Collaborative best practice: Implementation of ...

2013 National Rehabilitation Nursing Conference

Collaborative best practice: Implementation of pressure ulcer prevention in spinal cord injury Anna Kras-DupuisRN, MScN, CNN, CRN Stacey GuyMSocSc, Dalton WolfePhD, Jane HsiehMSc & SCI-KMN

Presentation Goals • Intro to SCI KMN community of practice. • Implementation Science 101.

• Application to Pressure Ulcer prevention BPI in SCI. • London examples of key fidelity and sustainability strategies.

SCI KMN Comprises: Foothills Medical Centre: SCI Rehabilitation Clinic Glenrose Rehabilitation Hospital

Goals of SCI KMN  Develop expertise in Best Practice Implementation at each site and across sites, using Implementation Science Principles.  Focus on secondary complications in individuals with SCI: **pressure ulcers, pain, bladder.

3 main objectives:

Why Pressure Ulcer prevention? • One of most common secondary complications • Rates vary between acute, rehabilitation, LTC and community settings • Up to 95% will develop at least one pressure ulcer during lifetime • Prevalence 8-32% (within 20 years) • High recurrence rate: 36-80% will develop another ulcer within 1 year of healing • Many human and economic consequences

Pressure Ulcer Pressure ulcer is a defined localized injury to the skin and/or underlying tissue as a result of pressure or pressure in combination with shear and /or friction (EPUAP, NPUAP, 2009) Common sites include: sacrum, ischium, trochanter, ankles and heels.

Spinal Cord Injury and Pressure Ulcer Evidence • SCIRE: Critical review and synthesis of prevention and treatment interventions for pressure ulcers in peer reviewed, spinal cord injury literature(19802005) was conducted (2010) • PVA CPGs (2001)

• “Canadian Best Practice Guidelines for Pressure Ulcer Prevention and Management in SCI” (2013)

What is Implementation Science? Implementation science is the scientific study of variables and conditions that impact changes at practice, organization and systems levels; changes that are required to promote the systematic uptake, sustainability and effectiveness of evidence-based practices in… settings.

Why do we need to understand Implementation Science? Diffusion/Dissemination of information by itself does not lead to successful implementation (research literature, mailings, promulgation of practice guidelines) Training alone, no matter how well done, does not lead to successful implementation

Implementation Science

INTERVENTION

Effective

Effective

NOT Effective

Actual Benefits Poor outcomes

NOT Effective Inconsistent; Not Sustainable; Poor outcomes

Poor outcomes; Sometimes harmful

Science to Service

Science Evidence-Based Practices

Implementation

Implementation Frameworks Multi-dimensional, Fully integrated  Implementation Teams  Implementation Drivers  Implementation Stages  Improvement Cycles

Implementation Drivers 3 Dimensions:  Staff Competencies  Organizational Support  Leadership 9 Drivers:  Selection, Training, Coaching, Performance Assessment  Systems interventions, Facilitative Administration, Decision-support Data systems  Technical and Adaptive Leadership

Performance Assessment (Fidelity) Coaching

Systems Intervention

Training Selection

Facilitative Administration

Integrated & Compensatory

Decision Support Data System

Leadership Technical

Adaptive

© Fixsen & Blase, 2007

Stages of Implementation Exploration Installation

• Decide What to adopt and Implement

• How it will happen. Plan what needs to be in place to implement the What

Initial Implementation

• Activate the Who – key personnel to put the plan on the ground and implement the What

Full Implementation

• Make sure it works, then do it better (PDSA) and make it “business as usual”

SCI KMN Journey • Used draft of “Canadian Best Practice Guidelines for Pressure Ulcer Prevention in SCI” • On line voting process (called Delphi): from over 50 practices down to TWO non-negotiables: •

1. “Conduct comprehensive Risk Assessment for pressure ulcers...”

•

2. “Provide structured and individualized education...”

• Implementation Science 101 • SITs formed and agreements reached

What We Know… o Multiple risk factors for pressure ulcer development o Risk assessment tools are useful but predictive value post-SCI is questionable and no “gold standard” o Pressure ulcers are still occurring despite effort, money and time allotted to prevention o Need to identify individual risk factors and target interventions to the person

Risk Factors for Pressure Ulcers Limitation in activity (low

Male

Smoking

Lower level of education

Co-morbidities: (renal,

Injury completeness

Unemployed

Autonomic dysreflexia

Incontinence / moisture

Do not practice standing Anemia

Lack of sensation

In nursing home / hospital

Hypoalbuminemia

Poor nutritional status

Race, ethnicity

Spasticity

FIM score self-care)

Limitation in mobility (transfers, locomotion, total FIM score)

