Reduction of Nosocomial Wounds
Phillip Cook
American Sentinel University

Hospital acquired wounds or nosocomial wounds have been a problem to the health systems across America for some time. They can be caused by several factors such as pressure, friction, or shear. In 2008, The Centers for Medicaid and Medicare (CMS) began withholding payment for hospital acquired conditions such as pressure ulcers ("Centers for Medicare," 2012). Hospitals have placed a priority on identifying those patients that are high risk for nosocomial wounds as well as protocols for preventing the wounds.
Background of the Project
Nosocomial wounds are a possibility for any patient that is admitted to the hospital. Patients are admitted to hospitals in various physical conditions and nosocomial wounds are caused by several factors. According to the Mayo Clinic (Mayo Clinic staff, 2011), nosocomial wounds are a result of pressure on the skin that inhibits the blood flow to skin and underlying tissues. This may come as a result of different problems such as: 1. Sustained pressure from the skim being trapped between a boney prominence and a surface such as a wheelchair or a bed. 2. Friction from moist skin being pulled across a surface 3. Shear from two surfaces moving in the opposite direction such as the bed and the patient. This movement damages the tissue making it more vulnerable to sustained pressure.
Add to this the compromised nutritional status of the patients and developing a nosocomial wound becomes a very distinct possibility for many patients.
Pressure wounds may develop in many different areas. When a patient is lying supine, the areas of concern are the elbows, heels, sacrum, coccyx, occipital area, and the dorsal thoracic area. When the patient is sitting, the ischial tuberosity, coccyx, and feet are of concern. Off-loading in these areas or frequent repositioning will go a long way in prevention of pressure ulcers. Use of specialized surfaces or cushions can only go so far in prevention of pressure ulcers. Nosocomial wounds are a direct reflection on the quality of nursing care a patient receives. The nurse may have protocols or standards of care to follow, but it all really comes down to the nurse’s assessment and his/her follow-up actions. The licensed nurse is responsible for the overall care of the patient and as such must direct the care of the unlicensed staff working with them. Use of the unlicensed staff is vital to getting the “tasks” done, but the registered nurse is the leader of the team and has the ultimate responsibility. The unlicensed staff has to know their tasks and where to communicate information they may acquire.
Purpose of the Project The purpose for this project will be to address the inconsistencies of identifying patients that are high risk for developing wounds and how nursing addresses the needs of the patients. The Braden scale is most often used for predicting the risk of developing a pressure sore and make consistent assessment of the needs of the patient (http:/ / www.bradenscale.com/ , July 1, 2012). Education of the nursing staff will be vital in getting consistent assessments. Making consistent use of the scale to guide the care and treatment of the patient is important in achieving the goal of zero wounds. This project will also review different products that help protect the skin from shear and friction when repositioning patients as well as how staffing levels effect the development of wounds. There are an abundance of products that claim to help reduce pressure wounds by reducing shear and friction. Protocols will need to be developed with the use of the chosen product. A review of staffing for licensed staff versus unlicensed staff on their effects on wounds will be done to justify changes in staffing levels. The changes must also fall within the budget for the hospital. The last quarter there were four nosocomial pressure wounds in the hospital. The goal for this project is a twenty-five percent reduction in wounds from the previous quarter. This will be determined from the number of wounds divided by the total number of patient days for the quarter. The reduction in wounds will not only save the patient further days in the hospital, but also save the hospital from having to provide treatment for a wound for which they will not be reimbursed. A continued reduction in wounds to zero will be the ultimate goal over the next year. That will take a change in culture.
Research Review
There have been many studies to show different ways to reduce the incidences of nosocomial wounds. Standard nursing practice is to turn patients every 2 hours and place at risk patients on a specialty surface. Most hospital beds have a pressure reduction mattress, usually made with foam, that will assist in preventing pressure wounds, if all the other precautions are taken. According to Messer, the patients that were most at risk were those of “advanced age, HIV, diabetes, sepsis, anesthesia/sedation, and fever.”(Messer. 2012, p 88-89). Identifying these patients is the first step in preventing the incidences of wounds. Use of the Braden Scale is one of the most accepted tools for identifying high risk patients. For the purpose of this project, that is the tool that will be used.
Nurses gain a wealth of knowledge through everyday experiences and through in-services. In a study by Thomas, 2012, it was found that those nurses with recent in-services on prevention of nosocomial pressure wounds were much more likely to chart appropriately and render appropriate care for those patients with wounds (Thomas, 2012). In many facilities, the WOCN will perform these in-services as needed for the staff. Education of the staff on how to identify, care and prevent wounds will go a long way in reducing the incidences of nosocomial pressure wounds.
