Enlist, engage, and educate:

Transfer mobility teams to the rescue! By Diana A. Ruiz, DNP, RN-BC, CWOCN, NE



ressure ulcer prevention is internationally recognized as a basic standard of nursing care. The occurrence of pressure ulcers in the acute care setting is considered a nursesensitive indicator and an adverse event, carrying heavy ethical, legal, and moral implications. Many national organizations such as the National Pressure Ulcer Advisory Panel and the Wound, Ostomy and Continence Nurses Society strongly support the prevention of such adverse events because they’re costly, physically debilitating, and potentially preventable. 1 As a result, innovative strategies should be considered to address this ongoing national challenge. This article describes a quality improvement study that evaluated the outcomes of the implementation of a transfer mobility team (TMT) concept staffed by healthcare

April 2014 • Nursing Management

students on one pilot unit in an acute care setting.

The well-known villain Pressure ulcers have been associated with an extended length of stay, sepsis, and increased mortality.2 Furthermore, a 2010 report by the Society of Actuaries found that pressure ulcers are both the most common medical error and the error with the largest annual measurable cost. Despite cohesive national efforts to reduce incidence rates, ongoing occurrences continue to drive unnecessary healthcare costs.3,4 In response to a need for a national reduction in hospitalacquired conditions in 2008, the Centers for Medicare and Medicaid Services (CMS) Pay for Performance initiatives implemented a refusal policy for the higher reimbursement of stage III and IV hospitalacquired pressure ulcers (HAPUs), each estimated to cost over $43,000 per patient.5 As a result of high

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Enlist, engage, and educate: Transfer mobility teams to the rescue!

treatment costs, the ongoing occurrence of pressure ulcers weighs heavily on the financial status of our national healthcare system. With rising national attention to meet quality patient benchmarks while maintaining lean operating expenses, it’s essential for nurse leaders to proactively approach pressure ulcer prevention from a resourcedriven standpoint. One barrier to this standpoint is the nursing shortage that’s predicted to worsen as older and more experienced nurses begin to retire within the next several years.6 Due to the Affordable Care


nurse leaders should explore more flexible, resource-driven staffing models. Many staffing resources exist within the community that may be currently underutilized or overlooked all together. Some organizations aware of the pending shortage may turn to long-term retention efforts, such as phased retirement; an additional viable alternative is to focus on the creative and early recruitment of healthcare students.8 Often, healthcare students at the associate and baccalaureate level work part-time jobs while in school

It’s essential for nurse leaders to proactively approach pressure ulcer prevention from a resource-driven standpoint.

comparison with the average cost to treat a pressure ulcer.5 A similar concept, referred to as a “turn team,” staffed by unlicensed assistive personnel (UAP), has been reported in the literature with positive outcomes, including a reduction in healthcare-associated infection rates, musculoskeletal injuries, and HAPU rates.9 Therefore, additional flexibility and creativity in the employment of such a team concept has proven to be effective in the past. As nurse leaders, it’s a core responsibility to mitigate patients’ risk and advocate for quality patient care. The implementation of a TMT requires creative strategic planning, execution with continuous followup from project leaders, and ongoing outcomes evaluation. The integration of a TMT into existing staffing models is an innovative method, which promotes quality patient outcomes while maintaining costs at a minimum.

The hero appears Act calling for an increase in the number of insured individuals in combination with the continual aging of the American population, the subsequent need for even more healthcare providers will only continue to grow.7 However, due to the unknown ramifications of new reimbursement systems and funding structures, nurse leaders may be leery of hiring full-time, benefited, licensed, and support staff. The employment of as needed healthcare students can be an innovative approach to meeting focused patient care needs and reducing hospitalacquired infections/conditions all while building relationships with the future workforce in healthcare. In order to stay ahead of the impending nursing shortage crisis,

to meet financial needs. The opportunity exists to hire and extensively educate healthcare students to deliver focused, preventive care. Healthcare students at various levels of their education are typically eager to learn new clinical skills and expand their clinical experience. The employment of such students creates an opportunity to provide focused patient care while advancing the students’ clinical competencies simultaneously. Repositioning is believed to drive additional expenses in any pressure ulcer prevention program due to the staffing resources and time needed to complete the routine tasks.8 However, the cost to implement a TMT staffed by healthcare students is minimal in

