No resting on their laurels in reducing pressure ulcers

The staff at 631-bed OSF St. Francis Medical Center in Peoria, Ill., had worked hard and achieved considerable success in reducing pressure ulcers in their hospital patients. But they wanted to press on and do even better.

St. Francis has been a nationally recognized leader in patient safety and quality improvement, and served as a mentor hospital providing guidance to participants in the Institute for Healthcare Improvement's 5 Million Lives Campaign, an initiative conducted between 2006 and 2008 that sought to prevent 5 million incidents of patient harm.

National estimates cited by the IHI are that nearly 60,000 patients die each year from complications linked to hospital-acquired pressure ulcers and that the total annual cost for treating these pressure ulcers is nearly $11 billion. The CMS has estimated that pressure ulcer treatments add an average of $43,180 to patients' hospital bills. In 2008, Medicare stopped paying hospitals for treatment of advanced pressure ulcers.

Before the IHI campaign put a spotlight on bedsore prevention, St. Francis already was working on the problem. In July 2002, 9.4% of its patients acquired pressure ulcers. That number was knocked down to 4% by March 2005, 2.5% by December 2008 and below 1.6% by June 2012. By 2009, St. Francis said it was saving $3 million annually through the reduction in pressure ulcers. While those figures were impressive, there was concern that progress had stalled.

“We got rid of the low-hanging fruit,” said Kelly Nimtz-Rusch, a nurse who serves as director of clinical practice at St. Francis. “That's when you begin to say, 'Now what more can we do?' ”

Because every department had already implemented standard prevention practices, it became necessary to look into each specific area and ask, 'What are your barriers?' ” she said.

A closer examination found that some immobile patients in the cardiovascular intensive-care unit were still getting pressure ulcers. But rather than getting the ulcers from lying in bed, they were being caused by patients sitting in a chair for long periods of time. “Sitting was good for their heart and lungs, but bad for their bottoms,” Nimtz-Rush said.

Patients who undergo long surgeries may suffer deep-tissue injuries that put them at risk for pressure ulcers in the areas of the body with bony prominences. The solution was to give patients a “prophylactic sacra dressing” on their backside prior to surgery to help maintain skin integrity post surgery. Surgeons included the dressing in their pre-op orders, and patients and families were instructed about what was being done and why.

“In those six months, we have not seen a pressure ulcer in that area,” Nimtz-Rush said.

Another group of patients at risk of pressure ulcers were babies in the pediatric ICU who developed skin problems on their nose, back of the head or other areas where medical devices were attached to them.

Nurse Bevette Griffin said special gel pods have been found to reduce these types of sores in pediatric ICU patients. Nurses receive special instructions to be constantly aware about the risk of pressure ulcers and are taught how to attach the gel pods to babies and how to lay the baby down in a position that reduces the risk of injury.

Pressure ulcer prevention and other quality improvements require a constant effort, Griffin said. “I don't think anybody can put a project into place and think it's going to be perfect, because it never is.”

Along with three other certified wound nurses, Griffin heads up the Save Our Skin nursing team at St. Francis, which holds monthly meetings to review data and educate staff on new products and prevention techniques.

The St. Francis program includes providing all adult patients with pressure-relieving air mattresses that lower the risk of bedsores, assessing patients on admission and every 24 hours for pressure-ulcer risk, and reminding staff to reposition patients every two hours if they can't move themselves. For a time, this reminder took the form of playing a segment of Olympic Games theme music over the paging system every two hours, which was discontinued after a campaign to limit noise.

Training, measurement and feedback are provided often, and well-defined roles and responsibilities have been established for pressure ulcer prevention. These include identifying “process owners” who are responsible for ensuring compliance with skin protection protocols in their unit.

Patients who are considered at risk for pressure ulcers are given educational materials on prevention. These patients and their family members are involved in prevention strategies.

Nimtz-Rush reported that the efforts have paid off. The average quarterly rate of patients suffering pressure ulcers last year was 0.8%, including one quarter where the rate hit 0.2%.

Last December, St. Francis was recognized for the third time by the American Nurses Credentialing Center's Magnet Recognition Program. In commenting on the hospital's culture of safety, the recognition program, which is affiliated with the American Nurses Association, cited St. Francis' pressure-ulcer reduction program, saying the hospital was “far ahead of other organizations in the country.”

The tale of how St. Francis reduced pressure ulcers also is featured prominently on the Institute for Healthcare Improvement website. Griffin said she receives e-mails from hospitals across the country asking if she could reveal the secret to their success. “Bottom line, it's culture,” she said. “Improved nursing care is part of it, but if we didn't have administrative backing we would not be where we are.”

Nimtz-Rush agreed that a commitment to patient safety ran deep in the St. Francis culture. “We remind our staff that we don't ever want to be the cause of harm to our patients,” she said. “And pressure ulcers are harm to our patients.”

The Medicare policy of not paying hospitals for treating pressure ulcers has made a difference, said Kathy Duncan, a nurse on the IHI's faculty. “I've been a nurse for 31 years and for 25 years the focus (was) how do we treat pressure ulcers?” she said. “Now we say how do we prevent them?”

Duncan said the IHI is offering online courses for students in healthcare fields focusing on the critical need to prevent pressure ulcers. One course includes the fictional story of a man who had trouble walking his daughter down the aisle at her wedding because of the lingering effects of a pressure ulcer. The intent is not just to say pressure ulcers are bad but that they can affect people for a long time. In real life, Duncan mentions that it was an infected pressure ulcer that led to the death of quadriplegic actor Christopher Reeve.

Follow Andis Robeznieks on Twitter: @MHARobeznieks