 Great, excellent. All right, let's go ahead and get started. We are waiting for Robin Betts, one of our panelists, but she should be on momentarily. And we have a lot of great information to share today. So I want to go ahead and get started. Welcome everybody. My name is Donna Prosser. I am the Chief Clinical Officer here at the Patient Safety Amendment Foundation. We thought this month a really great topic would be pressure ulcer prevention and management because we have just recently published our first apps on this topic. And with the advent of COVID, what we have seen as an increase in pressure ulcers in hospitals these days. And so we thought we'd get our expert panel together to talk about what we can do to prevent and manage pressure ulcers, especially in this day of COVID. As you can see, as always, we are providing CE for our nurses, our pharmacists, and our physicians that are on this call today. The CE is only available for those who actually attend the webinar. So as always, this presentation will be available on our YouTube channel after the webinar, but only contact hours are available for those who are on the call now. We have no conflict of interest to report, not the planning committee, and not any of the speakers today. So with that, I'm going to go ahead and we will introduce our panelists. I'll actually ask them to each say a little bit about themselves. We're joined today by Dr. Daria Terrell, who is an orthopedic surgeon and an expert in all things patient safety these days, right, Daria? Leah Binder, who's president and CEO of the LeapFrog Group. Sarah Abelusha is joining us from, I'm going to ask her to tell us where she is from over and not here in the United States. So I apologize, Sarah. I've just lost your city there off the top of my head. Debra Maluski is a physical therapist and edging professor at Chapman University. And then Robin Betts will be joining us shortly. She's vice president of quality and clinical effectiveness at Kaiser Foundation in Northern California. So Daria, if I'll start with you, let's go ahead and have all of you guys introduce yourselves and say a few words. Good morning. Can you hear me? Sure can. Thank you. All right. So I'm very pleased to be here this morning. And as Donna mentioned, my name is Daria Terrell. I'm an orthopedic surgeon in Chicago. I also am certified as a room care physician. And so I am very happy to be here with everyone. I have a special interest in public health matters and preventive medicine. And so these patient safety topics are very near and dear to me. And happy to be here. Thank you. Thank you. And Leah. Hi. Yes, thank you for having me today. I'm Leah Binder. I'm president and CEO of the LeapFrog Group, which is a nonprofit based in Washington that represents employers and other purchasers of health benefits advocating for greater safety and quality in hospitals and other health settings. But I'm actually joining you today in another capacity, which is that of a daughter and granddaughter who has actually had in my family to endure a stage four pressure ulcer for my grandmother. Thanks for joining us, Leah. Sarah. Hi, everyone. Thank you for this invitation. Can you hear me? We can, yes. OK, good. I'm Sarah Ruchiv. I'm a senior pharmacist. Working at Hart Hospital in Qatar. I did my bachelor's pharmacy. Then I did the master in epidemiology in public health. And the reason I'm here today, because I was invited, as I was a pharmacist involved in our research of pressure ulcer, and it was published in BMJ recently. Well, thank you for joining us, Sarah. And I'm so sorry I forgot that you were in Qatar. But now I will not forget that. Thank you. Debbie. Hello. Good morning. Yes. I appreciate the opportunity here to present our physical therapy perspective on the management of pressure ulcers. I'm humbled by this panel here. I am an adjunct professor at Chapman University. I'm a practicing physical therapist in an acute care hospital. And I have had direct, obviously, experience in patients who have pressure ulcers. And we are directly involved in attempting to prevent pressure ulcers. And one of the topics I do lecture is on wound management, as well as having had experience working in skilled nursing facilities in wound care. So I'm very happy to be here today. Thank you very much. Wonderful, wonderful. And I know that we are just waiting on Robin, but she should be joining us momentarily. So with that, why don't we go ahead and get started? Daria, I'll hand it off to you so you can tell us all about what pressure ulcers are. And Daria, I happen to notice in the audience we have folks that are wide range. There are folks that maybe don't have a whole lot of background in pressure ulcers. And then we also have wound care physicians that are on the call. So I know that's a little bit difficult to hit both of those audiences. But if you could try to do that, that would be awesome. All right. So I have been charged with the awesome task of trying to explain pressure ulcers and the science of it without boring you to death. So here goes. Obviously, this is something that we all want to be cognizant of and making sure that we're doing everything that we possibly can to think about these things and do everything that we can to prevent them. Next slide. So I have a friend who's from Michigan. And she goes almost every year to pick peaches with her daughters. And they brought back some peaches for me this year. And it reminded me of what happens with wounds. In preparing this talk, I just started thinking about this bag of peaches that I got. And so I'm going to ask you to indulge me. And just think about one of my favorite fruits peaches as we go through this little talk. Thinking