Muscle atrophy

pulmonary, CV disease, diabetes)

Ulcer history (PU in acute care)

Underweight

SCIRE (2010), Verschueren et al, 2011

Non-adherence

Risk Assessment Tools (selected) Braden: • 6 subscales including sensory perception, mobility, activity, moisture, nutrition, friction and shear • Lower score equals higher risk (range 6-23) •Not specifically tested for individuals with SCI

SCIPUS (Rehab): •Developed for assessment of risk for individuals with SCI in rehabilitation settings •15 domains •0-25; the higher the score, the greater the risk •Risk: Low (0-2), Moderate (3-5), High (6-8),

Very High (9-25)

Salzburg et. al (1996) A new pressure ulcer risk assessment scale for individuals with spinal cord injury. Am J Phys Med Rehabil 75:96-104.

London Journey • Formed Site Implementation Team (SIT): core group of individuals with experience and interest, accountable for guiding the overall implementation. • Operationalized both Risk Assessment and Patient Education practice – one at a time • Risk Assessment: initial implementation in June 2012 • Patient Education: initial implementation in December 2012

Best Practice Recommendation Conduct comprehensive, systematic and consistent assessment of risk factors in individuals with SCI i) Assess and document risk on admission and reassess on a routine basis, as determined by the health-care setting, institutional guidelines, and changes in the individual's health status. ii) Use clinical judgment as well as a risk assessment tool to assess risk iii) Assess demographic, physical/medical, and psychosocial risk factors associated with pressure ulcer prevention.

Risk Assessment Practice: The Nuts and Bolts Nurses will initiate pressure ulcer risk assessment with the SCIPUS tool within 24 hours of admission and will complete this assessment within 72 hours of admission. Within 1 week of admission, the IPT will review additional extrinsic and intrinsic (demographic, SCI related, physical/medical, psychosocial) risk factors and develop an action plan based on both the level of risk from SCIPUS and other identified risks. Within 1 month (from initial assessment), or with significant change in status, nurses will reassess the SCIPUS and the IPT will reassess relevant risk factors and will revise the pressure ulcer prevention plan, if needed.

Electronic SCIPUS

**IPT = INTERPROFESSIONAL TEAM

What We Want to See: Performance Measures o All (most) new patients with documentation of comprehensive pressure ulcer risk assessment within (72 hours SCIPUS, 1 week IPT) o All (most) patients have documented action plan associated with their PU risk assessment (within 1 week) o All (most) patients re-assessed at 5 weeks or with significant change in status o All Pressure Ulcers staged (based on NPUAP) and documented (Wound Monitoring Tool) – at admission and by discharge

Implementation: Doing It Well • Paying attention to key elements (training, coaching, data collection, performance assessment)

• Deliberately going through stages • Improvement cycles Initial Implementation: series of Plan-Do-StudyAct (PDSA) /improvement cycles (aka “pilot”) Learn from mistakes Survive the awkward stage Remember: “anything worth doing is worth doing poorly until you learn to do it well”Zig Ziglar

Key Drivers • • • •

Training Coaching Performance Assessment Data systems

Data Analysis Purpose: • Is the process working? • How can the process be improved? Methods • Collection period: 01 June 2012 to 31 October • 2 data collectors • Weekly collection • Counts & frequency

Average group rate of completion for risk assessment admission and reassessment 100% 90% 80% 70%

88%

60%

76%

50% 40% 30%

71%

65% 57%

50%

20% 10% 0% 01 June to 31 Aug

01 Sep to 31 Dec Admission Completion Rate

01 Jan to 31 March

Reassessment Completion Rate

24 Hour SCIPUS Target 100%

96%

90%

100% 90%

80% 70%

75%

60% 50% 40% 30% 20% 10% 0%

05 November to 31 December

01 January to 31 March Initiated by target

Initiated

SCIPUS Assessment and Reassessment 100%

95%

93%

90%

100%

80%

70%

60%

60%

60%

55%

50%

40%

30%

20%

10%

0% Assessment 05 Nov to 31 Dec

Assessment 01 Jan to 31 March Completed by target

Completed

Reassessment 01 Jan to 31 March

Staff Evaluation: Survey (3 months) Purpose: • What does the care team think of the process? Results: 21/ 26 completed survey  100% understood process expectations  95% understood reassessment expectations 95% risk assessment tool easy to use 95% think completed section most of the time in a timely fashion

Staff evaluation: survey cont. √ 48% tool influences practice √ Tool in IPC most of the time 57% √ Never discussed in rounds 19% => suggestions to improve

√ 86% aware of coach. 43% consulted coach => all found this helpful

√ 30% experience barriers to carrying out practice (vacation, patient’s health, location of tool)

√ Revisions: reminders, clarity on deadline of reassessment

Electronic SCIPUS Survey • 6 months after implemented • What do you think of the e-SCIPUS system? • Completed by 7 nurses

The electronic system is easy to use.

