Investigation leads to new assessment, critical path
Putting a STOP to mushy heels
An isolated incidence of skin breakdown could signal a potential problem affecting numerous patients. That's what a multidisciplinary team at Fairfield Medical Center in Lancaster, OH, found when it looked into a report of just one patient having mushy heels, which is a partial loss of the epidermal layers.
A complete chart review, however, revealed more than 30 cases of the same problem. "That's when I got all the disciplines together and asked for help and what we should look at," says Doris Moffat, MBA, CNAA, RN, vice president of nursing at the 195-bed facility in suburban Columbus.
The hospital now assesses patients upon admission for skin breakdown and places patients on a critical pathway designed especially for wound care. Fairfield's critical path incorporates the Rockville, MD-based Agency for Health Care Policy and Research's (AHCPR) pressure ulcer treatment clinical practice guideline into its critical path.
The pathway, implemented last summer, is called the STOP path, named for the hospital's Skin and Tissue Observation Project (STOP). The program includes a risk assessment, the STOP pathway, and a set of eight criteria for pressure ulcer prevention. As of December 1995, only two cases of pressure ulcers were documented, and both cases involved transferred patients from other facilities, Moffat says.
Additionally, patients in the hospital over five days are assessed and placed on the STOP pathway if necessary. Patients placed on the path at admission have an average length of stay (LOS) under four days, adds Moffat.
Case managers at Fairfield also use an assessment tool as part of the wound care program. Fairfield, however, took AHCPR's assessment tool and adapted it to their own use. The Pehrson risk assessment scale used at Fairfield is the combination of the hospital's existing nursing assessment and the Norton scale, which is AHCPR's recommended risk assessment tool.
"Before, we were using the Norton scale and scoring patients at admission, but we weren't scoring after surgery," adds Moffat. The Pehrson scale rates a patient from an optimal score of four to an at-risk score of one in the following categories:
* activity;
* friction/shear;
* incontinence;
* mental condition;
* mobility;
* nutrition;
* physical condition;
* sensory perception.
Two additional factors are included in a patient's score. Patients over age 65 lose one point from their total score. Patients in the hospital more than five days lose one point for every five days of hospitalization. A patient hospitalized for 10 days, for example, would lose two points from the total score. Patients who score 24 or below on the hospital's Pehrson scale are placed on the STOP pathway and subsequently scored each day.
But Moffat and the development team didn't stop with an assessment tool and pathway. "By the time we conducted the chart review, we had the entire medical and nursing staff involved. We had orthopedists, podiatrists, and general medicine physicians helping to identify potential causes," says Moffat.
The hospital's purchase of new beds six months before the mushy heels were identified led some staff to believe the beds were to blame. Two internal surveys conducted by the manufacturer, in conjunction with other hospitals experiencing similar skin breakdown problems, helped the hospital eliminate the beds as a contributor to the problem, says Moffat. Simultaneously, the pneumatic antiembolic stocking (PAS) manufacturer changed from a closed-heel design to a footless stocking design and agreed to replace the hospital's existing closed-heel stocking inventory. "Similar problems in two other hospitals were reported to the PAS manufacturer, and they agreed to trade out our inventory," notes Moffat.
STOP also includes a list of recommendations to help prevent pressure ulcers during hospitalization. Recommendations from the development team include:
* PAS stockings will:
-- not be applied simultaneously;
-- be removed each shift for 20 minutes.
* Pehrson risk scale will be revised for:
-- patients over age 65, score decreases by one;
-- LOS over five days, score decreases by one and by one for each additional five days;
-- nutritional status will be added, weight gain/loss recorded;
-- scoring will occur every day;
-- score less than 24 automatically refers patient to tissue therapy and nutritional therapy.
* Heel pads will be applied in surgery for:
-- all patients over age 65;
-- all patients malnourished or obese;
-- cases scheduled for longer than 1.5 hours.
* Contour sheets will be used on all beds.
* Egg-crate mattresses only upon physician order, pressure ulcer preventive mode to be activated on bed.
* Positioning during prep and anesthesia training will be provided.
* Tissue therapy consultation and guidelines will be followed.
Use of the critical path, combined with the new medical devices and list of recommendations, all seemed to be a team effort, Moffat says. "We had everyone coming up with possible solutions, and it really became a team effort." *
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