Prevention of the wounds is the goal of the project, however sometimes the prevention includes early detection of a problem that was not earlier identified. Wounds are staged in accordance to the depth of tissue involvement. Stage I wounds are the least invasive wounds and are identified by redness and blanching of the skin in the area suspected. There is no broken skin for this type of wound. A stage II wound will involve the skin levels, without involvement in the fat or muscle layers. There may be some drainage in this type of wound. A stage III wound will involve the fat layer of tissue, but will not include muscle layer. A stage IV wound will include all layers of tissue as well as bone exposure is possible. These wounds are the most difficult to treat and may take months to years to heal.
Bed surfaces are a consideration when looking at prevention of pressure ulcers. Patients that have no nutritional issues and can reposition themselves will usually do fine with a pressure reduction mattress. Patients that have a high risk for developing pressure ulcers will require a more sophisticated surface. There are many different types of surfaces available from gel, air, alternating pressure or a combination of each of these ("6. Prevention of," 2012). The most effective surface has been the air fluidized systems that provide constant low surface pressure and helps manage excess drainage from the wounds along with incontinence (Benbow, 2008).
Other prevention methods to be considered are the nutritional status of the patient as well as their vascular perfusion. Patients who are identified as high risk for pressure ulcers need adequate nutritional support to assist in preventing pressure ulcers. Additional oral supplements may be required to provide appropriate calorie and protein needs ("6. Prevention of," 2012). The vascular status of the patient must also be considered when making the risk assessment. This includes patients who are diabetic and/or have problems with oxygenation or blood pressure (Alderden, 2011).
The Institute for Healthcare Improvement (IHI) has suggested guidelines or bundles to prevent pressure ulcers. A Bundle is a set of best practices that if done together, has shown to produce positive results (Agency for Healthcare, 2011). The suggested components for the bundles are: * Skin Assessment that is comprehensive. * A risk assessment that is standardized for the facility. * A plan of action for completion of goals along with a care plan.
Using the bundle to create a clinical pathway will reduce any variation in care and provide efficient, evidence based care. Clinical pathways have also shown to improve outcomes and care planning.
Every patient is an individual, and as such, cannot have a cookie cutter approach to their care. Every care plan will need to be customized and tasks completed without failure each shift/day. It will also be multidisciplinary and, unfortunately, not a real glamorous job. Tailoring the care to meet each individuals needs will assure the best care is being provided.
Key Stakeholders
Preventing pressure wounds is a problem that takes all disciplines to be involved. Nursing has the most contact with the patient and has the largest pool of personnel and will take the heat for any nosocomial pressure wound. The registered nurse has ultimate responsibility for the care of their patients, but it takes a team of caretakers to make sure everything possible is done to prevent pressure wounds. Early identification of patients that are high risk and getting the information to the rest of the team is vital in prevention. Having an interdisciplinary team is crucial for communicating those at risk.
An implementation team will be asked to design, develop, and evaluate the program, while working with different teams throughout the hospital. The team will consist of persons with clinical expertise and hospital leadership. The leader will be responsible for defining roles, assigning responsibility, and monitoring accountability of the members of the team (Agency for Healthcare, 2011). Change is better accepted when the members of the team consist of the front-line workers.
Licensed nurses are responsible coordinating the care for the patients. Under their supervision, the patient’s treatment plan is scheduled and carried out. Making sure the patients that are at risk are turned and on the proper surfaces is one of the many tasks on the nurse’s to-do list. In most medical-surgical areas, the task of turning is given to unlicensed personnel. Bed surfaces are determined by protocols by most facilities or by the wound care team.
Other disciplines that have contact with the patients are also part of the team that will prevent pressure wounds. One of the keys in assuring the patient has the proper nutrition to promote healthy skin will be involvement with the dietitian. The rehab department will assist in getting the patient mobile to relieve pressure. The lab department will be crucial in monitoring albumins or pre-albumins. All other departments that have contact with the patient are responsible for assuring the patient has been repositioned. With all of the cuts in the hospitals, bedside nursing has also been trimmed and everyone is expected to fill in where their license and training allows.
Expansion of the roles of the other departments is expected to have some push back. Their departments are being trimmed as well, but the main focus of the health care team is to improve the health or quality of life for the patient. A team that is all working together toward that purpose is the goal of every administration. Reviewing the organizational structure of the facility and aligning the clinical departments to team up and focus on total patient care may be a challenge for the hospital administration.