YES

NO

Why is the electronic system not easy to use? • “Confusing at first till do a few....” • “Two times I have accidentally marked it as completed when I was only trying to access it.”

I prefer the electronic system to the paper-based system.

YES

NO

If you do not prefer the electronic system to the paper-based system, please explain why. • “I find that I can reference it more easily in paper format.” • “I find that I tie up two computers (looking for lab values) because I am afraid that I will have trouble getting back in to the program.” • “We have to visit the site twice to complete all the data entry.” • “I try to enter as much data on the first day of admission, but blood work isn't obtained until day 2, then I have to remember to obtain the blood results and enter it into scipus.”

The electronic system takes a longer time to complete than the paper-based.

NO YES

I remember to fill out the overall SCIPUS score on the paperbased copy both at admission and reassessment.

YES

NO

Why do you think you sometimes forget to fill out the overall SCIPUS score on the paper-based copy? • “Not aware its due. Forget to check.” • “Time” • “I thought all was recorded on the computer.” • “Too many places to transfer data in an already hectic paced day!!!!!”

I remember to fill out the Action Plan on the paper-based copy both at admission and reassessment.

Why do you think you sometimes forget to fill out the Action Plan on the paper-based copy? • “Time restriction.” • “Not doing on a consistent basis- i.e. weekly, daily. I may not see a pt. for over a month.” • “Too much data to in too many places in an already hectic paced day!!!”

How can we improve the process of completing the electronic SCIPUS and the overall score/ Action Plan on paper?

• “Different way to remind us its due.” • “Will get easier with time.” • “Going back and forth from the task list to the patient chart on the computer to obtain information can be time consuming.” • “Need more education.” • “Put it all on computer don't have in so many places –consistency is the key.”

Implementation with Fidelity and Sustainability • Just in time iterations to tools and process • Real time data collection and timely feedback:

Group Individual disciplines Coaching Staff engagement along the way

Patient Education: Best Practice Recommendation • Followed same process

• Provide structured pressure ulcer prevention education to help individuals post SCI gain and retain knowledge of PU prevention practices. • Provide individuals with SCI, their families / significant others… with specific information on effective strategies for the prevention and treatment of PU, to assist with gaining and retaining knowledge. Additional agreements

•

*Provide “refreshers” on PU prevention, deliver education at Grade 3-6 level

•

Standardized content, delivered by IPT, based on adult learning principles

•

Actively involve patient / family

•

Use variety of methods (based on learning style): written, on-line resources, etc.

•

Use peer mentors

Education Team at Work! • Active involvement, commitment and energy • Actively supported by SIT  Agreed on important mindset: patient should take more active role with our support  Looked at both content and process  Opportunity to revise previous education program and add new “touch”  Rigorous review of existing resources and gaps  Implementation with fidelity, improvement cycles

Patient Engagement • Empowered confident patients will take more active role in managing their condition • Knowledge is required but not sufficient for behaviour change • Active learning strategies are the key: patients learn by doing / practicing skills • Patient engagement in multiple ways, frequently, by many • Education through “interaction”

Education Practice: The Nuts and Bolts • Within 2 weeks of admission, IPT will schedule a 30minute “just in time group” session for patient / family AND provide patients with “self-management” resource kit • Nurses/OTs/OTAs to facilitate daily skin checks integrated into routine (twice a day). Most important: help person self-direct! • IPT will reinforce prevention strategies with every opportunity during 24 hours • IPT will document education provided in the patient’s health record

**IPT = INTERPROFESSIONAL TEAM

Tools

30 Minute Education Session

www.sci-u.ca 2 x iPADS to display video on unit

Tools

Checklist Laminated card

Education Practice: The Nuts and Bolts • IPT will facilitate patient’s access to various learning modalities, including written, audiovisual and on-line resources, and will encourage patients to keep track of their learning in “patient checklist” • IPT will engage peer mentors to support patient education • IPT will evaluate the effectiveness of patient education and patient knowledge / skills related to pressure ulcer prevention

Survey completed by patients before discharge

What we want to see: performance measures • All / most patients, within 2 weeks prior to discharge, with

documentation of education strategies for prevention of pressure sores. • All/most patients who within 2 weeks prior to discharge indicate that the education was effective. [Effectiveness assessed by score > 7/10 on a Likert scale]

• All/most patients who, within 2 weeks prior to discharge, complete the education effectiveness questionnaire

In Summary • What is the SCI KMN community of practice? • What and how has Parkwood Hospital

implemented this best practice? • Next steps