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

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“Saving The Skin: pressure ulcer prevention in the ICU”

Barbara Logue RN, BSN, CCRNCynthia Copeland RN, BSN, CCRN

Cardiothoracic ICU (56ICU)Barnes-Jewish Hospital

October 2014

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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.

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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.

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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.

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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

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EVALUATION OF OUR CURRENT PRACTICES

• Turning schedule• Braden scale assessment tool• Skin assessment

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DEVELOPING AN INTERDISCIPLINARY TEAM

• Wound/skin liaison •Unit manager• Staff RNs • Wound/ostomy team• Bed providers •Skin product suppliers • Physical therapist •OR involvement• Dietitian

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• 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

DEVELOPING OUR

STRUCTURED PERFORMANCE IMPROVEMENT

PROCESS

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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

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TEACHING TOOLS

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RESULTS

• Excellent clinical care that has resulted in observable improvement

• Continuous performance improvement• Team-building• Changing, adapting, building

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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 bedwould reduce the occurrence of pressure ulcersin this high-risk population

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Pressure Ulcers in ECMO PatientsPre-Implementation

Pre-implementation0%

5%

10%

15%

20%

25%

30%

35%

0.166

0.31Unit-Acquired PrU

Trendline

Hospital Acquired PrU

Unit target

Hospital target

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ECMO Support

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Multisystem Failure

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High Risk Patients RequireIntensive 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

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Total Care Sport with Continuous Lateral Rotation Therapy ( CLRT)

• Comparable hospitals use low air loss mattress with CLRT with success ECMO

patients on Total

Care Sport

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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

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

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ECMO Patient Arriving from ORon Total Care Sport Bed

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ECMO patients on CLRT Therapy

Depending on patient tolerance, beds are programmed to rotate every 30

minutes 10-30 degrees

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Pressure Ulcers in ECMO PatientsPre- and Post-Implementation

Pre-implementation Post-implementation0%

5%

10%

15%

20%

25%

30%

35%

16.6%

0.0%

31.0%

11.5%

Unit-Acquired PrUTrendlineHospital Acquired PrU

Unit target

Hospital target

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Nurses

Physicians

Ancillary Staff

Management

OR Staff

Pressure Ulcer Prevention

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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.

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Questions?

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