IHI faculty member Kathy Duncan is director for the Preventing Pressure Ulcers Expedition. In this interview with IHI Communications Specialist Jo Ann Endo, she talks about why preventing pressure ulcers continues to be challenging and how education is only part of the solution.
Q: Teams have been focusing on preventing pressure ulcers for a long time. What continues to make it so challenging?
A: The prevention of pressure ulcers is about the reliability of prevention measures that often get shuffled to the bottom of the “to-do” list. Without really good processes and reliable staff to implement those processes, to make sure we are providing the right care 100% of the time for 100% of the patients, these low-tech practices – like turning patients at least every two hours, fluid balance, and making sure patients are on the right surfaces – are often low on the priority list. Prevention measures can get forgotten because you aren’t treating something that is there; you’re trying to prevent something. It’s not the same as giving IV meds or taking care of ventilators or changing dressings. You have to make these practices routine or they just won’t happen. There is very little new science, so these practices aren’t new. The challenge is helping staff develop processes they can do over and over again as part of their regular, systematic work.
Q: For the upcoming Preventing Pressure Ulcers Expedition you’ve lined up exemplar teams for every session to describe their efforts. What have you learned so far about their keys to success?
A: We have reached out to six different hospitals who have had success with pressure ulcer prevention. They are very proud of their work. The hospitals range from relatively small to very large system hospitals, and they have all adapted and implemented really reliable processes.
Many have worked on triaging to make sure the patients at highest risk get the right redistribution mattresses. A couple of hospitals have worked on building in systems that help them document whether or not they’re doing all they need to do for their patients. Some have done great work on not only educating nursing staff, but everyone that comes in the room, everyone who is touching the patient, to help prevent this patient’s skin from breaking down. Some hospitals have worked with their transport departments, as patients are going from place to place within the facility, to make sure that they are not shearing the skin as they are moving patients from one cotton sheet to the other cotton sheet. Some organizations are beginning to focus on not only pressure-type wounds, but also device-related pressure ulcers like those caused by oxygen tubes or G-tubes.
Q: While education is important, it sounds as though education can only help so much if you are not building reliable processes.
A: Yes, it is often not an education problem. I am convinced it really is about reliability. The people who are doing the work really need to be designing the work so that it becomes part of their routine, part of their habits.
It is also about looking at everyone who is touching the patient. Everyone can offer the patient a glass of water if we are trying to make sure they are staying hydrated. You can also provide staff with information – whether they are a nursing assistant or an environmental services person – that we need to be extra careful moving this person so we are not scooting them across the sheets.
The plan for the Expedition is to talk through some tools and processes that have really been helpful for each team presenting on each of the Expedition calls. We are going to talk through their journey. How did they get started? Where were they when they started? What kind of processes did they put in place? What went well? What didn’t go well? How are their outcomes? What are you still working on? Hopefully, we’ll have one hundred ideas from those six hospitals! They have all been testing changes and spreading them from unit to unit or facility to facility, and other people can get some really good ideas to test in their organizations.
Q: Aside from the clear benefits of protecting patients from harm, what are the other potential benefits of pressure ulcer prevention?
A: Pressure ulcers, once they happen, are very slow healing. It’s very hard to keep them from getting infected. Once they get an infection, it is an open, weeping wound and it is really hard for them to fight off. Pressure ulcers can cost the hospital about $40,000 for each occurrence. They can add 12 to 20 days to length of stay. If you think about preventing readmissions, we don’t want patients going home and having to come back into the hospital if we can help it. Those costs can be avoided. And we just don’t want patients to leave the hospital worse than when they were admitted in the first place.
Q: What are some keys to improving care across the continuum when it comes to pressure ulcer prevention?
A: Pressure ulcer prevention is not a sprint, it’s a long relay race. It’s a long way around that track. So, having a patient in a facility for four or five days is really not long enough to say that you have protected their skin. As they go from level of care to level of care or from facility to facility, we need to share what we know about how or why patients are at risk for skin breakdown and what’s worked to prevent pressure ulcers. Here’s what type of barrier cream we’ve been using. This patient likes iced water or the strawberry nutritional drink, not vanilla. We need to pass that kind of information along from facility to facility.
We should be educating the patient and their family about what we are doing and why we are doing it, so even when they go home, or to a lower level of care, they can continue that same care. Explain to patients why they can’t stay in their recliner all day, why they really need to get up and move around. Talk to them about making sure they’re increasing protein and increasing their fluids while they are home. Why are we repositioning them so often? What are we looking for when we are looking for skin breakdown? We can teach patients and families about looking for blanching skin or reddened skin, so they can be aware of what skin looks like right before it really actually breaks down or opens up. We can help them contribute to the health of their skin. If families understand that we are committed to turning this person every couple of hours, they can let us know when we don’t. They can say, “Hey, he has been on his back since four o’clock this afternoon. Are you going to turn him now?” If we educate the patient and the family, they can help make sure we provide the best care for preventing pressure ulcers because they want the best for the patient, too.