Nursing Research Utilization: Literature Review and Solution in reducing pressure ulcers

RESEARCH REPORT

Daniel L Young, PT, DPT, Corresponding author. Assistant Professor, Department of Physical Therapy, School of Allied Health Sciences, University of Nevada, Las Vegas, 4505 S. Maryland Parkway Box 453029, Las Vegas, NV 89154-3029. Phone: 702-895-2704, Fax: 702-895- 4770, email: [email protected]

Debashish Chakravarthy, PT, DPT, Medline Industries, Inc., Mundelein, Illinois.

Kiarash Mirkia, MD, FACS, Sunrise Hospital, Las Vegas, NV.

Medline Industries, Inc provided financial support for this study and the writing of the manuscript

Evidence for the Validity of the Medline Pressure Ulcer Prevention Program (mPUPP)

Daniel L Young, Debashish Chakravarthy, Kiarash Mirkia

ABSTRACT

Introduction: Pressure ulcers (PrU) develop on I million people every year and the costs for treating this problem approach $ 11 billion. While not all PrUs can be prevented, most can be and Medicare has begun to deny payment for PrUs that develop in hospitals. A pressure ulcer prevention program has been developed and the researchers sought to evaluate the impact of the program.

Methods: The program was based on previously published evidence that clinician involvement, patient, family, and caregiver education, and good skin care are important components of a successful prevention program. All facilities participating in the program, for which pre and post program PrU incidence data were available, were included in the study. Pre-program PrU incidence data were collected from 99 facilities and compared to post-program PrU incidence data.

Results: The mean pre-program PrU incidence was 6.18 (range 38 to 0) and the mean post program incidence was 2.82 (range 24 to 0), yielding an average improvement for the entire sample of 3.36 (range -8 to 34), a 54% improvement This difference was statistically significant, t (98) = 6.349, p<.001. No statistical differences between PrU rates or changes in facilities of different types or sizes were observed.

Conclusions: The program demonstrated validity by reducing PrU incidence in facilities of different types. Whether this improvement is different from other pressure ulcer reduction programs is not known.

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Pressure Ulcers (PrU) have long been a problem for individuals and institutions caring for people with disability, illness, or advanced age. Recent information indicates that more than I million people develop a PrU every year and that the cost of care for these wounds exceeds $11 billion.''' The magnitude of the problem has attracted the attention of the largest payer for the care of these people. Medicare. With enforcement of the Deficit Reduction Act (DRA) of 2005 beginning October 1, 2008, hospitals can no longer collect the additional payment f o r PrUs acquired in the hospital.^ The new Patient Protection and Affordable Care Act signed into law March 23, 2010 stipulates that Medicaid will not pay for stage III or IV PrU if they are hospital acquired.' This means that unless a PrU is documented as being present when the patient is admitted, the hospital will care for the new wound without payment from patients insured by either Medicare or Medicaid.

W i t h this change in reimbursement policy, and the published knowledge that the cost of PrU prevention is more cost effective than standard care,^ facilities are looking for effective ways to reduce PrU incidence. Several examples from the published literature highlight these efforts and their findings or effectiveness. Sharkey et. al., describe a program implemented in long term care facilities to reduce PrU incidence. The program focuses on using certified nursing assistant observations through electronic documentation to generate reports that could be used to drive interventions and highlight at risk patients.^' An earlier version of this program was described the year before.'" A hospital group in Minnesota implemented a program involving education of providers and patients, point-of-care resources, and nutrition assessment." A Seattle hospital improved its system for monitoring PrU incidence, implemented monthly multidisciplinary reviews on hospital acquired PrUs, and applied an algorithm to determine whether the PrUs were avoidable.'^

PrU prevention efforts for specific

populations or vulnerable areas of the body have been given special attention in the literature. In the acute orthopedic patient population, efforts included a simple foam wedge after getting input from stakeholders and had positive results in heel ulcer elimination.'^ A long term care facility PrU reduction program with a specific component for heel ulcers, like other programs, combined caregiver e d u c a t i o n , p r e s s u r e r e d u c t i o n equipment, skin care products, and focused documentation to reduce its incidence.'"' In addition to the elderly and heel ulcers, young injured war veterans have been studied for their PrU risk and incidence reduction program components.'^

An increasing level of consensus in the literature demonstrates that clinician led efforts, education, and evidence based practice for risk assessment and prevention are more successful in terms of patient outcomes.'^" The N D N Q I (established by the American Nurses Association (ANA) in 1998) has established an effective training program for nurses on pressure ulcers to combat poor knowledge among staff nurses regarding PrU identification, staging, and prevention." A connection between PrU risk (as seen with a drop in Braden score) and the implementation of the Registered Nurses Intervention Checklist interventions has also been shown.^" In addition, involvement of hospital management may improve outcomes in pressure ulcer reduction programs.^' Despite all of the effort and attention, Jankowski highlights that deficiencies exist in: "lack of physician involvement; limited involvement of unlicensed nursing staff: lack of plan f o r communicating at-risk status; and limited quality improvement evaluations of bedside practices."" This clearly indicates that more work needs to be done in the area of PrU reduction.

