J Wound Ostomy Continence Nurs. 2015;42(4):327-330. Published by Lippincott Williams & Wilkins

WOUND CARE

Factors Influencing Adoption of Hospital-Acquired Pressure Ulcer Prevention Programs in US Academic Medical Centers William V. Padula



Robert J. Valuck

■ ABSTRACT PURPOSE: Recent data show a decrease in hospital-

acquired pressure ulcers (PUs) throughout US hospitals; these changes may be associated with increased success in implementing evidence-based practices for PU prevention. The purpose of this study was to identify wound care nurse perceptions of the primary factors that influenced the overall reduction of PUs. DESIGN: Cross-sectional descriptive survey. SUBJECTS AND SETTING: Surveys were sent to wound care nurses at 98 University HealthSystem Consortium (UHC) hospitals. The UHC consists of more than 120 academic medical centers and affiliated facilities across the United States. Responses solicited from this survey represented a geographically diverse set of hospitals from less than 200 beds to more than 1000 beds. INSTRUMENT: The survey questionnaire used a framework of 7 internal and 5 external influential factors for implementing evidence-based practices for PU prevention. Internal influential factors queried included availability of nurse specialists, high nursing job turnover, high PU rates, and prevention campaigns. External influential factors included data sharing, Medicare nonpayment policy, and applications for Magnet recognition. METHODS: Hospital-acquired PU prevention experts at UHC hospitals were contacted through the Wound, Ostomy and Continence Nurses Society membership directory to complete the questionnaire. Consenting participants were e-mailed a disclosure and online questionnaire; they were also sent monthly reminders until they either responded to the survey or declined participation. RESULTS: Fifty-five respondents (59% response rate) indicated several internal factors that influenced evidencebased practice: hospital prevention campaigns; the availability of nursing specialists; and the level of preventive knowledge among hospital staff. External influential factors included financial concerns; application for Magnet recognition; data sharing among peer institutions; and regulatory issues.



Mary Beth F. Makic



Heidi L. Wald

CONCLUSIONS: These findings suggest that the Centers for

Medicare & Medicaid Services nonpayment policy influenced a large majority of hospital’s changes in practice. The availability of nursing specialists for wound consult influenced hospitals internally. These factors are informative of the impact policy has on changes in hospital prioritization of adopting evidence-based practices for PU prevention. KEY WORDS: CMS policy, Influential factors, Pressure ulcers, Quality improvement

■ Introduction Hospital-acquired pressure ulcers (HAPUs) are a critical issue for hospitals. In 2008, the Centers for Medicare & Medicaid Services (CMS) enacted nonpayment policy for prioritized hospital-acquired conditions, including pressure ulcers not present on admission.1 This policy transferred the burden of these conditions onto hospitals. Epidemiological data since 2008 strongly suggest that hospitals have increased their efficiency in pressure ulcer prevention. Incidence rates dropped from 7% in the 2000s

 William V. Padula, PhD, MS, Section of Hospital Medicine, University of Chicago, Chicago, Illinois.  Robert J. Valuck, PhD, RPh, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado.  Mary Beth F. Makic, PhD, RN, Critical Care, University of Colorado Hospital, Aurora, Colorado.  Heidi L. Wald, MD, MSPH, University of Colorado School of Medicine, Aurora, Colorado. The authors declare no conflicts of interest. Each author made equal contribution according to the ICMJE guidelines for authorship. Correspondence: William V. Padula, PhD, MS, Department of Medicine, Section of Hospital Medicine, University of Chicago, 5841 S Maryland Ave, MC 5000, Chicago, IL 60637 ([email protected] or [email protected]). DOI: 10.1097/WON.0000000000000145

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to 4.5% in 2012.2,3 While CMS policy is an important component of hospital’s efforts to reduce HAPU occurrence, it does not directly translate into quality improvement. According to Wald and colleagues,4 hospital quality improvement is influenced by a number of internal and external factors. Internal influential factors included availability of nurse specialists, high nursing job turnover, high HAPU rates, and prevention campaigns. External influential factors included data sharing, Medicare nonpayment policy, and applications for Magnet recognition. These factors transform clinician behavior from a “workaround” culture into one that supports evidence-based practices (EBPs).5 The National Pressure Ulcer Advisory Panel endorses a bundle of 5 evidence-based interventions for HAPU prevention.6 They are: (1) risk stratification; (2) patient turning and repositioning; (3) moisture, incontinence, and nutrition management; (4) use of modern support surfaces (eg, beds and overlays); and (5) ongoing clinician education.7 Evidence-based protocols are associated with improved pressure ulcer prevention, given the reduction in pressure ulcer incidence since 2008.8 The purpose of this study was to determine which influential factors facilitated improved implementation of EBPs among hospital clinicians. We hypothesized that policy, regulatory, and financial factors were important for transforming hospital clinician behavior. By surveying nurses’ perception of these influential factors using a structure developed by Wald and colleagues,4 we aimed to provide insight about how hospitals respond differently to factors surrounding pressure ulcer prevention.