How will each department accept the change and what will it mean to their staffing plans or their budgets? Every department has been stretched to their limits and it is difficult to see where there is any opportunity for either more work or less staffing can be implemented, and still perform their work. A balances approach with staffing changes and education of all the staff will be needed to make this work. Staffing changes does not neccesarily mean less staffing. It may just mean reallocating the staff to make sure patients are properly repositioned or boney prominences are properly padded. The goal of this project is to look at how this can be done with little or no effect on the budget.
The Neuman’s System Model recognizes that each patient is unique and responds to treatment in different ways. The stressors for each patient may be known or unknown and will affect patients in another way than expected. When a patient’s line of defense is compromised or is unable to cope with a stressor, the patient’s physical condition deteriorates. The identification and prevention of these stressors is the primary intervention for the patient. Treatment of nosocomial pressure wound would be considered a secondary prevention intervention. Tertiary prevention will begin after the wound begins to heal and head toward the primary prevention ("Neuman's Systems," n.d.).
Possible stressors that will need to be addressed are the patient’s mobility issues, nutrition status, and staffing issues. These stressors, when poor, are known to have a negative impact on the patient’s skin condition. What can be done to reduce these stressors? How will changes that are made affect the budgets? Let’s look at possible solutions.
Mobility issues are a real problem for many patients. Whether the patient has just had surgery or a cerebral vascular accident, patients have a difficult time being mobile. Pressure on the boney prominences that reduces blood flow is caused by lying or sitting in one position for extended period. Reducing this pressure can come in different ways through repositioning or different bed surfaces. A study done by Moore, Cowman, and Conroy examining the methods and amount of turning, found that patients turned on a 30 degree tilt every 3 hours had fewer incidences of pressure wounds than those that are turned laterally 90 degrees every 2 hours (Moore, Cowman, & Conroy, 2011). Pressure ulcers will happen if the patient is exposed to pressure for extended periods. Reduction of this stressor is possible through a comprehensive education program with all of the hospital staff.
Nutrition plays a role in the prevention of pressure wounds. Monitoring the patient’s caloric, protein, and fluid intake as well as lab values such as albumin or pre-albumin, although these are not reliable when the patient has an infection. Medications that may increase or decrease a metabolism of a nutrient will also need to be monitored (Posthauer, 2012). Any patient found to be at risk for pressure ulcer should be referred to a dietitian. Once again this is another stressor that can be reduced by using available resources and a heightened awareness with all of the staff.
The use of different types of bed surfaces is another tool that can be used to reduce or prevent pressure ulcers. Surfaces are designed to help prevent shear, friction, and manage pressure loads. According to a study done in Australia, there are two primary types of mattresses, a surface that is reactive or constant, and a surface that is active or alternating pressure ("6. Prevention of," 2012). The reactive surface would be used for those patients that are at a moderate risk for developing pressure ulcers. The active surface would be appropriate for those patients that are high risk and are totally dependent on nursing for mobility. This stressor can be mostly avoided by choosing the proper surface.
Operations
The reduction or elimination of pressure wounds will take a comprehensive approach and extensive education with all staff. The wound care coordinator as well as physicians will play a large role. It will also require some staffing changes that will be unique and different from what is considered normal. Having staff buy-in will be key in making this project successful. A protocol for bed surfaces will also need to be established.
Education of the staff will begin with the leadership of the hospital. Explaining the role that each department will have in this project begins here and will only be successful through the cooperation of all departments. According to Grint, “A leader is required to facilitate the construction of an innovative response to a novel problem, rather than rolling out a known process to a previously experienced problem.” (Grint, 2008, p.3). Leadership working together will assure that the project at least has a chance to succeed.
Education of the staff will involve mandatory training/education conducted by the staff educator as well as the wound care coordinator. The focus of the teaching will be the causes of nosocomial wounds as well as the different ways for prevention. Making sure all of the staff has been educated and have the resources needed to be successful is going to be essential in getting complete buy-in from everybody. Education of every department and their role in prevention is significant in buy-in. Current practice identifies patients that are at high risk through the Braden Scale, completed every Tuesday, in the interdisciplinary progress notes As a Long Term Acute Care Hospital (LTACH), the patients are in the hospital longer than in the Short Term Hospitals, so weekly evaluations was thought to be sufficient.