about the first picture that you see, the collection of peaches. And as they were being brought in the car, they're in a bag. They're kind of sitting on top of each other for the peaches. It's another peach that's causing the pressure for everyday human beings. It could be something as innocent as a pillow, a mattress, a bowling catheter. Sometimes your wheelchair, the side of your wheelchair, the side of your couch. And then when we think about going to the next picture, what happens? So we might notice a little discoloration. And sometimes that discoloration is just on the surface. And then actually, if we go back to the slide, the last picture was a picture of a peach cut open. So you can see how sometimes the bruising on the outside actually penetrates a little farther. So I thought this was, I'm a very visual person. So I thought this was a good way of trying to introduce the concept. So if we really want to get into the nuts and bolts of the definition, a pressure ulcer is a localized injury to the skin and the underlying tissue. And it's usually over a bony prominence. So I think it's easier for most people to think of the heel, the elbow, the sacral buttock area as bony prominences. But sometimes, especially for patients who are intensive care unit patients, something as simple as your ear can actually be a bony prominence and can be a site of pressure ulcers and skin breakdown. And these occur as a result of pressure in combination with a shearing force. So again, if we're thinking about our peaches, and like I said, the peaches are causing pressure to each other when they're all stacked on one on top of each other. But for human beings, the pressure is being caused both by the bony prominences as well as whatever surfaces we happen to be on. And then if you look at the demonstration there on the right, it's depicting how the combination of friction and shear can actually help or how all those things combine in the development of pressure ulcers. As patients are being moved across a bed or up and down in a bed, that's creating a shearing force. Patients sliding off from the bed to a chair or sliding from one bed onto a cart, those are all shearing forces. And so these contribute to the development of pressure ulcers. Next slide. So just bringing this a little further, I think we kind of understand the concept of the pressure and shear, but one thing I wanted to point out is when we do have this combination of these two forces, one thing that happens is that leads to decreased blood flow. And so in order to heal and in order for our tissues to be healthy, they need adequate blood flow. And many times in the case of pressure ulcers, that pressure and the shearing force are disrupting the circulation to a certain area. So that means that those areas are compromised. And as a result of that, the tissue is not able to have the appropriate circulation and the body often doesn't respond quick enough to reperfuse, as we say, or regenerate that circulation to that area. And as you can imagine, then that leads to the areas being revitalized and or developing necrotic tissue. Also the pressure actually can directly deform cells and deform the tissue, much like if you go back to that image of the peach, and we think about the one peach that's kind of dented in or other fruits that we've seen, and there's actually a physical deformation. And the same thing happens with our skin. If we think about our skin is actually the largest organ in our body. And I think sometimes we don't think about the skin as an organ, but it truly is an organ and it is the largest organ in our body. So if we look at the images on the right, it's giving us the schematic of the layers that are involved in pressure ulcers. So we see the surface, so that surface pressure, it's either coming from, like I said, it could be something as innocent as a pillow, but that pillow, though soft and light and fluffy, it's still adding pressure. Then we have our dermal layer, and that dermal layer is where our new cells are being made and there's all of the other, the subcutaneous layer actually has blood vessels and all the other cells that are help supporting the skin as an organ. And we also have our sweat glands. So again, if we think of the skin as an organ, I think that actually helps us to be able to conceptualize how disease processes such as diabetes or cancer or anything that compromises us then can affect our skin. So the bottom picture there, where it says fragile skin, that's showing us how when you're older or if you're compromised by a skin or by a medical condition that you start to have problems because the layers that are supposed to support the skin are not there. So, how do we know that there's a problem? So what are the symptoms of a pressure ulcer? Symptoms can be things like changes in the color of the skin, like we saw that outer layer of the peach changes color. Some patients actually have pain or discomfort in areas. Obviously they're more obvious or sometimes I've had patients present and they didn't even realize there was a wound until they saw drainage on their sock or on their pants. And obviously if these ulcers get infected, we can have other systemic changes such as fever. Moving on, we're gonna talk about a little bit of the staging or how we talk about and how we classify these injuries. So the most benign, if you will, is what we call a suspected deep tissue injury. So we think that it's moving on that continuum. And hopefully if we notice it at that point, we can do things to prevent it. So what do we see? We might see red, maroon, purple discoloration of the skin. And then again, like I said, that's the time you wanna say, hey, look, if we don't do something