While not all PrUs are avoidable," implementation of a comprehensive pressure ulcer prevention program can lead to significant reductions in PrU incidence. In addition, changes to existing PrU reduction programs can

improve their effectiveness and specific skin care products may contribute to this improvement.^'' This growing need for improved prevention of facility acquired PrU and the growing evidence of comprehensive program success has led to the development of a program by Medline Industries, Inc., Medline Pressure Ulcer Prevention Program (mPUPP). This paper will describe the mPUPP and provide evidence for the validity of the program to effect PrU reduction among participating facilities.

MEDLINE PRESSURE ULCER PREVENTION PROGRAM The mPUPP program is organized and administered by a program team. This team includes three groups of people. Two program administrators report to executive level company leaders. These administrators are responsible for program development and oversight. They track program participants, oversee m a r k e t i n g materials, and coordinate the efforts of others working to administer the program. The second group in the program team is the program service representatives. They are responsible for data collection and follow up with participating facilities on a quarterly basis to review progress and provide support. These individuals work with local representatives, the third group, who identify facilities that may benefit from mPUPP and ensure they have the support they need. The mPUPP team contacts each facility at the initiation of the program to provide orientation and explanation of all aspects of the program. During this contact, usually via phone call, they also collect baseline data on the PrU incidence in these facilities. Currently, the program is expanding its online resources for facilities to access interactive quarterly reports. These reports will allow the facility to view progress, track improvements, and quantify savings that come from PrU reductions.

The second piece of the program is education for caregivers who w o r k for the facility and for families. All participating facilities have access to an education resource at www.

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Figure I. Screenshot of the Medline University homepage for the Figure 2. Screenshot of the Medline University pressure ulcer Pressure Ulcer Prevention Program prevention course list (not all courses are visible)

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Figure 3. Screenshot of a Medline University interactive Figure 4. Screenshot of a Medline University pressure ulcer prevention course on pressure ulcer risk assessment assessment question

Preventing Pressure Ulcers - Question 2 of 10.

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MedlineUniversity.com (MedlineU). MedlineU is a web-based suite of interactive educational material. Figure I shows the home page for material specific to the mPUPP while Figure 2 shows how the educational courses related to PrU are presented. MedlineU combines foundational information about integument anatomy and physiology, PrU development and healing with evidence based guidelines on risk assessment and treatment interventions. Figure 3 is a screen shot of one of the interactive course modules on PrU risk assessment. Assessment pieces are also available t o allow individuals and facilities

track and measure the change in knowledge realized through use of the individual modules. Figure 4 illustrates an assessment page on which the learner can respond t o a specific question. Family education materials can be provided by clinicians to families to support the prevention efforts of the facility or to guide families as they take their loved ones home. Beginning in the summer of 2012 these materials will also be available through MedlineU.

The t h i r d aspect t o the program is t h e p r o d u c t c o m p o n e n t . An advanced line of skin care products for cleaning, moisturizing and barrier

protection, as well as pads and briefs for incontinence management have been made an integral part of the mPUPP program.* These products support other caregiver interventions like positioning, mobility training, attention to the choice of support surfaces, and scheduled voiding. These products have been designed to ensure integument integrity by maintaining appropriate moisture balance through bathing and cleansing and episodes of incontinence. Clinical representatives involved with these products have extensive knowledge of the material science and clinical benefits of these products, and are trained on the

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Evidence for the Validity of the Medline Pressure Ulcer Prevention Program (mPUPP)

evidence base associated with the Figure 5 clinical use of these products in various J.O settings. Clinicians involved in PUPP can also help facilities select product lines that synergistically support the educational components of mPUPP.

Even with the evidence supporting the components of the mPUPP, clear and objective analysis of the program was desired to validate the impact on PrU reduction. With IRB approval, de- identified data on all mPUPP program facilities for which pre-program and post-program PrU incidence data were available were provided to the researchers for further analysis. Thus, the researchers were unaware of facility names and locations. Interim data provided for a snapshot analysis resulting in a sample of 99 facilities further broken down into 55 hospitals and 44 nursing homes. The mean number of beds for the sample was 166 and the median was 120.

