison nurses to assist staff with the long standing challenge of pressure prevention.

3. --Focus on preventable cost
--No payment for Stage III and Stage IV pressure ulcers --Identifiable present of admission skin status
--Prevention driven by nursing care
Starting in 2008 the Centers for Medicare and Medicaid Services specified they would no longer cover additional costs for hospital acquired pressure ulcers resulting in transformational change in hospital payment/reimbursement practices.

4. STATISTICS Estimated 60,000 hospitalized patients die each
year from complications due to hospital
acquired pressure ulcers.
Estimated cost of managing a single full-thickness pressure ulcer averages $70,000
Total cost for treatment of pressure ulcers in the United States is estimated at $11 BILLION a year.
The prevalence of pressure ulcers in heath care facilities in increasing.
Rates vary considerably by clinical setting with acute care leading the list.

5. ANALYSIS OF BARRIERS
Current practices not standardized but guided by primary nurse
Nurse’s belief that pressure ulcers could not be prevented in certain patients
Reluctance to identify and document
Unawareness of available products
EDUCATION, EDUCATION, EDUCATION
PRESSURE ULCER PREVELANCE EXCEEDING 20% CONTINUED TO BE A PERSISITENCE PROBLMEN N OUR CT-ICU DESPITE OUR CONCERTED EFFORTS TO REDUCE INCIDENCE.

6. EVALUATION OF OUR CURRENT PRACTICES
Turning schedule
Braden scale assessment tool
Skin assessment

7. DEVELOPING AN INTERDISCIPLINARY TEAM
Wound/skin liaison •Unit manager
Staff RNs • Wound/ostomy team
Bed providers •Skin product suppliers
Physical therapist •OR involvement
Dietitian

8. DEVELOPING OUR STRUCTURED PERFORMANCE IMPROVEMENT PROCESS
Use of Braden Score q12 hours
Redefining role of skin liaison nurses
Better utilization of wound/ostomy nurses
Use of support surfaces for all patients
Improvement of documentation
Team approach for performance improvement
Education for all clinical staff
Change thinking from inevitable to preventable
Evaluation of products and availalbility
Consistent data collection to evaluate outcomes

9. DEVELOPING OUR PRESSURE ULCER PROTOCOL
-Nursing and medical leadership involvement
-Renewed emphasis on bedside shift report
-Evaluation of units’s pressure ulcer therapy supplies
-Aggressive use of prevention tools
-Better communication of suspected pressure ulcers
-Real-time pressure ulcer identification
-Care tailored to problem
-Weekly posting of pressure ulcer rates so everyone could see results of our efforts
With MULTIPLE FACTORS CAUSING PRESSURE ULCERS MULTIPLE INTERVENTIONS WERE TRIED UNTIL WE FOUND THE RIGHT COMBINATION.

10. TEACHING TOOLS

11. RESULTS
Excellent clinical care that has resulted in observable improvement
Continuous performance improvement
Team-building
Changing, adapting, building
BY APRIL 2011 TRENDS IN OUR DATA SHOWED THE CHANGE WE HAD HOPED FOR—5 WEEKS IN A ROW OUR UNIT ACQUIRED PRESSURE ULCER RATES REMAINED 0. FOR THE MOST PART WE HAVE BEEN ABLE TO MAINTAIN OUR TARGET GOAL OF 4%. THAT IS UNTIL 2013 WHEN OUR EXTRA CORPOREAL MEMBRANE OXYGENATION POPULATION NEARLY DOUBLE DUE TO THE H1N1 EPIDEMIC. AND NOW CYNTHIA WILL EXPLAIN HOW WE DEALT WITH THAT.

12. Purpose
ECMO is a therapy that provides support of the heart and lungs when patients have severe cardiopulmonary failure
They are at extreme risk of developing pressure ulcers
We did this evidence-based project to see if implementing a change in the therapeutic bed would reduce the occurrence of pressure ulcers in this high-risk population

13. Pressure Ulcers in ECMO Patients Pre-Implementation
Forty-eight patients received ECMO in the 4 months before we implemented the OR improvements and ICU bed change. Out of these, eight patients (16.6%) developed 10 unit-acquired pressure ulcers, and 15 patients (31%) developed 25 hospital-acquired pressure ulcers. Both of these rates were well above the hospital targets for unit-acquired and hospital-acquired pressure ulcers.
Hospital target
Unit target

14. ECMO peripheral and Central Cannulation Sites
ECMO Support
ECMO peripheral and Central Cannulation Sites

15. Multisystem Failure

16. High Risk Patients Require Intensive Interventions
This patient is on ECMO with an open chest, IABP, ventilator, multiple vasopressors, inotropes, blood transfusions and is receiving CLRT at 20 degrees every 30 minutes

17. Total Care Sport with Continuous Lateral Rotation Therapy ( CLRT)
Comparable hospitals use low air loss mattress with CLRT with success
Information from comparable institutions utilizing ECMO therapy in the prevention of Pressure Ulcers.
ECMO patients on Total Care Sport

18. Implementing Guidelines Specific to ECMO Population
Operating room support
New roles for secretaries, ICU technicians and charge nurses
ECMO patients placed on Total Care Sport with (CLRT)
In-services provided for all 56ICU staff by Hill-Rom staff and by skin care liaisons

19. ICU Technician prepares, delivers and signs in Total Care Sport bed with OR

20. ECMO Patient Arriving from OR on Total Care Sport Bed

21. ECMO patients on CLRT Therapy
Anonymous audits were conducted twice a day to evaluate and ensure beds were programed appropriately and rotation function was in use.
Depending on patient tolerance, beds are programmed to rotate every 30 minutes degrees

22. Pressure Ulcers in ECMO Patients Pre- and Post-Implementation
Twenty-six patients received ECMO after we implemented the OR improvements and ICU bed change. Out of these, no patients developed a unit-acquired pressure ulcer, and only 3 patients (11.5%) developed 3 hospital-acquired pressure ulcers. Both of these rates represent significant decreases in pressure ulcer development in this very critically ill patient population.
Hospital target
Unit target

23. Pressure Ulcer Prevention
Nurses
Physicians
Ancillary Staff
Management
OR Staff
Pressure ulcer prevention presents an important challenge in critically ill ECMO patients. Pressure Ulcer prevention requires OR staff, nurses, doctors, ancillary and management. No one clinician can be responsible for doing it all! It takes everyone working as a team together to prevent pressure ulcers in critically ill ECMO patients.

24. Acknowledgments
We thank the OR and 56ICU staff for their tremendous efforts which led to our positive results.
We would also like to thank the Greater St Louis Chapter of the AACN, especially Dawn Held who made this all possible.

25. Questions?