Heel AlgoritHm
Is Patient at RIsk for Heel Pressure and Foot Drop?
No
YeS
YeS
No
• Follownursingguidelinesforroutineskincare• Ensureadequatepositionchanges
• Follownursingguidelinesforroutineskincare• Ensureadequatepositionchanges• InstitutePressureUlcerPrevention-SkinCareInterventions • Elevateheelsoffbed • Repositionevery2hours • Assessskinintegrityeveryshift
Is Patient Ambulatory?
EducatePatientonPressureReducingTechniques
Establishpatientappropriateness
PAtieNt mUSt:1. Have the potential to be AMBULATORY2. Be AMBULATORY3. Be recommended of off loading heel with gait/mobility4. Referral to Physical Therapy
ReviewCriteriaforPressure-RelievingHeelProtector
Establishpatientappropriateness
PAtieNt mUSt:1. Be NON-AMBULATORY2. Have a total Braden Score of 18 or less3. Have TWO of the following Co-morbidities:
DiabetesMellitus Stroke PVDHemiparesis Quadraparesis MalnutritionUnconscious Comatose CHFSpinalCord/HeadInjury PeronealNerveInjuryLegorotherTrauma Age65orgreaterImpairedPerfusion DecreasedSensationLegCompartmentSyndromeOnParalyticorVasopressiveMedicationsMulti-SystemOrganFailure
Surgeriesthatlimitmotionofthelegs(hipfractures,THR,TKR)
4. If a patient does not meet the above criteria but the nurse has concerns about heel protection–Call for a wound care consult to assess.
Evidence-Based Quality Improvement Initiative andNursing/Physical Therapy Collaboration Results in Decreased Hospital-Acquired Heel Pressure Ulcers
PresentedatTheSymposiumonAdvancedWoundCare,October16–18,2014;LasVegas,NV
Frances M. Dyckman, MSN, BSN, PHN, APRN-CNS, CWOCN; Christine Love, PT, DPT
BACKgroUND
TheTripleAimisanationalqualitystrategythathasgainedmuchattentionsincetheAffordableCareAct(ACA)legislationleveragedthisconceptin2010.The3primaryaimsoftheTripleAimare:1
“BetterCare:Improvetheoverallquality,bymakinghealthcaremorepatient-centered,accessible,andsafe.”
“HealthyPeople/HealthyCommunities:ImprovethehealthoftheU.S.populationbysupportingproveninterventionstoaddressbehavioral,socialand,environmentaldeterminantsofhealthinadditiontodeliveringhigher-qualitycare.”
“AffordableCare:Reducethecostofqualityhealthcareforindividuals,families,employers,andgovernment.”
Thepreventionofhospital-acquiredheelpressureulcers(HAhPUs)isamajorfocusoftheTripleAim.ThedevelopmentofHAhPUsisassociatedwithincreasedpatientmorbidityandpain,decreasedqualityoflife,extendedhospitallengthofstay,andincreasedcosts.2Theheelisthesecondmostprevalentanatomiclocationforpressure-relatedbreakdown.3
Evidence-basedguidancehasbeenpublishedonHAhPUprevention,whichconsistsofappropriateheeloffloading.4Althoughthereisnoconsensusonthemosteffectiveheel-offloadingdevice,adeviceshouldensurethatlegweightisredistributedalongthecalfwithoutunduepressureontheAchillestendon,effectivelyfloatingtheheeloffthesurfacewhileimmobile,andpreventingfootdrop.5
Publichospitalsarefacedwithpatientswithcomplexissues,someofwhomarehomeless,livinginpoverty,and/orhavehighriskfactorsforHAhPUdevelopment.Thisqualityassurance/performanceimprovement(QAPI)interventionwasimplementedtomeettheobjectivesoftheTripleAim,reducetheincidenceofHAhPUs,andimprovepatientoutcomes.
metHoDS
ANALYSeS:Past,present,andfuturemethodologicanalysesandcomparisonswereconductedtohelpidentifystrengthsandweaknessesthatneededtobeaddressedforHAhPUprevention.
Riskassessmentprotocolsandpreventionguidelineswerenotbroadlyunderstoodandacceptedbystaff.InadditionthepreventionoftheadverseeventsofHAhPUandplantarflexioncontractures(footdrop)werenotapriorityforthestaff.Therewasaneedforevidence-basededucationonhowtoappropriatelyidentifypatientsatriskforHAhPUdevelopmentandhowtoimplementrisk-stratifiedinterventionsbaseduponBradenRiskAssessmentScoring.
