Published in the April 2008 issue of Today’s Hospitalist
SEVEN YEARS AGO, when critically ill patients arrived at OSF Saint Francis Medical Center in Peoria, Ill., the condition of their skin was not a top concern for nurses and doctors.
“We were trying to stabilize patients and keep them breathing,” says Hoa Cooper, RN, MS, director of hospitalist services and clinical care management at the 700-bed hospital. “The patient’s skin was the last thing we thought about.”
When a 2001 study found that the hospital’s pressure ulcer rate was nearly 10%, however, keeping patients’ skin healthy became a top priority.
The hospital set out to aggressively reduce the percentage of pressure ulcer incidents. Every patient on admission began to be evaluated from head to toe for potential skin problems.
That evaluation was only one of a host of innovations aimed at preventing pressure ulcers. By the end of 2007 “six years after the initiative began “the close-to-double-digit pressure ulcer rate had dropped dramatically to 1.4%.
Pressure ulcers, which affect nearly 1 million people annually, are not only painful, but can also lead to life-threatening infections.
Preventing pressure ulcers eliminates the risk of wound infection, says Brian Curtis, MD, medical director of OSF’s adult hospitalist service at Saint Francis, and it reduces the chance that patients will develop sepsis. Preventing pressure ulcers also goes a long way toward decreasing length of stay.
And, Dr. Curtis points out, hospitals will soon have another reason to embrace prevention efforts: Beginning in October 2008, Medicare will no longer pay for preventable, hospital-acquired complications, a list that includes pressure ulcers.
How did Saint Francis achieve such a drastic reduction? Here’s a look at how the hospital tackles the issue:
- Regular assessments. Staff examine patients at admission using the Braden Scale. That’s followed up with a repeat evaluation every 24 hours until discharge.
During exams, doctors and nurses pay special attention to bony prominences, Dr. Curtis explains, especially the coccygeal/sacral skin and heels. To make sure assessments are thorough, TED hose and socks must be removed.
- SOS signs. When patients have a Braden score of 18 or less, staff put an SOS (Save Our Skin) sign on each of those patients’ doors. This helps identify patients who are at risk of pressure ulcers and helps nurses remember to reposition them throughout the day.
To also remind nurses to turn patients regularly, Saint Francis plays a short segment of the theme music used during Olympics broadcasts over the loudspeakers every two hours. (The hospital also sends nurses pages with reminders.) Staff also place SOS stickers on the charts of patients who are having surgery to make sure that every caregiver who comes in contact with these patients is aware of their risk factors.
- Moisture management. Nurses place dry-flow pads under incontinent patients to wick urine or stool away from the skin. Pre-moistened, disposable barrier wipes are also used to help cleanse, deodorize and protect patients’ perineal skin.
- Pressure redistribution mattresses. To eliminate the delays and paperwork needed to order special mattresses for patients who develop pressure ulcers, Saint Francis purchased pressure redistribution mattresses for every bed in the hospital. “Now we don’t have to worry about getting a physician order,” Ms. Cooper says. “It makes things easier for everyone.”
Bonuses and bragging rights
To reinforce those practices throughout the hospital, an SOS team member from each adult unit attends monthly meetings, reports pressure ulcer incidents on a quarterly basis and serves as the program’s champion.
And to get the attention of physicians and nurses, the hospital puts its money where its mouth is. The hospital-wide pressure ulcer rate is one of four indicators “the others are related to training, hand hygiene rates and patient satisfaction “that affect all staff, who are individually eligible for a bonus ranging from $250 to $500 each year. Units that fail to meet those indicators must undergo monthly reviews until they improve.
“We want to hard-wire this so it becomes second nature,” Ms. Cooper says. “Our target pressure ulcer rate is 3% of our patients. If units don’t reach that, the council has to put an action plan in place, which motivates the staff.”
And to make things even more interesting, the hospital publishes each unit’s quarterly scores. “All units know exactly how they’re doing,” Ms. Cooper says. “It creates a little friendly competition.”
A team approach
While nurses are responsible for most of the interventions, physicians play an important role, both with keeping the issues in the forefront of administrators’ minds and participating in and evaluating the protocols.
Hospitalists, for example, help identify potential problems or at-risk patients. “If we see skin breakdown, we are proactive,” Dr. Curtis says. Hospitalists will have the wound nurse evaluate the patient and will ask that the patient be placed on skin-protective precautions.
“As hospitalists, we have the unique advantage of evaluating patients several times a day.” Ms. Cooper agrees. “Hospitalists are our eyes and ears,” she says. “They find out what’s working and what’s not.” Hospitalists are also the experts who participate in process improvement, keeping staff up-to-date with new protocols.
Dr. Curtis says that implementing hospital-wide preventive strategies like these requires a team effort. “If a nurse notices redness on a patient,” he explains, “doctors come and support that. This is not a top-down effort, this is a group effort.”
The physical and financial tally
While the initiative has been a huge success, it required some education on the part of staff.
“At first, the nursing staff didn’t realize how bad the problem was,” Ms. Cooper recalls, “so we tried to communicate in a way that would get to their hearts.” Since the hospital dropped its pressure ulcer rate, for instance, nurses now hear that 2,000 more patients every year are discharged free of pressure ulcers, she says. “Nurses are interested in patient outcomes that they can relate to.”
The team also communicated the potential cost savings, which ran between $3 million and $4 million a year in unreimbursed medical expenses. Those data helped persuade hospital administrators to invest in the pressure redistribution mattresses. “It was cumbersome and difficult to get the approval,” says Ms. Cooper, “but within six months, the hospital had saved more than it spent.”
That made a strong business case for investment. “If we do the right thing up-front for patients, the back end of costs and treatment will take care of itself,” Dr. Curtis says.
Ingrid Palmer is a freelance health care writer based in West Chester, Ohio.