Vivian Sternweiler, MS, RN Certified Wound Care Nurse and Coordinator, Wound Program, at New England Sinai Hospital.

A Success Story: New England Sinai Believes Patients First Can Improve Patient Care

On a warm June morning last year, the Vice President of Nursing at New England Sinai Hospital, Karen Hughes, received a thick envelope from the Massachusetts Hospital Association (MHA).

She knew exactly what it contained before opening it.

Six months earlier in December 2006, Hughes' team at the hospital had surveyed their patients to count occurrences of pressure ulcers - commonly known as "bedsores." Three months later, in March 2007, New England Sinai and nearly every other hospital in Massachusetts had conducted an intensive one-day pressure ulcer survey as part of Patients First - the initiative created through a joint MHA-Massachusetts Organization of Nurse Executives (M.O.N.E.) partnership. The papers Hughes now held in her hand showed how New England Sinai had performed in curtailing pressure ulcers.

Hughes knew what the envelope contained because New England Sinai had gotten a six-month jump on the pressure ulcer process. What occurred during those six months and in the weeks and months that followed at Sinai - a 212-bed long-term acute care hospital in Stoughton, Massachusetts - was truly remarkable.

The hospital expanded its clinical staff, invested a quarter of a million dollars in new patient mattresses throughout the hospital, and incorporated a wound recognition and care system in which every member of the hospital staff - from bedside caregivers to nutrition and respiratory staff, among others - participate.

"The Patients First initiative is to promote patient safety and high-quality care, which is dear to our hearts," said Vivian Sternweiler, a certified wound care R.N., and coordinator of the hospitals wound program. "It was a round peg in the right hole and it helped us build on the efforts we had undertaken."

PRESSURE, FRICTION, SHEAR, MACERATION

Estimates on the frequency of pressure ulcers in hospital settings vary widely, but it's safe to say that anywhere between 3 to 5 million patients yearly develop some sort of bedsore. A pressure ulcer develops when persistent "pressure" on a bony site obstructs healthy capillary flow, leading to a breakdown in skin tissue. In hospitals, where patients are propped up in beds, the skin can be stretched across the underlying tissue, and bedsores can develop due to this "shearing force." The sores can also develop through "friction" - that is, the skin rubbing against a coarse sheet or rough mattress. And then there are ulcers that develop through "maceration," or waterlogged tissue resulting in severe wounds that are draining fluids.

"The skin is an organ - one of the most visible - and it can be easily challenged," said Sternweiler. In a long-term acute care facility such as New England Sinai those challenges are amplified - not because of the quality of care, which is excellent, but because of the nature of the patient.

"Wound care for us is a primary focus because of the patients we see," said Hughes. "They are chronically, critically ill for a long period of time. Many of our patients have co-morbidities, eight or nine diagnoses, anyone of which can fire off at any time."

In addition, on New England Sinai's Stoughton campus alone, approximately 50 of 140 patients are on ventilators. "That's a huge workload for the body - to progress from ventilators to unassisted breathing," Sternweiler said. "The first organ that is affected is skin; that is, the body focuses on breathing at the expense of skin."

Hughes says that a great acute care hospital can save a person's life but, in doing so, a patient has to expend enormous physical resources that can put them at risk for pressure ulcers. "We have many patients that are immobile for extended periods of time, or severe illness depletes their nutritional stores," she adds. "And yet hospitals such as ours - long-term acute care hospitals - are held to the same pressure ulcer prevalence standards by the public and third-party payers."

And since New England Sinai is the only long-term acute care hospital in the Patients First database, its posted numbers may not compare well with the acute care hospitals on the site. It's a discrepancy that Karen Nelson, R.N., MHA's senior director of clinical affairs, whose department oversees the Patients First website, concedes.

"By including a 'Hospital Comment' section on each hospital's measures page, we gave facilities an opportunity to explain their special situation or to outline the steps they've taken to improve their outcomes," Nelson says. "We didn't want to create a mere repository of numbers and charts, but rather a resource where hospitals could see what their peers are doing to improve patient care."

WHAT SINAI DID TO IMPROVE

Before the Patients First initiative, New England Sinai screened patients for the risk of pressure ulcers using the well-known Braden Scale, which rates on a scale of 1 to 4 a patient's condition relating to sensory perception, moisture, activity, mobility, nutrition, friction & shear. Hughes had reviewed the occurrences before Patients First and knew her team could do better.

"The first Patients First prevalence audit confirmed what we already knew," Hughes said.