about this, this is gonna get worse. When we actually talk about stage one pressure ulcers, these are ulcers that actually have a redden area that's different from if you squeeze the skin or something happens and it's red, but you release the pressure, the color comes back. That doesn't happen with a stage one injury. It's redness that doesn't fade. And then if you look at the schematic there, it's just showing how that superficial skin layer is affected. In stage two, you can either see a blister. So what we would consider a normal blister, either one that's fluid filled or blood filled, a blister by definition is a pressure ulcer. Sometimes I see them in patients that have fractures. And then if we don't see a blister, the other way we classify a stage two ulcer is a partial thickness skin loss. So if you, again, looking at the schematic, you see there's actually a divot. So if we took off not the layer of the peach, the skin of the peach is not just red, but now it's been sheared off. And there were a couple of those peaches in the bag. The skin had just been sheared off and there was actually the actual peach fruit itself that was visible. Next, we have stage three. A stage three is considered a full thickness tissue loss. And again, I like the imagery of the two. So you can see in real life what it looks like and then looking at the layers that are infected. So now we've got the superficial skin layer, the subcutaneous layer, and this is actually getting down and involving the fatty layer. And then in a stage four, now, unfortunately, we've affected all the layers. So this is a full thickness tissue loss. So we're all the way down at the pit of the peach down to the seed. So we've gone through the skin, the subcutaneous layer, fat, muscle, and most of the time, unfortunately, these are down to bone. I did want to highlight one other stage, which is the next slide. And that's an unstageable wound. So these are wounds that unfortunately we see often. They're covered by what we call a necrotic eschar. So you see this black tissue, which often is very, very adherent. But the point is we don't really know what's under there. I don't know if I take that layer off. Am I down to fat? Am I down to bone? Am I gonna see tendon or muscle? And that's why we classify them as unstageable. And normally we will try to do something to kind of loosen up that tissue so that we can take it off, and then that way we can stage it. And our treatment of regimens are gonna be more effective once we get rid of that necrotic eschar. So the last thing I wanted to really talk about is risk factors. So who do we need to look out for? What do we need to look out for to make sure that we're doing everything possible to prevent pressure ulcers? So patients who are immobile, for whatever reasons, decrease in consciousness, decrease in ability to move because of broken bones, pain. Patients that are present because they're in pain. They're not moving. Fecal and urinary incontinence is a big issue. Again, if you think about the beginning when we talked about our equation for pressure ulcers. So if patients are incontinent and they're laying on layers of moist bedding, linen and clothes and moist skin, that is leading to the pressure ulcers. Poor nutrition, again, decreased level of consciousness. If we think about our intensive care unit patients, burn patients, patients that for whatever reasons have decreased levels of consciousness. And as Donna mentioned in our opening, we've seen a lot more of this with the severity of COVID-19 cases. Other medical conditions, body weight can be a factor. Those who are very thin are often at greater risk because their bony prominences are more apparent. Smoking, elderly people, again, thinking about how the layers change and how that outer skin layer may not be as effective in protecting us against the differences between the surface and the bony prominences and then fragile skin. Those are some of the most common risk factors. And the whole thing is we want everyone to be aware of these conditions, what causes the pressure ulcers, why they start, and hopefully then that way we're all better equipped to make sure that they don't develop. Thank you so much, Daria. Leah, these pressure ulcers, especially these stage four pressure ulcers can be absolutely devastating to a patient and a family member. I'd love for you to share your story with us. Thank you, yes. This is my grandmother and my son. That's me as a teenager. I think it was about 15, 14 maybe. And my grandmother, Estelle Greifer, we were very close. She died a year and a half ago and she was 103 when she died. So she lived a very long life. Her mind was as sharp as ever. She was one of the smartest people I ever knew and continued to be so right to the end. But she did suffer from what was staged as stage four pressure ulcer at the end. And I wanna talk a little bit about what happened to her and what happened to our family as a result. She lived in Florida and none of our family lives in Florida. So she had some friends who let us know that she had gone to the hospital because she fell. My grandmother, the risk factors that Daria just went through, my grandmother had several of them, one of which was she's very low body weight and she was like 90 pounds and she had fragile skin and she was 103, so she was older. So she and she fell, she had fallen a lot in probably, I can't even tell you how many times, but she always recovered and just was as sharp as ever and on her way, she lived on her own by the way, never had assisted living or anything else and she just was a very, very smart, sharp, active woman. So she anyway, but she fell. And but this time there was some difference in the