Itwasdeterminedthatafterthereturntotheoriginalheeloffloadingdevice,analgorithmstandardizingapplicationcriteriafordevicewouldbeusedforinterprofessionaleducationandtofacilitatecollaborationinalleffortstopreventHAhPU.
evALUATION: ThebaselineHAhPUratewascalculatedandcomparedwiththepastinterventionrate.Eachheelulcerwasanalizedusingaroot-causeanalysisprocesstodeterminethegapsincare.Afterdeterminationofthegaps,aPDSA(PlanDoStudyAct)performanceimprovementanalysissupportedtheneedforthechangeinprocessandintervention.ItshouldbenotedthattheheeloffloadingdeviceutilizedforHAhPUpreventionhadbeenchangedtoalessexpensiveoptionbetweenNovember2011toFebruary2012.Theinterventionfocusedonproductselectionwithfunctionalcriteriatoincludeheeloff-loadingforextremebariatricpatientsandpreventionofplantarflexioncontractures,andtheheeloff-loadingdeviceusedpriortoNovember2011wasre-implemented.PostPDSAandinterventioninitiation,acaregiverperceptionsurveywasadministeredtothePhysicalTherapyandNursingstaff.ThissurveywasdesignedtoassessthecompetencywithriskassessmentandtheperceptionofthepriorityforpreventionofHAhPUandplantarflexioncontractureprevention.Interventions:
• Heeloff-loadingdevice*changed• Nursingeducationtoriskassessmentandproperdeviceapplication• Physicaltherapyeducationtouseofalgorithmforheelpressurerelief• Coordinationofinterprofessionalcommunicationswithregularmeetings• Algorithmdevelopmentforevidence-basedHAhPUprevention• Incorporationofheelpressurereliefalgorithmtostandardizeofevidence-based bundlesofcare
reSUltS
TheQAPIinterventionwasdeemedsuccessfulafteraninitialbefore-afterreviewofHAhPUrates,whichshowedanapproximate70.6%reductionofHAhPUs.AsustainedimprovementrequiredfocusededucationandcompetencychecksduringtheMarch2012house-widenursingskillsday.InclusionofthiscompetencycheckonaregularbasishasensuredaconsistentreductioninourHAhPUrateinthepost-interventionperiod.
CliNiCAl imPliCAtioNS
Theimplicationsofthissuccessfulprojectarewiderangingforpublichospitalsandotherhospitalsystems.Bydrivingbestpracticestothepatient’sbedsideandenhancingcollaborationbetweennursingandphysicaltherapystaff,wehaveimprovedpatientoutcomes,staffeducationandcompetencies,patientqualityofcare,anddecreasedexcesscosts.
Across-discipline,respectfulrelationshipwasforgedduringourQAPIexperience.Itwasrecognizedthattheinputofanexpertclinicianisnecessaryduringthedecision-makingprocessforproductchanges.Preventionproductsarenowrecognizedasimportantcomponentsforpatientsafetyandtheavoidanceofadverseevents.
Althoughcostsaredifficulttojustifybasedoncostavoidance,thefiscalandmaterialsmanagementdepartmentnowrecognizesthecontributionofcontinuedanalysisofbestpracticesanddollarsspentinpreventionversusdollarslostafteranegativeavoidableeventsuchasHAhPUdevelopment.
METHODS continued
reFereNCeS
1.BerwickDM,NolanTW,WittingtonJ.TheTripleAim:Care,Health,and Cost.Availableat:http://content.healthaffairs.org/content/27/3/759. abstract2.SullivanN,SchoellesKM.Preventingin-facilitypressureulcersasa patientafetystrategy:asystematicreview.AnnInternMed. 2013;158:410-6.3.VanGilderC,AmlungS,HarrisonP,MeyerS.Resultsofthe2008-2009 InternationalPressureUlcerPrevalenceSurveyanda3-year,acute care,unit-specificanalysis.OstomyWoundManage. 2009;55(11):39-45.4.EuropeanPressureUlcerAdvisoryPanelandNationalPressureUlcer AdvisoryPanel.Preventionandtreatmentofpressureulcers:quick referenceguide.WashingtonDC:NationalPressureUlcerAdvisory Panel;2009.5.JunkinJ,GrayM.Arepressureredistributionsurfacesorheel protectiondeviceseffectiveforpreventingheelpressureulcers? JWoundOstomyContinenceNurs.2009;36(6):602-8.
Prevalon®Pressure-RelievingHeelProtector(SageProductsLLC,Cary,IL)
