Pressure ulcers are among the most common soft tissue injuries that occur in
nursing homes and hospitals. They also cause pain and increase the risk of
infection. The treatment of pressure ulcers often requires the person to be in
bed on a special surface for long periods daily, which may result in feelings of
social isolation and depression. In 2008, the Centers for Medicare &
Medicaid Services (CMS) deemed pressure ulcers a “never event,” which meant they
were considered preventable. The designation prompted CMS to exclude
hospital-acquired pressure ulcers from reimbursement.
These events also spurred the creation of the Pennsylvania Restraint
Reduction Initiative (PARRI). Under the auspices of Kendal Outreach, PARRI has
been collaborating with nursing homes in Pennsylvania since August of 2008 on
pressure ulcer prevention, mainly focusing on process and prevention.
Boosting Best Practices
Having compiled a collection of best practices from nursing homes that
demonstrated success with pressure ulcer prevention, PARRI created in 2010 “A
Practical Guide to Pressure Ulcer Prevention,” which includes process
components, data collection tools, assessment tools, and prevention techniques.
In 2011, the concept of the Pennsylvania (PA) MAP-IT for Healthy Skin
emerged after a year of planning and working with other entities in the state.
MAP-IT stands for Manage, Assess, Plan, Implement, and Teach. An expert panel
discussion led to identification of potential barriers as well as some key
discoveries, which helped launch a successful program. There already existed an
abundance of resource materials, evidence-based interventions, standards, and
guidelines that were collected and made available for all MAP-IT participants
and as a repository for the general public.
Education Key To Success
The cornerstone of the program has been, and continues to be, educational
opportunities for staff providing all levels of care, with a particular focus on
the education of frontline and direct care staff and their roles in preventing
pressure ulcers.
A website (
www.pamap-it.org/) has helped disseminate information, keep
communication open, and accord additional educational opportunities for
staff.
In April 2012, the MAP-IT initiative was officially launched. From this
auspicious beginning, partnerships among health care organizations were
established. Hospital, long term care, personal care, and home health care
organizations with established associations were assembled into a continuum of
care. Two continuums of care were recruited, with each consisting of one
acute-care agency, skilled nursing homes, personal care homes, and home health
care agencies.
The organizations in each continuum were identified by the discharge
planners working in the acute setting, based on the post-acute referrals for
care.
Identifying Process Weaknesses
The first step in the development of each continuum was to have the
participating agencies complete an organizational needs assessment to help
identify gaps and/or weaknesses in the current pressure ulcer prevention and
treatment process in each participating organization.
Included was a checklist of pressure ulcer-related topics, which
included screening for pressure ulcer risk, developing a pressure ulcer care
plan, assessing and reassessing pressure ulcers, monitoring prevention of
pressure ulcers, monitoring treatment of pressure ulcers, and assessing staff
education and training
needs.
Pennsylvania’s MAP-IT for Healthy Skin adopted the Institute for
Healthcare Improvement’s model of collaboration across the health care
continuum, a process that gathers a group of health care workers, along with
experts in the field, to enable better learning from each other. This system
employs evidenced-based practices throughout the continuum and encourages
consistent use of such practices in all care settings.
The PARRI team has provided in-services and individual consultation to
participating organizations to fill gaps identified by the needs assessment. The
PARRI education modules have been used by the MAP-IT organizations to educate
their own staff, their clients, and family members.
Many of the modules have activities that help revitalize staff
enthusiasm for pressure ulcer prevention.
Additional proficiency has continued to be gleaned through best practices
that are shared among participating organization members.
Education has been a large part of this collaboration, using both
experts and practitioners to emphasize best practices. The first topic of
prevention to be targeted was the appropriate response for all direct care staff
and nursing staff when a change in the skin color, texture, or temperature is
discovered, aptly named the Red Alert Program.
Prior to the
Red Alert Program, staff completed a survey to help determine future educational
needs. Based on these survey results, PARRI staff developed a second in-service,
known as the SKINCARE Bundle, based on the SKINCARE bundle from Penn
Presbyterian Hospital (see sidebar, left).
Organizations were asked to incorporate this material into training for
new staff and annual training or as needed.
Another level of education was added by offering continuum participants
the Wound, Ostomy, and Continence Nurses Society’s new program for Wound Trained
Associate (WTA). The WTA program is an online class that focuses on wound
physiology, prevention, treatment, and care.
