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A Successful Long-Term Care Quality Improvement Intervention to Prevent Facility-Acquired Heel Pressure Ulcers

Vicky S Lyman, RN, ICP, WOCN; Infection Control Nurse; Loretto System, Syracuse, NY

Caring for Older Adults

Pressure ulcers (PU) are an important public health problem, with long-term healthcare facilities reporting incidence rates ranging from 11%1 to 23.9%.2 Research has demonstrated a PU can increase patient mortality by 7.23%, prolong length of stay by 3.98 days, and can add $10,845 to the cost of care per patient.3 The patient's heel is the second most common anatomical area for pressurerelated skin breakdown.4 Amlung et al4 reported heel pressure ulcers (hPU) account for 30.3% of all PU. The heel's susceptibility to PU breakdown is attributed to tissue ischemia and thrombotic occlusion of capillary vessels as a result of shear forces, sustained direct and repetitive moderate pressure, and reperfusion injury.5 Loretto System noted a high incidence of hPU in 2005, with rates between 2.1% to 5%, and in 10 months a total of 87 facilityacquired hPU were documented. A quality improvement (QI) intervention was initiated to effectively prevent hPU, and modify the facility-wide hPU prevention protocol in accordance with best practices.

The following QI intervention was instituted in January 2006: An in-house assessment tool was utilized to identify patients at high risk for hPU. Patients with a Braden Scale6 score 18 and with 1 of 7 highrisk comorbidities (diabetes; peripheral vascular disease; stroke; hemiparesis; low albumin; hip fracture/total knee replacement; and hypertension) were treated according to the protocol A soft heel protector boota was adopted as standard-of-care for hPU prevention, with prevention guidance written into the hPU prevention protocol A comprehensive educational program was developed and administered to enhance nursing staff knowledge of best practices for hPU prevention and facility protocols.

a

Prevalon® Sage Products, Inc., Cary, IL.

References

1. Park-Lee E, Caffrey C. Pressure ulcers among nursing home residents: United States, 2004. NCHS data brief. 2009;(14):1-8. 2. Horn SD, Bender SA, Ferguson ML, et al. The National Pressure Ulcer Long-Term Care Study: pressure ulcer development in long-term care residents. J Am Geriatr Soc. 2004;52(3):359-367. 3. Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA. 2003;290:1868-1874. 4. Amlung SR, Miller WI, Bosley LM. The 1999 National Pressure Ulcer Prevalence Survey: a benchmarking approach. Adv Skin Wound Care. 2001;14:297-301. 5. Barton AA. The pathogenesis of skin wounds due to pressure. J Tissue Viability. 2006;16(3):12-15. 6. Braden B, Bergstrom N. Braden Scale for Predicting Pressure Sore Risk. Available at: http://www.bradenscale.com/braden. PDF. Accessed on June 30, 2009. 7. Walsh JS, Plonczynski DJ. Evaluation of a protocol for prevention of facilityacquired heel pressure ulcers. J Wound Ostomy Continence Nurs. 2007;34(2):178-183.

2009 NADONA/LTC National Conference, July 11 - 15, 2009

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Reprints provided compliments of Sage Products, Inc. 800-323-2220 · www.sageproducts.com

14%

12%

The QI intervention resulted in a statistically significant 98% decrease in the development of facility-acquired hPU (Figure 1).

10%

Figure 1. Biostatistical analysis 10 months pre-intervention compared to 10-months post-intervention

18% 18%

8%

16%

16%

The successful implementation of this QI intervention resulted in a significant reduction in facility-acquired hPU. The Loretto System experience with improved hPU patient outcomes was similar to that of Walsh and Plonczynski7 who reported the combination of frequent heel skin assessment by nursing staff and use of a soft heel protector boot prevented hPU, as compared with a control group. Future clinical research is necessary in order to make additional definitive conclusions. There are numerous clinical implications as a result of this successful QI intervention:

Percentage of facility-acquired hPUs

14%

14%

6%

12%

12% 10%

4%

10%

8% 6%

97.7% decrease in hPUs

(P<0.001)

Long-term healthcare facilities should review PU prevention protocols on a regular and ongoing basis to ensure protocols are updated according to best practices Concise and comprehensive nursing education is critical to affecting change on a facility-wide basis hPU can be successfully prevented by identifying at-risk patients, and ensuring they are cared for in accordance with facilityapproved protocols

8%

4%

6%

2%

2%

0 4%

0%

2%

Pre-intervention

0% Pre-intervention Pre-intervention

Post-intervention

Post-intervention

Post-intervention

Pre-intervention = 02/05 ­ 12/05 Pre-intervention

Pre-intervention

Post-intervention = 04/06 ­ 01/07* Post-intervention

Post-intervention

Heel offloading can be successfully accomplished with a well-designed heel protector (Figure 2)

*wash out period 01/06 ­ 03/06; took 90 days to implement consistent heel offloading.

Biostatistical analysis was conducted on the pre- and post-intervention datasets (comparing 10 months baseline to 10 months post-intervention, with a 90-day washout period). With data from 550 patients in each time period, there was adequate statistical power to detect an absolute difference of more than 6% as statistically significant with an alpha level of 5% and a beta level of 20%. Chi-squared test was used to assess the change in the rate of facility-acquired hPU post-intervention. The test statistic and P-value were reported and P-value less than alpha-level of 0.05 was considered statistically significant. The results of this data analysis revealed a statistically significant reduction in the rate of facility-acquired hPU from 15.8% (87/550) to 0.36% (2/550), chi-squared test statistic =88.3, P<0.001, reflecting a relative reduction of 98%. The biostatistical analysis was conducted on like time periods. Over the course of the ensuing 24 months from February 2007 through February 2009, only 3 additional facility-acquired hPUs have been identified.

Although this QI intervention was not designed to analyze economic outcomes, it is estimated based on costs reported in the literature3 that the preintervention facility-acquired hPUs may have cost an additional $943,515; therefore, it is hypothesized that the prevention of hPUs in the post-intervention time period resulted in an estimated savings of $921,825.b

b

Figure 2. Pressure-relieving heel protector

The cost of prevention was not deducted from this number.

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