■ Methods To measure wound care experts’ perceptions of influential factors that led to improved pressure ulcer outcomes in the United States, we surveyed clinicians at academic medical centers of the University HealthSystem Consoritum (UHC). The UHC represents more than 120 academic medical centers and their affiliated facilities, including those with Magnet Hospital Recognition. Magnet

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recognition is earned from the American Nurses Credentialing Center, and these hospitals are dedicated to benchmarking and quality improvement initiatives for issues such as hospital-acquired conditions.9 The UHC hospitals are geographically diverse, representing all 48 contiguous states of the United States. They range from less than 200 beds to more than 1000 beds. The survey targeted pressure ulcer experts such as Certified Wound, Ostomy and Continence Nurses (CWOCNs). Following approval of the Colorado Multiple Institutional Review Board, we identified 93 UHC hospitals by searching the membership directory of the Wound, Ostomy and Continence Nurses Society. These CWOCNs were phoned to participate in a survey about pressure ulcer prevention. Willing participants were e-mailed a cover letter and questionnaire that included questions about influential factors prioritizing pressure ulcer prevention.

Instrument The instrument used in this survey was a 14-item questionnaire with contents pertaining to the influential factors, as well as how hospitals implemented EBPs for pressure ulcer prevention. Influential factors were queried in 2 items with checkboxes allowing respondents to “check all that apply” and could be completed in 1 to 2 minutes. Influential factors were organized into internal and external domains based on a framework of chief nursing officers’ primary influences to prioritize quality improvement initiatives.4 External influential factors were organized by financial, professional, and regulatory subdomains. Internal influential factors include subdomains for experience, hospital resources, and organizational characteristics. Specific internal and external influential factors were developed and organized by interviewing experts in medicine, nursing, and health services research prior to the survey (Figure 1). The survey included 5 external influential factors of prioritized pressure ulcer prevention: (1a) financial influences developing from CMS nonpayment policy; (1b) professional influences of hospital efforts applying for Magnet

FIGURE 1. Influential factors organized in terms of internal and external domains.

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J WOCN ■ Volume 42/Number 4 recognition; (1c) professional participation in hospital collaborations; (1d) professional data-sharing such as UHC; and (1e) regulatory influences such as The Joint Commission. Seven internal influential factors were listed in the survey, including (2a) high pressure ulcer incidence or prevalence; (2b) internal hospital prevention campaigns; (2c) high job turnover rate among nurses; (2d) availability of wound care specialists for consult, such as CWOCNs; (2e) level of preventive knowledge among clinical staff; (2f) influence from hospital leadership; and (2g) high numbers of patients with a body mass index more than 30 lb/m2. Each of these factors was framed as a “yes” or “no” forced response item. These select influential factors were chosen based on feedback from experts interviewed earlier with a knowledge of the work by Wald and colleagues4 and expertise in pressure ulcer prevention or implementation science. Their expertise provided insight as to what developments within hospitals might have been the reason for implementing change.

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Padula et al TABLE 1.

Self-reported influences on pressure ulcer prevention based on a “yes” or “no” response Characteristic

Na

%

Financial

46

83.6

Professional–-Magnet application

36

65.5

Professional–-Hospital collaborative

14

25.6

External influential factors

Professional–-Data sharing

41

74.6

Regulatory

42

76.4

Other

12

21.8

High pressure ulcer incidence

23

41.8

Hospital prevention campaign

37

67.3

High nursing job turnover

4

7.3

Internal influential factors

Availability of nurse specialists

45

81.8

Study Procedures

Level of preventive knowledge

36

65.5

Following the institutional review board approval, HAPU prevention experts at UHC hospitals were contacted through the Wound, Ostomy and Continence Nurses Society membership directory to complete the questionnaire. First, calls were placed between August and November 2012 to members. With their permission, consenting participants were e-mailed a disclosure and online questionnaire. Participants were e-mailed monthly reminders until they either responded to the survey or declined participation.

Corporate hospital influence

27

49.1

Patients with high body mass index

17

30.9

Other

8

14.5

Data Analysis Descriptive statistics evaluated hospital trends of influences on pressure ulcer prevention. All statistical analyses were performed using Stata software (StataCorp LP, Texas, © 1996-2014).