way that she was recovering, which was she was in the hospital for a couple of days and her friend said she's in so much pain, can't figure out what's going on. And so my brother and I flew into Florida and she was discharged to rehab and she was under just incredible pain and she had a pretty high pain threshold because she'd been through all these falls, we knew and it wasn't the same. She, there was something really, really wrong. We called the doctor and we couldn't get the right doctor and was just to just kind of disorganized, whether at the hospital or in rehab, it was always felt disorganized. Like nobody really knew what was going on. We're always different nurses, different aides, different people all over. We didn't know which doctor was in charge and kind of chaotic environment, which being in healthcare as an advocate, I knew was common, but in this case it was very dangerous because she really needed a lot of attention and we knew she was under high risk for pressure ulcer because she had this fragile skin problem and that was well-charted in her medical record. So anyway, eventually the doctor came in and said, yeah, it's not looking very good and she needs to be turned frequently and he gave her pain meds. He gave her a fentanyl patch, which was, I knew what fentanyl was and I thought that was pretty extreme, but at the same time I was so worried about her level of pain, which seemed to be constant that we finally said, all right. And so she had that plus other pain meds so eventually she was basically knocked out. And, but she had now and then had moments of fluidity and I knew that they weren't paying enough attention or they weren't turning her. I would say, you turn her. We hired a nurse to come in and watch her in rehab, which apparently a lot of people do and which we didn't know to do till way too late, I'm sure. But we had someone there 24 hours a day watching her and turning her and making sure she was doing okay. And that was okay. But then finally my grandmother in some moment said to me, I want to die at home. So I discharged her, this time all of a sudden there were all these people suddenly paying attention because I wanted to discharge her from rehab before the 30 days that Medicare will pay for. And I was just so offended that all of a sudden we mattered. And I had to fight and I had to say, look, I don't care. She's going home. And it was this big freakus. And I finally got her out of there. And so she was home, had a bed and we got a nurse and all that. But she was in so much pain and it was just awful. I could tell the pain. And so we finally had hospice come and they gave her morphine. And that's when they diagnosed the stage four pressure ulcer and they said that should never have happened. And I knew that was true. And I just felt like that was our fault. How could we have missed this? How could we have let this get to this terrible point? And what a horrendous, it was on her tailbone. What a horrendous way to see to the end of her days. So I held her hand when she died and I felt that she had waited for me to be there that morning. It was extraordinary. I felt like that was a compliment to me that she waited for me. And so I'm not sorry she died. Nobody, we all die. And she knew she was someday gonna die. She was 103, although we did have to wonder when she got to the certain age. If in fact she might be the first immortal, but she wasn't. And I don't think she ever anticipated she would be. So it is not the fact that she died. That's the tragedy here. It's the fact that she died in such excruciating pain and it was so incredibly unnecessary. And that's outrageous. Our healthcare system can be so much better than that. My grandmother was a very glamorous New York woman. And you can even see in this picture and read her, she always dressed perfectly. Like she always just had the right fashion sense. Even in this picture, she looks so much more fashionable. I look like the old lady and I was 14 and she's fashionable. And then I read in ARC, ARC has best practices for handling pressure ulcers. And they say part of the reason that we don't put those practices in place, which are simple practices like multidisciplinary teamwork put in the patient at the center, turning the patient frequently, all of the things we know the healthcare system unfortunately is not that great at. And part of the reason they said is because pressure ulcers in the skin are not perceived as glamorous and that other body parts are just enjoy more a higher status. I think we have to get to a point in healthcare where it's not body parts that give a high status. It's human beings and giving them outcomes that are dignified. That's what should be the highest status. And that's what my grandmother deserved and your loved ones deserve as well. Thank you. Alia, thank you so much for sharing that powerful story. We sometimes forget behind these wounds that there are patient faces, there are family faces. So thank you very much for reminding us of that. Sarah, do you wanna tell us a little bit about how we can treat these ulcers? For ulcers, as we know in our hospital, what we are doing, the nurses are following are the breaded scale score for assessment of the skin ulcers. And as we know, there's many, there's stage one, two, three and four as it's mentioned. So for stage one, usually there is no medical treatment, they just do prevention, which is they apply barrier creams for the patients to avoid skin damage. And for stage two, they always apply moisturizers and they cleanse the wound if there is any wound. But for stage three and four, if the wound, it should be, if there is no necrotic in the tissue, what they do, they apply moisturizer and as we