Where oh where has our *PUPPY gone…..

1. Where oh where has our *PUPPY gone….. *Pressure Ulcer Prevention Plan Yesterday

2. Meet Our Nursing Home! • Quaint Home nestled in South Dakota’s back roads • 50 Residents • 55 beds • 70 Caring Staff Members • 2 cats • 1 dog • 20 fish

3. Our Quarterly Quality Improvement Team • Medical Director • Director of Nursing • ESS Director (Safety) • Administrator • Consulting Pharmacist • Quality Assurance Coordinator • RN (rotates quarterly) • C.N.A. (rotates quarterly)

4. Our QI ‘Sub Team’ • Team members from each department • Led by QI coordinator • Meet monthly • Small committees beginning and ending within this team

5. Our Care Plan Team…. • Director of Nursing • Social Services • MDS Coordinator • Restorative Coordinator • Activities • Dietary Manager • Day Shift C.N.A (rotates) • Evening Shift C.N.A (rotates)

6. Our Saga begins! • DON wondered how many of our nosocomial pressure ulcers currently have documentation for signs of Stage 1 pressure ulcers • Worksheet A completed • 5 Charts reviewed • 40% have documentation supporting Stage 1 • 60% have no documentation supporting Stage 1

7. Help! We can’t do this alone! • A team is needed! • An invitation was developed! • Posted • in bathrooms • staff break rooms • by time clock • Inserted in pay checks

8. Invitation... Bored? Lonely? Want more fun? Like to make a difference? Care about pressure ulcers? Want to help create excitement? Stop by Susan’s office to find out more!

9. Sign hanging in Susan’s office... Looking for excitement? You’ve come to the right place! A new pressure ulcer team is in the making! You’re invited to join! June 5, 2003 - 2:30 p.m. Conference Room Desire to make a difference necessary! See you there!

10. Our Team Takes Shape! • C.N.A – Evening • C.N.A. – Day • Quality Improvement Coordinator • RN – Day • RN – Night • Dietary Assistant • Activities Assistant

11. First Meeting!! • Guidelines set by team members • No finger pointing or blaming allowed! • Weekly meetings every Tuesday at 2:30 pm • Goal of 60 minute meetings --eventually to 30 minutes • Snack at each meeting - ask dietary! • Keep notes of each meeting! - Note Taker needed! • Start on time, end on time - Time Keeper needed!

12. Celebrate small successes • bulletin/story board --need volunteers! • No questions considered ‘dumb’ • All ideas have equal weight • Have Fun!! • Keep meetings on task • need a leader! • No Negativity Allowed!

13. Team Goal-Worksheet D • Increase the number of charts that reflect documentation of nosocomial Stage 1 pressure ulcers prior to development of nosocomial Stage 2 or Stage 3 pressure ulcers from 40% to 75% by July 1, 2003.

14. Worksheet E – Current Process • Discrepancies noted in current process for pressure ulcers! • Everyone has their own way!! • Flow sheet created • ‘Pressure Ulcer Prevention Flowchart’

15. Taking it to the Fishbone!! • Worksheet G used as a guide • Problem in process - pressure ulcers are not reported until they are a stage 2 • Ask why pressure ulcers are not reported until they are a Stage 2. • Proceed with fishbone

16. Why are pressure ulcers not identified until Stage 2 or 3? • Environment • Equipment • People • unaware of residents at risk • unaware of Policy & Procedure • if reported, no follow-up completed • unaware of risks and signs of Stage 1

17. Fishbone - Worksheet G Continued‘Why are pressure ulcers not identified until Stage 2 or 3?’ • Methods/Processes • No risk assessment • No procedure • Materials • Forms not available when needed

18. Brainstorming Solutions - Worksheet H • Unaware of Policy & Procedure • educate • Filing cabinet not in order • organize • Forms not available when needed • yellow sticky on master - educate staff to make copies prior to running out! • If reported, no follow-up • educate

19. Solutions continued... • Unaware of residents at risk • implement PUPPY pictures • No risk assessment • Implement Braden Scale and protocols • No procedure for C.N.A.s to report • implement PUPPY body cards