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The quality improvement pilot program, referred to as the TMT, was implemented at an acute care hospital in Texas. Despite the implementation of evidence-based pressure ulcer prevention guidelines, policies, and educational programs over the past several years, quality benchmarks weren’t consistently met or exceeded within the study’s acute care hospital. At times, the benchmark reached twice the Magnet®-designated hospital comparison of 2.8. Sustainability of favorable pressure ulcer outcomes was a challenge due to a lack of available support staffing resources within the hospital. After the completion of an abbreviated cost benefit analysis, it was determined that the potential return on investment and cost avoidance

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associated with the implementation of this proposed TMT program warranted the implementation of an initial pilot study on a unit with opportunities for improvement. At this point, the clinical significance of the pilot was determined to be directly associated with a projected avoidance of HAPUs and reduced length of stay. Additionally, the leadership team supported the innovative staffing approach as a quality improvement initiative and future workforce recruitment opportunity, again reinforcing the overall significance of the pilot.

Plan of action Formal approval for the quality improvement pilot study was obtained from key stakeholders, including the executive and nursing leadership teams. Institutional Review Board approval was also obtained due to the involvement of patient care, despite the quality improvement nature of the program. Patient consent wasn’t obtained during any care situation as the pilot wasn’t experimental and because repositioning and pressure ulcer prevention are considered fundamental aspects of care.9 Buy-in and ownership of the pilot study were obtained from the leadership and from nursing and support staff members on the pilot unit. After further feedback was obtained from the pilot unit staff, the transfer mobility assistant (TMA) role, created for nursing students, was clearly outlined and defined. Prevention-focused competencies were created, and the curriculum for onthe-job training was established by the pilot program coordinator, who also serves as the director of education and the Certified Wound Ostomy and Continence Nurse. The TMT pilot study was initiated on a 30-bed medical unit in

March 2012. The initial team consisted of three TMAs, all of whom were baccalaureate nursing students at the junior and senior levels. All TMAs were educated extensively on pressure ulcer prevention techniques, risk reduction strategies and resources, and minimal lift transfer equipment. In addition, all TMAs were educated on strategies to engage patients and families in individualized prevention plans, such as the utilization of the closedcircuit patient education TV system and patient handouts. Extensive unit-based orientation for a period of 3 weeks complemented the classroom education previously provided by the program coordinator and enhanced the team model of the pilot program. After the unit-based orientation was complete, each TMA was allowed to work flexible schedules of approximately 15 to 30 hours per week, depending on availability and patient census. Each shift length varied between 4 and 12 hours. The TMAs initially worked in pairs for the first several weeks to enhance the team concept of the program. After all competencies were verified and completed, and each TMA verbalized self-confidence in the role, they were allowed to work independently, but were strongly encouraged to seek assistance from the other members of the healthcare team when needed. The team concept was preferred throughout the scheduling process. In total, the pilot team worked an average of approximately 330 to 380 hours per month, or a maximum of 190 hours every 2 weeks. To control initial implementation costs, no overtime was approved. Therefore, the cost of employing three as needed students was less than approximately $5,000 per month, or $60,000 per year. This cost was

minimal compared with the average cost to treat just one HAPU. TMA duties were similar in nature to those of the UAP, but were more focused on the prevention of HAPUs, patient education, and patient engagement. A paper document, referred to as the TMA “brain,” was created for the TMAs to identify and organize patient needs based on the following: current Braden Scale score (obtained from the medical record); current patient skin condition (obtained from an automated electronic pressure ulcer report); nurse-provided report; and general information pertaining to diet, activity, isolation precautions, hygiene, and incontinence needs. After completion or revision of the “brain” for each shift, TMAs would then provide direct patient care based on the priority patients identified. If there was extra time, TMAs would then supplement the UAP role in an effort to capitalize on the resources available.