A non-formal assessment should be done in addition to the formal assessment with the Braden Scale. The non-formal assessment includes the clinical presentation of the patient along with paying attention to other risk factors. Risk assessments, both formal and non-formal, should be done as soon as possible so as not to delay treatment (Royal College of, 2001).
The Braden Scale looks at six aspects of the patient to evaluate their likely-hood of developing a nosocomial wound. The six aspects are sensory perception, moisture, activity, mobility, nutrition, and friction and shear (http:/ / www.bradenscale.com/ images/ bradenscale.pdf, January 21, 2013). A one to four scale is used in each of these areas, except for friction and shear, a one to three scale is used in that area, with a lower score making the patient a higher risk. With minimum score of six and a maximum score of 23, a score of 16 or under is considered at risk for development of nosocomial wounds.
Positioning
Education of the nursing staff (licensed nurses as well as unlicensed support staff) will consist of focusing on the pressure areas mentioned earlier as well as any external hardware the patient may have as part of their treatment. Off-loading will be accomplished through the use of gel repositioners, pillows, or foam wedges. Non-nursing personnel will be educated on proper ways to position patients with the equipment available.
Identity of those patients at risk is a challenge because not all disciplines read the Braden Scale that is completed once a week. Changing the requirement to daily will be one of the first modifications in the process. Daily Braden scores in the interdisciplinary progress notes will establish which patients are at risk each day. Recognizing those patients at the bedside can be done by placing an identifying magnet at the head of the bed. This will signal to all who come in the room that the patients are at high risk and need to be monitored for positioning. Also outside the room, a magnetic strip with zero to 24 mounted, with a push pin magnet, will be used to identify when the patient was turned last. This will give some accountability for those responsible for turning patients as well as make it possible for others to assist in getting the patient turned.
Getting patients turned in a timely manner has been the struggle and currently the cause of most of the pressure wounds. Budgetary guidelines are such that there is little room for additional staff or staff that have down time to assist. A survey of the nursing assistants was done to get their opinion of why the patients are not being turned properly or timely. Results were a time issue with the nursing assistants. Current patient load gives each nursing assistant 8-10 patients, with 60 to 70 percent of the patients requiring total care. Reducing the load on the nursing assistant would be a simple fix, but budgetary guidelines restrict the number of staff available. Some creative staffing will be needed to assure the patients are properly turned.
Nursing assistants have a difficult job, gathering vital signs, feeding patients, preparing rooms for admissions/discharges, bathing and cleaning patients, and turning patients. Completing these tasks for 8 to 10 patients can be almost impossible if one or two of the patients need extended time for feeding or any other task. This can place a patient, which is high risk for pressure wounds, into more of a risk. Asking other disciplines to pick up the slack is a short term option, but as that is not a long term solution. A task that is given to everybody will usually be done by nobody.
The proposed solution will be to take one of the existing nursing assistants and make then the turn tech for the hospital. The average daily census for the hospital is 38, so it will require someone that is motivated and knows the importance of their job. Their responsibility will be to make sure every patient that requires to be repositioned, gets repositioned every two hours. This individual will report directly to the nursing supervisor and will be the “charge” nursing assistant for the shift. They will team up with the other nursing assistants to turn and if needed, clean patients. By taking one nursing assistant out of staffing, it will increase the patient load of the other assistants by two to three patients, but their workload reduction will make it easier to complete the other work assigned. Making one of the nursing assistants as a “charge” nursing assistant will not relieve the nursing supervisor the responsibility of overseeing the other nursing assistants; however it will add another level of accountability to assure that patients are turned properly. The question that arises is how are the “charge” nursing assistants to be chosen?
Criteria for selecting the charge nursing assistant will first based on applications from the existing nursing assistants. A minimum of 1 year experience will be required for applications. For current employees, there can be no disciplinary action in their personnel folders in the past 12 months. Preference will be given to those currently pursuing their nursing degree. The position will be posted for 2 weeks internally and then be posted externally if qualified candidates have not applied. The position will require 4.2 FTEs which will involve two full-time (36hrs/week) and one part-time (12hrs/week) nursing assistants on each 12 hour shift.
Communication and training for implementing this program will need to be intense and diverse. Information will be placed on the communication board for everyone to read. Position applications will be placed in each nursing assistant’s box as well as be available through the human resources and education department. Nursing supervisors will have a four hour training/question and answer session to make sure everyone is communicating effectively and all on the same page. Nursing assistants will require a one hour education/question and answer session to assure they are all aware of their responsibilities when this program begins. The assistants that are hired into the program will require more training.