Abington Memorial Hospital (AMH) sponsored the program, which provides
certified training to all levels of nursing staff, including certified nurse
assistants, licensed practial nurses, and registered nurses.
The 40-hour training modules have been offered periodically to all MAP-IT
members.
Dialogue, Communication Prioritized
Data collection began in July 2012, prior to the Red Alert program, and
continues. Thus far, most organizations have benefited from the ongoing
education, collaboration, and communication afforded by MAP-IT. A few
organizations that have seen an increase in prevalence have been involved with
additional training and education from the PARRI staff, with positive results.
Another measured outcome was increased satisfaction regarding
communication across the continuum. Communication was initially identified as a
barrier for both continua, since it is common to attribute pressure ulcers to
care settings other than staff’s own.
Establishing relationships and allowing open, honest dialogue among
continuum members has brought effective communication to the forefront, making
it a priority for the first year.
Along those lines, communication guidelines were developed by both
continua to stipulate information that moves among health care settings
concerning the skin of patients. The combined recommended information was
published as “Guidelines for Communicating Skin Condition Across the Continuum”
and is available on the MAP-IT website (
www.pamap-it.org).
A consequence of the guidelines being developed was building
relationships of trust, mutual respect, and cooperation among the various
organization representatives. For example, in the western continuum a wound,
ostomy, and continence nurse from one organization offered to become the wound
expert for a small nursing home that could not financially afford its own wound
nurse.
This typifies the exchange of expertise and knowledge among members
being established through this program. Mentoring on an unofficial level has
also occurred among members. One member has retired but agreed to continue to
attend the meetings and share her expertise and experiences with other members.
Best Practices Identified
MAP-IT participants have identified some best practices of member
organizations for pressure ulcer prevention and treatment. For example, PARRI
staff recently interviewed an eastern continuum member, who shared his
facility’s process for maintaining a pressure-ulcer-acquired incidence rate of
less than 0.2 percent (see
www.pamap-it.org).
PARRI staff also identified a MAP-IT organization that has decreased
its incidence rate by 50 percent over five months.
In the eastern continuum, members are developing
information about the skin for consumers that will be posted on YouTube to
educate the general public about skin care and pressure ulcer prevention. In the
western continuum, members are concerned that insufficient lighting was
preventing them from visualizing the earliest manifestation of pressure ulcers.
A proposed pilot study will explore ideal lighting across the various settings
of the continuum of care.
Also, both continua are interested in additional education for nursing
staff on the correct use of the Braden Risk Assessment for Predicting Pressure
Ulcers.
The long-term goals for PA MAP-IT include identifying new continua of
care interested in pressure ulcer prevention. To serve the needs of the
underserved urban population, a third continuum has been identified and
initiated in Philadelphia.
Another goal is to use the PA MAP-IT process to improve other quality
measures that participants across the current continua choose. For example, PA
MAP-IT for Safe Environments would encompass both fall management and restraint
elimination and would be a good fit for both continua using the expertise the
PARRI team can provide.
PA MAP-IT for Palliative Care would involve quality of care and a
holistic approach to care at all levels of care and would enhance serious
illness and end-of-life experiences for patients and their families, as well as
staff involved in the care. As PA MAP-IT moves forward, the group anticipates
that the relationships will continue to grow and contribute to seamless movement
of patients within the health care continuum.
Education will continue to be at the forefront for participants. These
processes, in turn, will improve care and efficiency in the participating
systems, which will enhance the patients’ outcomes.
The MAP-IT process can be used as a model for other continua to develop
an enhanced experience for patient and staff alike.
Linda Hnatow, RN, a regional director of the Pennsylvania
Restraint Reduction Initiative, can be reached at lhnatow@kendaloutreach.org or
(610) 742-6416 begin_of_the_skype_highlighting 
(610) 742-6416 FREE end_of_the_skype_highlighting. Karen Russell,
RN, a regional director of the Pennsylvania Restraint Reduction Initiative, can
be reached at krussell@kendaloutreach.org or (724) 864-3767 begin_of_the_skype_highlighting (724) 864-3767 FREE end_of_the_skype_highlighting.
It
would be difficult to argue that most people would not be happier and healthier
if they could begin each day with a quiet, relaxed breakfast where there was a
view of the ocean or the mountains. A peaceful stroll through the woods or a
nice garden between the door of a home and the door of a car each day before
work would better prepare everyone psychologically and physically for the day’s
events. 
The Forest’s Healing Powers 