What followed was an intense effort from the top of the hospital down. Lester Schindel, CHE, New England Sinai's President & CEO, who had previously headed up a Massachusetts acute care hospital, supported the pressure ulcer issue as an organizational priority.

"We didn't have a local benchmark for the Patients First numbers - we're the only long-term acute care hospital reporting, so we were out there on our own," Schindel says. "Having come from an acute care setting, I knew our population was remarkably different from anything an acute sees in terms of their susceptibility to wounds. I also knew I had a great clinical team here and they needed the resources to get even better."

New England Sinai invested $250,000 in AtmosAire 4000 Self-Adjusting Mattresses for every bed in the hospital. Sternweiler says when older vinyl mattresses were replaced with foam mattresses in the 1990s, hospitals thought that would be "the end all and be all in ulcer prevention." But foam compresses over time, reducing its effectiveness, so Sinai bought the air mattresses, which actually redistributes pressure rather than reducing it.

"It took us one day to change over all our mattresses in all of our sites, which required everyone to pitch in to make it happen," says Hughes.

Sternweiler's colleague, Patricia Webster, R.N., WCC, did a concurrent audit of every skin care product in the hospital, narrowing down the types used and eliminating all bar soap in favor of liquid soap that increases moisture, while reducing the risk of pressure ulcers forming.

"Cleanse, moisturize, protect," Sternweiler says. "We repeat that like a mantra: 'Cleanse, moisturize, protect.' " (Sternweiler jokes that the old Byrds tune - "Turn, Turn, Turn" - also runs through her head because turning immobile patients on a regular, frequent schedule is a must for reducing bedsores.)

The three certified wound care nurses at Sinai lead Pressure Ulcer Prevention rounds throughout the hospital. They go over turning schedules for patients, do an inventory of what equipment is available (say, air chair pads), and then work with the clinical team to draft a care plan for prevention. The wound care nurses also do training sessions for all staff to prevent good-intentioned but potentially harmful mistakes, such as providing a patient in discomfort with a bed pillow on which to sit.

"A pillow in a chair or the old 'donut' people used to sit on actually promote ulcers, so we educated people about our preference for a certain chair pad," Sternweiler says. "After one of these training exercises, central supply let me know that we had run out of the pads - which was great news because it showed that staff was using them."

New England Sinai's nutritional staff is a key component of the wound care team since many of the hospital's patients have depleted nutritional stores in their bodies because of their serious conditions. The respiratory staff, whose goal is to get patients sitting up and breathing well, work closely with Sternweiler's team because a common pressure ulcer site is in the tailbone and sitting up could contribute to pressure ulcer formation or skin breakdown.

"The physician, physician assistant, nutritionist, and on and on all have to be aware of what we're doing," says Hughes. "It takes a team, and the rounds we've instituted really have made pressure ulcer prevention a collaborative effort."

THE RESULTS & WHAT'S NEXT

New England Sinai's overall pressure ulcer prevalence rates decreased from the first audit it conducted in December 2006 to the second in June 2007. Hughes notes that while Patients First reports total incidents, it does not distinguish between the severity of pressure ulcers, which are rated in stages from one (superficial) to four (very severe). She says during the last audit, a majority of the hospital's pressure ulcers were Stage 2, an improvement over earlier audits.

"Now when we do our audits, we have no surprises," Hughes says. "We analyze what happened and identify how we can resolve it." Sternweiler says that in the vast majority of times when a pressure ulcer develops the hospital is able to track something in the patient's condition that occurred in the previous 72 hours that caused it - that is, a downturn in a patient's condition, or a flare up of a co-morbidity.

Twice a year, Sternweiler presents a day-long talk for nurses at Sinai and in the community entitled "Pressure Ulcer & Chronic Wound Management" and she always devotes about 45 minutes to the question: "Are Pressure Ulcers Preventable?" While national patient safety groups, and third-party payers, like to discuss complete elimination of the ulcers, and while professionals like Sternweiler have dedicated a great part of their lives on wound care management, she urges caution.

"You can move patients, use all the latest in prevention techniques, and patients may still develop pressure ulcers," she says. "We care for severely ill, nutritionally challenged patients who are at high risk. Until we reach a point well beyond where we are now medically, we have to persevere as we're doing now at New England Sinai through the Patients First initiative. By that I mean we have to monitor and measure and share best practices to continuously improve patient care in our hospitals."

By John LoDico
(John LoDico is the Director of Publications at MHA)

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