■ Results Fifty-five out of 93 hospitals surveyed responded yielding a response rate of 59%, including 54 CWOCN respondents. These respondents represented a diverse set of US academic medical centers in the United States; 27 hospitals held Magnet Recognition. Fifty-three of the responding hospitals reported quality improvement strategies for pressure ulcer prevention, and 51 referenced the EBPs described earlier within their prevention protocol. Survey responses noted the influence of multiple internal and external influential factors that escalated prioritization of pressure ulcer prevention (Table 1). The majority of respondents indicated that key external influential factors included (1) financial concerns; (2) application for Magnet recognition; (3) data sharing among peer institutions; and (4) regulatory issues. Three internal influential factors were identified by a majority of respondents; they

Out of 55 total respondents.

a

were (1) hospital prevention campaigns; (2) the availability of nurse specialists; and (3) the level of preventive knowledge among hospital staff.

■ Discussion Most academic medical centers concerns over HAPU prevention were influenced by 2 main factors. The CMS nonpayment policy was identified as a financial external factor that influenced a large majority of hospitals (83.6%). Likewise, the availability of nurse specialists for wound consult influenced hospitals internally (81.8%). These factors illustrate the impact public policy exerts on changes in hospital prioritization of quality improvement initiatives. Policy influence appears to be an effective agent of change on the behavior of hospital clinicians. According to Gonzales and associates10 framework of implementation and dissemination science, policy is essential to implementing EBPs for achieving improved health outcomes, such as the prevention of pressure ulcers. Furthermore, Saint11 stated that policy changes lead to socioadaptive changes when the adoption of quality improvement interventions is used to support implementation of EBP. Based on these findings, further study is needed to determine if hospitals respond to policy by internally staffing clinical experts who can initiate quality improvement programs crucial to patient safety.

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Limitations This study has several limitations, some of which are inherent to the cross-sectional, survey design. We surveyed clinicians from UHC hospitals, and these data might not be generalizable to hospitals in general. The 55 hospitals that responded may have represented the majority of UHC hospitals focusing on QI for HAPU prevention, resulting in reporting bias. Nonresponding hospitals may have had differing perceptions. Validation of the survey instrument was limited to a pilot test. A larger pilot with participation from additional sites would have been ideal, but not feasible given time and resource constraints.

■ Conclusions While hospitals overwhelmingly cite CMS policy as an influential external factor, findings from this study demonstrate multiple internal and external factors that influence local pressure ulcer prevention policy. Identification and understanding the interactions among these factors can improve these efforts as hospitals continue to be challenged to implement prevention programs designed to improve patient outcomes.



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ACKNOWLEDGMENTS

We thank Dr Manish Mishra, Dr Kavita Nair, and Dr Jonathan Campbell for their contributions to preparing this study.

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■ References 1. Kurtzman E, Buerhaus PI. New Medicare payment rules: danger or opportunity for nursing? Am J Nurs. 2008;108(6):30-35. 2. Whittington K, Briones R. National prevalence and incidence study: 6-year sequential acute care data. Adv Skin Wound Care. 2004;17(9):490-494. 3. Lyder CH, Wang Y, Metersky M, et al. Hospital-acquired pressure ulcers: results from the national Medicare Patient Safety Monitoring System study. J Am Geriatr Soc. 2012;60(9):1603-1608. 4. Wald HL, Richard A, Dickson VV, Capezuti E. Chief nursing officers’ perspectives on Medicare’s hospital-acquired conditions non-payment policy: implications for policy design and implementation. Implement Sci. 2012;7:78. 5. Tucker AL. The work-around culture: unintended consequences of organizational heroes. In: Edmondson AC, ed. Harvard Business School Faculty Research Symposium. Boston, MA: President & Fellows of Harvard College; 2010:2-5. 6. Padula WV, Wald HL, Makic MB. Pressure ulcer risk assessment and prevention. Ann Intern Med. 2013;159(10):718. 7. Ratliff CR, Bryant DE. Guideline for prevention and management of pressure ulcers. WOCN Clinical Practice Guideline; no. 2. Vol 2. Glenview, IL: Wound, Ostomy and Continence Nurses Society; 2003:52. 8. Padula WV. Comparative Effectiveness of Quality Improvement Interventions to Prevention Pressure Ulcers at U.S. Academic Hospitals. Ann Arbor, MI: ProQuest/UMI, University of Colorado; 2013. 9. Clark ML. The Magnet Recognition Program and evidencebased practice. J Perianesth Nurs. 2006;21(3):186-189. 10. Gonzales R, Handley MA, Ackerman S, O’Sullivan PS. A framework for training health professionals in implementation and dissemination science. Acad Med. 2012;87:271-278. 11. Saint S. CLABSI, CAUTI and clostridium: strategies for preventing iatrogenic infection. Paper presented at: Society of Hospital Medicine National Meeting; March 25, 2014; Las Vegas, NV.

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Factors Influencing Adoption of Hospital-Acquired Pressure Ulcer Prevention Programs in US Academic Medical Centers.

Recent data show a decrease in hospital-acquired pressure ulcers (PUs) throughout US hospitals; these changes may be associated with increased success...
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