Nursing Plans of Care MU v v v

Nursing Plans of Care MU v v v Keith Hampton, MSN, APRN, ACNS-BC Nicole Webb, APRN, DNP Cameron Johnson, Application Analyst Melissa Pickett, APRN, ACNS-BC, CWOCN Gayla D. Maier, RN, BSN, ONC, WCH Facility Nurse Educator

Pressure Ulcer Prevention Plan Originally started as a Lighthouse project Based on the Braden total risk score Pros: Short plan of care Cons: Pre-determined set of interventions Was not an individualized plan of care Was not outcome driven Not in line with current literature on Braden © 2011 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 1

Pressure Ulcer Prevention The story of a patient Melissa Pickett & Gayla Maier

Pressure Ulcer Prevention Plan Current Plan of Care Goals are based on the Braden sub scale scores Cons: More interventions than the Lighthouse Plan of Care Pros: Can be individualized to the patients needs I-view charting will trigger the pre-determined met vs not met goals based on documentation The interventions for the care plan goals can be charted in I-view or from the care plan screen Based on current literature related to use of the Braden Tool © 2011 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 3

Braden Total Score Interventions are grouped, based on level of risk “cookie cutter plan of care” Example: Total risk score of 19 Interventions: Did not trigger based on total Braden Score. No Interventions Initiated Braden Subscales Interventions are based on the individual clinical factors that encompass that sub scale “individualized plan of care” Example: Next slide……. © 2011 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 4

Braden Sub Scales Total Braden Risk Score 19 Subscale scores Sensory Perception Moisture Activity Mobility Nutrition Friction & Shear 4 4 3 2 3 3 © 2011 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 5

This patient developed a Stage III pressure ulcer Problems: • Braden total score only was taken into consideration with regards to nursing interventions 4 No evidence (no documentation) of any teaching, efforts to reposition patient or other interventions prior to developing the pressure ulcer • Clinical factors were not taken into consideration 4 Pain scale score greater than 4 which was preventing her from repositioning self 4 Co-morbidities were also not considered © 2011 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 6

Current Pressure Ulcer Prevention Plan of Care A subscale of less than 4 or 3 (for friction and shear) would have triggered an unmet goal requiring the nurse to chart an intervention Interventions on education are in this care plan Pain is addressed with this care plan This care plan could have been further individualized to better meet this patient’s needs © 2011 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 7

What Barbara Braden say about subscales scores? Barbara Braden, presentation from WOCN conference 2010 says: “Each subscale score serves as…. 1. initial appraisal of patients specific problems and functional deficits, 2. flag for assessments that need to be explored further, 3. a guide to the types of interventions that may be required” “Total scores and levels of risk serve as…. 1. an estimate of the probability that a pressure ulcer will occur, 2. a guide to the intensity of the interventions that should be used” © 2011 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 8

What does the literature say about subscale scores? “Assessing patient risk of developing a PU does little good for the patient or the institution unless information from that assessment is linked to effective preventive interventions. ” Bolton, L. (2007). Which pressure ulcer assessment scales are valid for use in the clinical setting? Journal of Wound Ostomy Continence Nursing, 34, 368 -381. © 2011 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 9

How were care plan interventions chosen? From our skin management protocol Evidence Based © 2011 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 10

References Detroit Medical Center, Wayne State University. Using the Braden Scale in clinical practice (CD -ROM). (2004) Bolton, L. (2007). Which pressure ulcer assessment scales are valid for use in the clinical setting? Journal of Wound Ostomy Continence Nursing, 34, 368 -381. Braden, Barbara. (2010). WOCN Conference, powerpoint presentation. The Braden Scale. Reflections and Insights after 25 years. Bryant, R. A. & Nix, D. P. Acute & chronic wounds. Current management concepts. 4 th ed. (2012). St. Louis, MO: Elsevier, Mosby Noonan, C. , Quigley, S. & Curley. Using the Braden Q Scale to predict pressure ulcer risk in pediatric patients. (2011). Journal of Pediatric Nursing, 26, 566 -575. Wound Ostomy and Continence Nurses Society (WOCN). (2010). Guideline for Prevention and Management of Pressure Ulcers (2). Mount Laurel, New Jersey: WOCN. National Pressure Ulcer Advisory Panel (NPUAP). (2009). Pressure ulcer prevention & treatment. Quick reference guide. © 2011 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 11

Pressure Ulcer Prevention Plan of Care Nicole Webb & Cameron Johnson March 24, 2010

Goals Continue Lighthouse Project Complete Pressure Ulcer Prevention Plan of Care Complete Wound Plan of Care Develop top 20 -25 DRGs based on this model This will occur for entire MU enterprise § Develop patient-centered Plans of Care © 2011 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 13

Care Plans Power Orders Folder 14

Care Plan Power Orders Folder, cont’d 15

Icons Note each one § Icons have specific meaning © 2011 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 16

Pressure Ulcer Prevention Plan of Care Outcomes

Outcomes Can select or un-select components by checking or un-checking the boxes 18

Click the document in plan tab 19

Nurse can click the boxes for “quick” charting 20

Note Negative and positive responses 21

Pressure Ulcer Prevention IPOC Interventions

Interventions 23

Demo of patient-centered goals March 24, 2010

Patient-Centered Goals 1. Add to Phase § 2. Choose Outcome/Intervention § 3. Choose Patientspecific © 2011 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 25

Patient-centered goal, cont’d 4. Type in the word “patient” and click Search You can then pick the goal and/or intervention Type in the (free-text) the patient’s goal and/or intervention 26

Care Plan Timeline 27

Closing Remarks Keith Hampton

Closing Remarks and Questions 29