know, there's many dressing types they use for pressure ulcers. But depending on the wound, if they say that it needs surgical consultation, they refer the patient. But if they see that after the dressing, after 14 days, if they see that there is no improvement, they apply a topical antibiotic. And then again, they will watch the wound. If there is no improvement, they consider referring the patient to the infectious team. So they do further investigation. For example, they do culture to know if the patient needs systemic antibiotic. Yes, Dr. Thank you, Sarah. Sorry, I was muted. Thank you very much. So tell me about some of the other pharmacological therapies that are out there in terms of cell regeneration. Is there anything exciting happening out there? What I did last week, I went up in the world in our hospital and I went to one of the world that there is many bedridden patients, especially heart failure patients, as you know, I've been working in a cardiac hospital. And I asked the nurses there, what you are usually doing for our patients? Because I can see that we're doing great job, as you see in our publication. We really reached zero pressure ulcer. And they said we always apply the barrier creams and for the last two years, we did not encounter any pressure ulcer. That's fortunately. And they said if there is any wound, we refer that to the wound infection team and they come and assess. And what she said, we always focus on the dressing types. We always put the form dressing, which really helps the patient to improve. Excellent. Thank you. Well, and Deborah, Debbie, I wonder if you can tell us a little bit about how physical therapists can participate in management of pressure ulcers? Certainly. Actually, I like the fact that I'm building on the last three presenters. This is really a pleasure of mine to show how we can fit in with the rest of the team. And that includes the family. But as we strive to meet the goal of patient health and safety within that healthcare environment, prevention of pressure ulcers is a major concern, as has been outlined. These ulcers do cause a significant cost in increased costs of care. It adds to months and years of additional medical treatment. And as outlined by Lee, just significant stress on the patient and the family. So prevention definitely requires a multifaceted approach and all members of the healthcare team are responsible and physical therapists are an active participant in that responsibility. Lee's story is really upsetting and it really shows the impact of a disorganization in a multidisciplinary approach. But as we use a multifaceted approach, we have five key strategies. And I have them listed here. It's in no particular order as far as importance. Individual needs definitely dictate the level of priority for each intervention. And if you refer back to Dr. Terrell's list of risk factors, you can see how this five key strategies falls into place. Education is the top priority for all patients. All our patients and all their caregivers must have an understanding of the importance and necessity of ulcer prevention. It doesn't stop there. They need to understand their risk factors that will predispose them to development of those pressure ulcers. And Dr. Terrell did detail the risk factors. There are more, but those are the key risk factors. They need to understand the areas on their body that would be susceptible to ulcer formation. And Dr. Terrell did mention a few areas like ears and sometimes little crevices on our faces if we use medical devices may be susceptible. Certain patients may need to understand that. They also need to understand the strategies that they can utilize to prevent compromise and skin integrity. So I'm gonna detail these key points a little bit and then move on to the specifics of physical therapy. Positioning is used as both a passive and an active intervention. The passive techniques are uses of cushions, splints, wedges, pillows. We obviously have to be judicious about how we use those and where we put them to support the body parts and to put the patient in a position that would be safe for them. Then we involve active positioning, which would be changes in body position. And we must follow that turning schedule. There is a specific schedule that certain patients need more frequent turning than others, but it's really critical to schedule offloading of areas that have pressure from weight. Obviously ulcers do develop in very short periods of time and those patients with multiple comorbidities, particularly the elderly are very vulnerable. The elderly have much thinner dermal layers so they are going to be much more susceptible. They're weaker so they may not pre position themselves as much, they may be more predisposed to having confusion and effects from all their medical conditions. It's interesting, I do use that same example of a ripe peach that Dr. Terrell brought up. That's the most visual graphic that I've been able to use to demonstrate to families how quickly a piece of soft tissue can degrade and develop a wound. So therefore, all members of the healthcare team and the patient's home care team must be diligent in using these techniques to disperse and offload pressure. We use mobility. Mobility is exactly what it sounds like. It refers to moving around. And ideally, we encourage patients to walk. Either encourage them to actively get up and walk or assist them to get up and walk as much as possible. Walking isn't always possible, but mobility does provide health and wellness benefits. It also provides benefits to the skin health through the promotion of repositioning as I just previously discussed and also through facilitation of circulatory function. Mobility