All facilities had fully implemented the educational components of the program and any product use changes prior to data collection. PrU incidence values represent the number of PrUs present in the facility for one month. The PrU values came from the most recent full month prior to program implementation and the most recent full month prior to the call to collect the PrU numbers. All programs self counted and reported these PrU numbers. Comparisons were then made among facilities of different types Figure 6 (skilled care and hospital) using the pre and post PrU incidence data.

RESULTS For all facilities combined, the mean pre-program PrU incidence was 6.18 (range 38 to 0) and the mean post- program incidence was 2.82 (range 24 to 0), yielding an average improvement for the entire sample of 3.36 (range -8 to 34), which is more than a 54% improvement (see figure 5). A paired samples t-test comparing the pre (mean = 6.18, SD = 6.88) to post (mean = 2.82, SD = 4.10) PrU incidence indicated a statistically significant difference between the means, t(98) = 6.349, p<.OOI.

Overall Change in Mean

Pre Program

Comparisons between nursing homes and hospitals revealed no differences. Specifically, no difference was found b e t w e e n t h e p r e - p r o g r a m PrU incidence for nursing homes (mean = 5.84, SD = 5.25) and hospitals (mean = 6.45, SD = 7.98), F( 1,97)=. 193, p=.661 (Figure 6); no difference between post- program PrU incidence for nursing homes (mean = 3.05, SD = 3.84) and hospitals (mean = 2.64, SD = 4.33), F(I,97)=.24I, p=.624 (Figure 7); and finally no difference between the change in PrU incidence for nursing homes (mean = 2.80, SD = 4.26) and hospitals (mean = 3.82, SD = 5.96), F(I,97)=.9I9, p=.34O (Figure 8).

Post Program

DISCUSSION The results of this study indicate that the mPUPP can p r o d u c e significant reductions in PrU rates for both hospitals and nursing homes. While the mean change was larger for hospitals, the statistical analysis did not indicate that this difference was greater than chance alone could have produced. The non-significant results of the comparisons between the hospitals and nursing homes provide evidence for the validity of this study as well as the ability of the program to succeed in different settings. If the pre or post program PrU numbers had been significantly different, any comparisons involving both hospitals and nursing

Pre Program Pressure Ulcers

Nursing Home Mean Hospital Mean

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Evidence for the Validity of the Medline Pressure Ulcer Prevention Program (mPUPP)

Figure 7

Post Program Pressure Ulcers

Nursing Home Mean

homes together would affect the impact of the other. Because no difference was observed, the data can be confidently analyzed in the aggregate. It also supports the value of the individualized approach to program implementation, as the same overall mPUPP can be just as effective for hospitals and nursing homes.

Several aspects of the mPUPP have good support in the literature. Clinician- focused education is one component of several other successful PrU reduction p r o g r a m s . ^ ' " ' " " - " In mPUPP, clinician education is provided through MedlineU and adds the ability for facilities and

Hospital Mean

clinicians to quantify their knowledge and learning. Specific attention to skin care and even specific products can help in PrU prevention.^'' The extensive line of competitive skin care products available with the custom mPUPP may be one of the major reasons why this program has been remarkably successful.

Similar to other studies in the field this work had some limitations. The PrU data for each facility were self reported and bias might have influenced the reporting. However, this collection method was consistent across facilities and is used by regulatory agencies for

Figure 8 Change in Pressure Ulcers

Nursing Home Mean • Hospitai Mean

quality monitoring. This study evaluated 99 facilities using mPUPP, but did not compare these to facilities using any other PrU reduction activities or programs and such comparison would strengthen the analysis. In addition, over 700 facilities today are at some stage of mPUPP implementation. Some were just learning about the program, some were still working to get all clinical staff through the MedlineU education modules and complete the assessments there, and others had not been participating long enough to have 30 days of post program PrU incidence data. Furthermore not all of these facilities could be included in this study because they had not provided information about their PrU incidence before or after and they may have results quite different than what has been found in our sample.

CONCLUSIONS The mPUPP is effective in reducing PrU incidence in participating hospitals. This effect may be the result of a combination of program features such as individualized assessment of facility needs, caregiver education, and the use of specific skin and wound care products. Further work is needed to quantify the impact of these individual program elements and t o make comparison between this and other PrU reduction programs. Despite these unanswered questions this study provides compelling evidence that significant PrU reductions can be facilitated by mPUPP.

* The core consumable or disposable products involved in the mPUPP program are the Remedy® skin care line and the Ultrasorb® brand of pads and briefs.

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