20. Third Meeting! • Priorities Set!! • Revise Policy & Procedure • Risk Assessment Form • PUPPY pictures • PUPPY Body Cards for reporting • Organize Filing System • Staff Education • Gathering of examples and samples begins! • Fellow nursing home teams • Surf web

21. Review Policy & Procedure • Include Braden Risk Assessment Form • Protocols • Implementation Plan – Worksheet I used • Goal – All residents will have Braden completed by Sept 30 • Begin with new admissions • Weekly according to MDS schedule

22. Review Policy & Procedure • PUPPY picture cards • Implementation Plan (worksheet I) • PUPPY cards will be implemented with Braden Scale. Nurse will place them when resident identified at risk per Braden Scale • Evaluation – random 10% staff interview

23. Review Policy & Procedure • PUPPY body cards • Implementation Plan (worksheet I) • C.N.A. will complete and Log • Give to CN • CN gives to MDS Coordinator after documentation and care plan updated • C.N.A.s will receive education on 6/3/03 • Will discuss further at 6/3/03 meeting

24. Fourth Meeting • PUPPY Rollout discussed • PUPPY Fair • Stations decided on • Prizes • Flyer designed • Each team member volunteered for tasks

25. Late Breaking News! Fun! We can prevent pressure ulcers! Join us at the PUPPY Fair to find out more! June 15 - 1 p.m. - Dining Room See you there! Prizes! Food! Games!

26. Fun! Prizes! It’s coming! PUPPY Fair June 15 - 1 p.m. - Dining Room See you there! Games! Food!

27. Department Heads Needed! • QI Coordinator updates at weekly department head meetings • each department head was given list of current staff members in their department • contact staff members and ask if they’re planning to attend the PUPPY fair • if staff replies yes, a coupon is given to staff

28. Name__________ Department__________ This coupon entitles bearer to: One free bag of puppy chow Must be redeemed upon registration during PUPPY Fair! Offer good only June 15, 2003

29. PUPPY Fair Booths • PUPPY Picture Booth • colored PUPPY pictures • laminated and cut out • poster explaining purpose and directions for use • Need a staff member to explain booth!

30. See This PUPPY? Think.... Pressure Ulcer Risk!

31. Managing Moisture Booth • Incontinence products used to keep residents dry • Moisture barrier cream (if your home uses it) demonstration • Poster explaining importance of managing moisture • Nurse to explain booth

32. ‘Oh What a Relief it is!’ Booth • Sample of all pressure relieving devices currently used • Poster for booth • Nurse to explain booth

33. This Price is Right! Booth • Participants guestimate costs of • pressure ulcers • pressure ulcer prevention • pressure ulcer treatments A picture of a real wound and costs associated with healing could make a big impact on staff!

34. Getting Picky With It Booth • Booth set up with equipment • with cracks • infection control issues • causing skin tears • worn out • no longer serving its purpose • Educate staff on the need to have equipment fit and be in good condition for our residents in order to prevent skin tears, pressure ulcers and infections

35. Rolly Polly PUPPY Booth • Educates staff on our current turning schedule for residents at risk

36. Food, Water and Pressure Ulcers Booth • Create awareness in staff • Importance of snacks • food intake • importance of documentation • special interventions • colored napkins, or other ‘systems’ designed to alert staff to ‘at risk’ residents

37. PUPPY Team Goals and Progress Booth • Storyboard or bulletin board • ‘Take the Pledge’ form for staff to sign

38. How Much Pressure Does it take to Cause a Pressure Ulcer? Booth • Create awareness • that it takes 60 mm to create a pressure ulcer • dry skin and applying socks create sheering • use onion and have staff apply sock! • Use lotion and have them determine if it decreases sheering!

39. Sheering Effects Booth • Increase awareness • effects sheering has on residents’ delicate skin • importance of preventing sheering

40. Residents Skin is Just ‘Plum’ Thin Booth • Demonstrate how thin residents’ skin is • Increase awareness to use care with skin

41. Fifth Meeting • Braden Scale education for nurses • Braden Scale process and protocols set up • Filing system • Training Session for C.N.A.s set

42. Questions? • QI Process • Area in need of improvement • Collecting Data • Brainstorming • Planning • Implementing • Follow through