Cut expensive practices, products for wound care
Protocols, not products focus on quality
CQI professionals who want to dramatically reduce their facility’s cost of treating pressure sores can take a lesson from VHA Southwest Inc. in Dallas by asking one simple question: Are you using rotational beds appropriately?
A task force of wound care professionals from 12 member facilities found that often they weren’t. So they developed a reproducible protocol that allowed them to select the right bed for the right patient at the right time and saved more than $500,000 at two of the hospitals.
"The goal was to reduce expenses of pressure sore product expenditures while maintaining or improving patient quality," says Ed Wales, senior vice president of VHA Southwest.
"At first, I thought we would begin by talking to the vendors to get a better deal, but I quickly learned that contract negotiation is only one step in reducing the cost of treating pressures sores," Wales says. "We needed to examine the practice of wound care treatment itself. "
For example, after the initiative, Baylor University Medical Center, a 900-bed, acute care facility in Dallas, reduced its costs for renting rotational beds by $352,240. "We discovered we were overutilizing rotational beds," says Sarann Nolen, RN, CETN, an enterostomal therapist (ET) at Baylor and VHA team member. "With attention to the protocol, we reduced rotational therapy by 70% with no increase in skin breakdown." She estimates the protocols will save another $60,000 in 1997. (See chart of savings, p. 119.)
Persuasive sales pitch
Rotational beds, she explains, are the ones that tilt the patient by using a flow of air within the pillow cushions. "They are actually designed to be used with patients who have pulmonary complications, rather than pressure sores, " she says. "But sales reps promoted them as such, and many nurses perceived that a patient on a rotational bed would not need turning as often," Nolen explains.
The same misperception was occurring at Trinity Mother Frances Health Systems in Tyler, TX, says Jeannie Ebnet, RN, CETN, an ET nurse. Implementing the VHA protocols saved the 300-bed hospital nearly $200,000.
Part of the problem, say Nolen and Ebnet, is that health care professionals were letting information from the bed companies propel the selection process, rather than using a protocol developed by wound care specialists.
"It was time to question what the vendors have sold us over the years," Ebnet says.
First, the VHA team, made up of ET nurses, agreed to work within their respective facilities to implement the resulting standardizations.
The team began by examining data from McFaul & Lyons, a consulting firm based in Trenton, NJ, that had conducted a comparative analysis on pressure sore expenditures for the 12 organizations.
"Baylor was in the 80th percentile in our use of rotational beds," explained Nolen. "Our goal was to reduce it to the 50th percentile and save $350,000."
The data also showed a high usage rate of rotational beds at Trinity Mother Frances. "We began to ask ourselves, Do we really need to utilize those types of beds?’" says Ebnet, whose facility went from the 80th percentile to the 20th.
During this time, Baylor assembled an internal CQI team to monitor rotational bed use. (Members consisted of a director of the respiratory department, a respiratory technician, ET nurses, a nutritionist, ICU nurses, nursing assistants, and floor nurses, as well as a representative from nursing education.) "For a month, anytime a bed was ordered, we evaluated who ordered it and why," Nolen explains. "We found that nurses perceived there was a skin protective value with rotational therapy."
Yet, a subsequent literature review did not support this premise promulgated by the bed companies, she notes.
"The monitoring also revealed that [trauma] patients were staying on the beds for as long as three weeks, although even the vendors’ literature stated that maximum efficiency was achieved in five days," Nolen says.
Nosocomial pneumonia rates examined
At Trinity Mother Frances, a team gathered infection control data to determine what kind of impact the beds had on nosocomial pneumonia rates, says Ebnet. "We didn’t find any evidence that using them affected the rates," she says.
After putting all the data results together, the VHA team established the following protocols for ordering rotational bed therapy:
• The patient must have the potential for recovery or positive outcome.
"If a patient has a DNR [do not resuscitate] order, then it wouldn’t be appropriate to use this bed’s level of technology," Nolen says.
• The patient should be hemodynamically unstable and thus unable to receive more traditional treatment.
"Some patients are unable to tolerate physical turning by a nurse; their blood pressure drops and the heart rate increases," says Nolen, who explains that turning on a rotational bed is less drastic than traditional turning.
• The patient must be able to tolerate the rotational aspect of the bed for 18 to 24 hours.
"You can turn off the rotational aspect of the bed and still have an air bed, which is appropriate to prevent skin breakdown," Nolen says. "But the bed is too expensive to be used in that manner. Patients who aren’t able to tolerate the rotation should be stepped down to another support surface."
• The patient should be intubated and on a ventilator or paralyzed with the need for continuous pulmonary toileting.
"Ask yourself two questions," says Nolen. "Will the patient be on the ventilator for more than 72 hours? And will the patient need chest physiotherapy every hour?" If the answers are no, you won’t need the rotational bed, she says, explaining that the bed also performs percussion on the chest to loosen secretions.
• Trauma patients with chest injuries who do not have unstable spinal injury and who meet the criteria should receive a rotational bed within 24 to 48 hours of injury.
The bed company recommends that the best use of this bed comes from using it early in the treatment process, notes Nolen.
• Discontinue the use of the bed if no improvement occurs after five days.
Notify the family of the patient of this policy before the placement, says Nolen. "So they won’t think you are suddenly depriving their loved one of important therapy. Explain that the best results are achieved in the first five days."
• Rotational beds should be used in the critical care unit only.
"Formerly, we had patients transferred to the floor who would get out of the bed and walk down the hall," Nolen says.
Gatekeeper limits access
The guidelines also called for a gatekeeper to screen ordering the beds, ensuring that only a medical director of critical care unit or a trauma surgeon can order them.
"Previously anyone could order them," notes Ebnet. What we found was not only that more nurses were ordering them than physicians, but also that nurses weren’t using them appropriately. They were under the impression that they didn’t have to turn the patients as often. "I really think it was a case of a sales job from the reps."
To make sure nurses received the correct information about rotational bed use, Nolen used a "super trainer" approach to reach Baylor’s 3,000 nurses. "Every discipline represented on the CQI team had a part in training the trainer, who in turn saw that every person on each unit was trained and recertified on a yearly basis," Nolen says.
While Ebnet is the gatekeeper at Trinity Mother Frances, Baylor has designated an intensive care nurse in each of the critical care units. "It’s a matter of customizing the protocols to fit the size of your facility," says Ebnet.
An intensive care nurse at Baylor also evaluates the patient on a daily basis to make sure the bed is being used properly. "The need for continued therapy should be assessed every day, and the bed must be reordered every five days," says Nolen.
Although both wound care experts have reduced their use of rotational beds to practically nil, both of them acknowledge that to decrease more costs and increase patient care, CQI teams should evaluate all support surfaces used in their facility.
"It isn’t as easy as just stop renting products," says Nolen. "This is just one piece in the wound management equation that balances reducing costs with maintaining quality."
For example, after thorough evaluation of support surfaces, Baylor and Mother Frances decided to purchase hospital-owned beds or rent less expensive beds. Therefore, the team designed a standardized decision tree for specialty support surface that helps clinicians select the appropriate bed. The concept, which includes suggestions of brand names in seven categories of surfaces, also allows for patients to be "stepped-up" to a more expensive surface or "stepped down to a less expensive one." (See decision tree, p. 120.)
"We also advocate using hospital-owned equipment such as a therapeutic replacement mattress or overlay before renting equipment," says Ebnet. "When renting, start with the lower cost overlays that provide good clinical outcomes. Consider nonpowered or low-air-loss overlays before using low-air-loss beds or high-air-loss beds."
(For more information, contact Sarann Nolen, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX 75246.)
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