Surfaces
The goal of support surfaces is to reduce friction, pressure, of shear on the patient. Current criteria for bed surfaces are determined by the wound care coordinator or the wound care physician. A patient that is determined to be a risk is placed on an alternating pressure air mattress or a gel filled mattress. Alternating pressure mattresses are obtained through a rental agreement and affect the cost of care for the patient. The gel filled mattresses are not appropriate for those patients that are high risk, especially with the track record for getting patients turned properly. Fluidized air surfaces are considered the “gold standard” for wound care; however they are used primarily for wound treatment rather than prevention because of the cost. The wound care physician has expressed concern for getting patients repositioned and tends to order the rental mattress over any other mattresses. Winning him over will go a long way in cutting expenses while improving outcomes. Success in getting patients turned in a timely manner will result in the wound care physician ordering the gel filled mattress more often. These mattresses are owned by the facility and require no rental cost.
The protocol for selecting the appropriate surface will require development of a decision tree. The decision tree will need to assess the patient’s ability to position themselves, their level of consciousness, and their ability to sense pain or pressure. Also to be considered when choosing a support surface is the weight of the patient. Each surface has a weight capacity and exceeding that will place the patient at a higher risk. Bariatric surfaces are available for patients that require a larger surface.
Surfaces come in many different styles, but basically there are active or reactive support surfaces. An active support surface will continually change the distribution load properties whether there is a load on the surface or not. A reactive surface will change its distribution load properties based on the load on the surface. Both of these surfaces may be non-powered or powered (Norton, Coutts, & Gary, 2011). A surface may also be a replacement mattress or just an overlay that will fit over the top of an existing mattress. A new surface does not mean that the patient does not need to be turned. Turning the patient is still the primary action that can prevent pressure wounds.
Evaluation of Success
Reduction of nosocomial wounds is the ultimate goal for this project. This will not only reduce the cost for the hospital, but the ultimate goal also is to “first, to do no harm” as stated by the Hippocratic Oath taken by medical professions (Mason, 2011). Quality of patient care is foremost in making changes. A patient that develops a pressure wound because of negligence in getting that patient turned or repositioned properly is inexcusable. The financial benefit of prevention of the wound is also going to be positive to the facility.
The reduction of pressure wounds will foster confidence from the wound care team that patients are being repositioned properly and will result in a reduction of rental surfaces used for prevention. It will also reduce patient days, which will benefit the patient and the hospital with a reduced overall cost. The Centers for Medicare and Medicaid Services (CMS) has teamed with the Agency for Healthcare Research and Quality (AHRQ) to name pressure ulcers (stage 3 or 4), acquired after admission, to be a “never event” ("Agency for," 2013, table never events 2011, line 20). These never events have been targeted by CMS as events that should never happen or are preventable. CMS has begun denying payment for these events in October of 2008 (Skrzyski, 2008). Any pressure ulcer caused by improper care will not be covered by Medicare or Medicaid. Private insurances are following suit and many are refusing payment for these events.
Success can be measured through the reduction of nosocomial pressure wounds and a reduction in the number rental surfaces. A reduction in wounds will also show up in the bottom line of the hospital with reduced costs and more timely discharges. This is a win-win process for everyone involved from the patient, facility, and the health care system of the country.
Sustained Success
Once success has been achieved, it is just as important to make sure that the success is sustained over time. Too often an improvement or change is made to facilitate a problem or an impending inspection and once the problem goes away, the staff falls back into the old habits and before long the issue is back. Sustainability is part of the solution to the problem. Making the changes a part of the orientation process will introduce all new employees to the expectations of the hospital. It is important to have the implementation team pass on the responsibility one of the hospital managers to have ownership of the process on an on-going basis. The champions of this project will also play a key role in the sustainability. It is important to keep them engaged in the program and replace them as needed (Agency for Healthcare, 2011). All of this will require support from the executive suit of the facility. Reports of progress from the changes made will be reported through the Patient Safety and the Quality Council.

Conclusion
Pressure ulcers are a problem in many facilities. They have been targeted by CMS as a “never event” and have been placed on the list of modalities that they will not submit payment. Reducing the incidences of pressure ulcers will require a multidisciplinary approach with all departments involved. There will be changes in practice that may be controversial, but will be necessary to shake things up. Support from upper management and having champions to lead the change will make the proposed changes more acceptable. Results from the reduction of pressure wounds will be improved quality scores as well as an improved bottom line. Patients will be benefitted by a reduction in their length of stay as well as lower hospital costs.

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