Saving the day Utilizing specific software, pressure ulcer outcomes were closely analyzed throughout the 1-year postimplementation period utilizing chi square analysis. Monthly HAPU rates were compared for the 9 months before implementation up through the 1-year postimplementation time frame. (See Figure 1.) Although the average of the monthly HAPU rates declined by 30% (3.9 per 1,000 patient days in the 9 months before, reduced to 2.7 per 1,000 patient days in the 1-year postimplementation), the outcomes weren’t statistically significant postimplementation (P = 0.075), but rather clinically significant. It’s important to note that the patient days denominator on the pilot unit was much greater in the months

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Enlist, engage, and educate: Transfer mobility teams to the rescue!

reviewed at length by the program coordinator and an additional Certified Wound Ostomy Continence Nurse colleague. Four common themes regarding the benefit of the pilot team emerged: (1) reduction and/or prevention of HAPUs at the unit level; (2) focused attention on repositioning, ambulation, and patient mobility; (3) increased awareness and attention on skin and prevention efforts; and (4) promotion of teamwork and ability for other healthcare providers to focus on individual roles due to the additional support provided by the TMAs. Overall, 90% of respondents (n = 20) at the 1-year time frame felt that the TMT concept contributed positively to the improvement of quality of care delivered, and 75% of respondents felt that the team allowed for an improvement in the quality of care delivered at the personal level. All of the respondents agreed that the TMT concept

after implementation, indicating a higher patient census postimplementation. In terms of cost avoidance, there was a reduction of a minimum of three ulcers in the 1-year after implementation, at an estimated cost avoidance of $130,000. Each of the HAPU occurrences after implementation didn’t progress to a stage III or IV, additionally supporting the estimated cost avoidance. It’s important to highlight that postimplementation rates never reached the preimplementation rates. Moreover, 8 months out of the 1-year postimplementation period, the pilot unit met and/or exceeded the facility benchmark of 2.8, which hadn’t been previously accomplished. Nursing staff comments from the 1-year postimplementation survey question, “state the most important benefit that the mobility team concept has provided you and/or your patients” were

should be implemented in additional patient-care units.

Sometimes, it takes a team Since implementation, the pilot unit’s monthly HAPU rates have declined incrementally to zero during some months, referred to as the “honeymoon phase” after initial go-live. (See Figure 1, section a.) However, sustainable outcomes have proven to be challenging as is evident for the months following July. (See Figure 1, section b.) The month of August resulted in approximately 130 less worked hours by the TMAs due to the personal vacations and the start of the fall school semester. Unfortunately, less worked hours quickly resulted in an increase in HAPU rates: increasing from 1.84 (July) to 9.6 (August). Immediate action was taken by the program coordinator and nurse manager of the pilot unit to address the issues faced during the month

Figure 1: Monthly HAPU rate on pilot unit: A 30% reduction 1-year postimplementation Rate 16

Preimplementation rate: 3.9 per 1,000 patient days


1-year postimplementation rate 2.7 per 1,000 patient days






8 6




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Figure 2: HCAHPS staff responsiveness question 80% 75% 70%







50% 46% 40% 30% 20% 10% 0%



of August. In addition, the senior team that composed the initial pilot team was transitioned into a critical care unit during the months of August and September to better align with the upcoming school curriculum. A new replacement team was hired and immediate results were obtained in the month of September, with a reduction in HAPU rates back down to 4.98, and again to zero in December. (See Figure 1, section c.) Ultimately, sustainable outcomes require diligence, constant attention and vigilance, and a commitment from all team members on the patient-care units. Therefore, ongoing clinical education and monitoring will continue as the mobility team concept assimilates into part of the facility culture. Monthly Hospital Consumer Assessment of Healthcare Providers and Systems (hcahps) scores, although not directly correlated with the implementation of the




