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Take steps now to prevent pressure ulcers in your ED
If patients spend hours or even days in your ED, they are at increased risk for pressure ulcers.
"Ten years ago, who ever dreamed a patient would be in the ED long enough to get pressure ulcers?" says Gary Howard, RN, MHA, director of emergency services at Vanderbilt Medical Center in Nashville, TN.
If you don't document pressure ulcers that are "present on admission," it might appear that this condition developed while the patient was in the ED, and the hospital will receive no reimbursement for treatment of the pressure ulcer, due to new requirements from the Centers for Medicare & Medicaid Services.
Pressure ulcers are an increasing focus in the ED at Scott & White Memorial Hospital in Temple, TX, says Sicily Reed, RN, director of the ED. [The wound care protocols and list of equipment used by ED nurses are included.]
Here are three interventions done by ED nurses:
• Triage nurses ask mandatory screening questions.
Nurses document answers to these questions: "Does this patient have any skin breakdown?" and "Are there any intravenous lines or tubes that were inserted prior to the patient's arrival?"
• Nurses perform skin assessments.
If pressure ulcers are noted, the nurse documents that they were present on admission.
"Locations and descriptions are recorded," says Reed.
• Nurses do hourly rounding.
ED nurses check for the "four Ps":
— Positioning: Make sure the patient is comfortable. Assess the risk of pressure ulcers.
— Personal needs: Schedule patient trips to the bathroom to avoid unsafe conditions.
— Pain: Ask patients to describe their pain level on a scale of 0-10.
— Placement: Make sure the items a patient needs, such as the call light, are within easy reach.
At Vanderbilt's ED, about a dozen ED nurses have received specialized training to prevent, assess, and treat pressure ulcers. These nurses are on the ED's Pressure Ulcer Prevention and Surveillance (PUPS) team.
"This team serves as a resource for the rest of the staff," says Marty J. Nichols, RN, an ED nurse at Vanderbilt. Nichols created several "resource folders" for ED nurses, with a pressure ulcer staging guide, skin tear and incontinence protocols, and written descriptions of the most used treatment products in the ED.
"We have access to everything that is available to take care of the patient," says Nichols.
Key items were placed in patient rooms to make them more accessible to nurses, including Sage wipes for incontinence, measuring tapes, and transparent medical dressings. "Do a quick assessment of present skin breakdown, as well as the potential for breakdown," says Nichols. "This provides continuity of care for the patient should they become an inpatient or a holding patient in the ED."
The ED is working on replacing its stretcher pads to provide a better surface for patients. "We have hospital beds brought to patient rooms for comfort and to reduce the risk of pressure ulcers," adds Nichols.
Remove patients from backboards immediately
To prevent pressure ulcers, ED nurses at Scott & White Memorial Hospital in Temple, TX, remove patients from backboards and slider boards as early as possible.
"Trauma patients are removed from backboards almost immediately upon arrival," says Sicily Reed, RN, director of the ED. "Slider boards are used for patients going for CT and are removed right after the CT is completed."
If the patient meets trauma criteria, then nurses and the physician are present upon arrival to assess the patient and remove the backboard. "If the patient does not meet this criteria, then the primary nurse calls the physician to the room, and the board is removed at that time," says Reed.
Is infection 'present on admission' in your ED?
Hospital-acquired infections and the lack of reimbursement for the care associated with these infections "is a major concern for all," says Janine M. Hogan, RN, MSN, MBA, APRN-BC, nurse manager of the adult ED at Boston Medical Center.
Hogan says the decision by the Centers for Medicare & Medicaid Services (CMS) to deny payment for hospital-acquired infections has had a "serious impact" on her department. "We are now charged with the responsibility of gathering appropriate data and documenting complete and thorough assessments, regardless of what complaint the patient presents with," says Hogan.
Mary Kilbourn, RN, an ED nurse at Scott & White Memorial Hospital in Temple, TX, says she put together a skin cart for ED nurses because of the new federal guidelines from CMS regarding reimbursement.
"The mandate states that if existing pressure ulcers are not documented upon admission, higher reimbursement payments for treating them will not be paid," says Kilbourn. "Since many of our admissions are initiated in the ED, it was very important that ED nurses become aware of skin care issues."
At Boston Medical Center, ED nurses do the following:
Recently, Boston Medical's ED nurses cared for an elderly, obese female with history of hypertension, dementia, cerebrovascular accident, and loss of ability to ambulate. During their assessment, the nurses noted some conditions that were "present on admission." These included areas of skin breakdown in the lower abdominal folds, and pressure ulcers on her buttocks.
"In order to ensure that the hospital is not charged with causing these problems, we needed to ensure that the nurse caring for the patient documented a complete description of the areas, including size and degree of breakdown," says Hogan.
Boston Medical staff members are working to limit the length of stay for ED patients, she says. "Those at high risk — elderly patients, morbidly obese patients, and severely emaciated patients — are either positioned frequently on ED stretchers or placed in inpatient beds," she says.
Hogan says her ED has had a major push with hand washing, to decrease the possibility of spreading infections.
"There is a heightened awareness surrounding washing hands, both on entering and exiting every patient's room," she explains. "We have been supplied with sanitizing hand wash at the entrance of every room." ED nurses also wear buttons that read "Got hands? Wash them."
One of the biggest challenges for ED nurses is the ability to control communicable diseases that are transferred between patients while in waiting rooms, says Sicily Reed, RN, director of the ED at Scott & White. They have all private rooms in the ED. "Once the patients get in a room, then they can be isolated, but it is challenge for us to have rooms for all patients as they arrive," she says. "Once triage is completed, if all rooms are full and the patient is identified as having an infection, then we adjust to accommodate the isolation."
ED nurses play a critical role in maintaining sterile technique during procedures that take place in the ED, says Hogan. "This is done as a measure to ensure that patients are exposed to a limited risk of infection in their most vulnerable states," she says.
Be sure equipment is clean before next patient
To reduce the spread of infection, ED nurses at Boston Medical Center identified specific "must-clean" areas in treatment rooms that are always cleaned between patients. These are stretchers, mattresses, monitor cables, blood pressure cuffs, oxygen saturation probes, and bedside tables, light switches, and door handles.
"ED nurses are asked to ensure that rooms are wiped down with bleach wipes and/or antiseptic/ antibacterial spray between patients," says Janine M. Hogan, RN, MSN, MBA, APRN-BC, nurse manager of the adult ED.
Match skin care supplies to stages of pressure ulcers
ED nurses at Scott & White Memorial Hospital in Temple, TX, store skin care supplies to treat and manage pressure ulcers in bins, according to the stage of the patient's pressure ulcer. The bins are labeled "Skin Protection," "Skin Tear," "Stage I," "Stage II, "Stage III/IV," "Unstageable," and "Surgical."
"The system helps to link the stages with the correct product," says Mary Kilbourn, RN, the ED nurse who created the skin care carts. "ED nurses can easily locate the correct staging bin and get the items they needed for that particular skin care treatment."