TMT, have shown some incremental improvements as well, particularly within the first months after implementation. An increase from 46% to 75% was seen in the “responsive of hospital staff domain.” (See Figure 2.) Sustainability again has been difficult, but postimplementation rates remain better than in the preimplementation period. Verbal feedback from patients receiving care from TMAs has also been positive, perhaps due to an increase in patient and family education and engagement. Moreover, a critical concept within the project is to obtain ongoing feedback from the clinical nurses and other hospital employees regarding the benefits of the team, and feedback has been positive regarding the support offered by the TMT.

Future victories Pilot study findings suggest that the implementation of a TMT,


employed with healthcare students, can be a cost-effective addition to a traditional staffing model. Although ongoing improvements are still anticipated and sustainability continues to be a focus area, the initial pilot study proved to be effective from a patient outcome and staff feedback perspective. Since March 2012, the TMT concept has been implemented on four additional patient-care units throughout the facility, including two critical care units. Preliminary funding has been secured through a statewide project and further plans include the expansion of the concept to all acute care units throughout the entire hospital. Additionally, there are plans to introduce a volunteer component within the TMT design to allow nursing students to fulfill community service requirements within their nursing curriculum. Furthermore, employment opportunities are now open to

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Enlist, engage, and educate: Transfer mobility teams to the rescue!

students in other healthcare disciplines to promote interprofessional collaboration at the student level. The implementation of TMTs on additional patient-care units to obtain a larger patient population sample and additional staff feedback may enhance the external validity of future studies in this area. Pressure ulcer prevention requires a multifaceted, innovative approach to be effective and efficient. The utilization of all available healthcare resources is vital to ensure economic salience and to deliver high-quality, patient-centered care. The creative employment of healthcare students in a competency-based and focused preventive role can improve patient outcomes and patient and staff satisfaction alike. NM

REFERENCES 1. Wound, Ostomy Continence Nurses Society. Guideline for Prevention and Management of Pressure Ulcers. Mount Laurel, NJ: WOCN Society; 2010. 2. Institute for Healthcare Improvement. 5 Million Lives Campaign. How-to guide: prevent pressure ulcers. Tools/HowtoGuidePreventPressureUlcers.aspx. 3. Shreve J, Van Den Bos J, Gray T, Halford M, Rustagi K, Ziemkiewicz E. The economic measurement of medical errors. http://www. research-econ-measurement.aspx. 4. Kring DL. Reliability and validity of the Braden Scale for predicting pressure ulcer risk. J Wound Ostomy Continence Nurs. 2007;34(4): 399-406. 5. Department of Health and Human Services. Federal Register. 2008;73(84). http://www. pdf/08-1135.pdf. 6. Hill KS. Nursing and the aging workforce: myths and reality, what do we really know? Nurs Clin North Am. 2011;46(1):1-9.

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7. Cohen SA. A review of demographic and infrastructural factors and potential solutions to the physician and nursing shortage predicted to impact the growing US elderly population. J Public Health Manag Pract. 2009;15(4):352-362. 8. Xakellis GC, Frantz RA, Arteaga M, Nguyen M, Lewis A. A comparison of patient risk for pressure ulcer development with nursing use of preventive interventions. J Am Geriatr Soc. 1992;40(12):1250-1254. 9. Hobbs BK. Reducing the incidence of pressure ulcers: implementation of a turn-team nursing program. J Gerontol Nurs. 2004;30(11):46-51. Diana A. Ruiz is the director of Population and Community Health at Medical Center Health System in Odessa, Tex. The author has disclosed that she has no financial relationships related to this article. DOI-10.1097/01.NUMA.0000444875.54945.d1

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Enlist, engage, and educate: transfer mobility teams to the rescue!

Would implementing these targeted groups in your organization help reduce HAPUs?...
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