is a general term and it refers to more than just ambulation. When a physical therapist performs an assessment, we ask a series of questions to help guide our plan of care. If we find that walking is not possible with the patient, could the patient potentially even stand? That would take pressure off of areas that are in a dependent position. If standing is unrealistic, how can we assist that patient to get out of bed and sit in a chair? If they can sit, we need to assess for support devices, but also can they propel themselves in a wheelchair? That would be one way that perhaps they could be changing their position. If a patient is bedridden or on bed rest, we look at whether they can move themselves around in the bed and help alleviate areas of pressure. It is the least ideal scenario, but it is realistic. It happens and it's better than no mobility at all. Another factor that must be addressed is the patient's nutritional status. Now, this is not really considered a physical therapy intervention, but if we approach the patient's health from a holistic viewpoint and with the knowledge that adequate caloric intake and nutritional balance are essential for both ulcer prevention and the healing of existing wounds, then this becomes an aspect of care that requires the attention from all disciplines. And that does include physical therapy. Not only should patients be given education on the effects of their nutritional status, they need to understand it affects their risk of ulcer development and overall health in general. We must ensure that patients can physically access adequate nutrition. This can be a huge barrier. Assessments should be done of social, cultural and financial issues that may impact the person's nutritional status. The rehab disciplines themselves work on the physical ability to perform activities involved in feeding oneself. That could be from preparing a meal to the action of bringing the food to the mouth or to properly chewing and swallowing food safely. These factors are not just physical therapy, concerns that are addressed collaboratively between occupational therapy, speech therapy and physical therapy. As mentioned, a critical factor to address is the maintenance of a clean and healthy skin environment. So that is done by the way of management of incontinence. Incontinence is a risk factor for the development of pressure ulcers. It fosters that moist environment, which is so critical in the development of an ulcer. It does require multidisciplinary attention and as Lee's example highlights, just everybody paying attention to the patient's immediate environment really can make a difference in whether their skin will remain healthy or not. The care team should be actively involved in the promotion of a ballon bladder training schedule and patients should be encouraged to mobilize to perform toileting to avoid that soiling of their clothing, their bedding or their seating surfaces. In addition, let's see. Okay, I've hit all those points. Can we move on to the next slide? So in addition to all of our interprofessional responsibilities, we physical therapists do have specific roles in the management of pressure ulcers. Our training gives us a specialized skillset, knowledge and background. We are the experts of the movement system and what does that mean? It means the integration of the function of every body system as it affects movement and as movement affects the body systems. So when we consider that immobility is the primary cause of pressure ulcers, we physical therapists are in a position to be integral members of the skin care team. Mobility is our niche and we use various interventions as our tools. We provide training and mobility techniques to promote greater ease and safety when mobilizing. We prescribe and teach exercise interventions to improve strength and range of motion impairments and hopefully allow a patient to be able to move themselves better. We teach those positioning and repositioning techniques to provide optimal offloading of pressure areas. And finally, we do assess for prescribed and fit devices to assist with positioning, wound prevention and wound healing. These devices include adaptive equipment, orthoses, splints, footwear and support surfaces. And there's new products coming out all the time. So we try to stay abreast of any new products that may promote a better positioning system for a patient. As the movement system specialists, we recognize that all the body systems interact and impact the function of the movement system. So as our training of those movement specialists, that includes training and wound management. And that does include integumentary and circulatory assessment, wound treatment and the use of physical agents. Our licensing allows us to use ultrasound, infrared, electrical stimulation, negative pressure, wound therapy, a variety of physical agents that we can use for advanced wound treatments to stimulate increased healing responses at the cellular level. And furthermore, there are physical therapists who specialize in wound care. They receive advanced wound care training. And that includes the use of conservative, sharp debridement of necrotic tissue. Now, in those pictures of Esgard, which appeared to be really deep necrotic wounds that Dr. Terrell showed, we would not be allowed to cut into a wound where we don't understand where the limits of the viable tissue margins are. But we are permitted under our licensing to perform some very conservative debridement of necrotic tissues. So as we draw from our unique training and perspectives, we create an individualized plan of care for our patients that enables us to mitigate the sequela of immobility and to treat wounds when they do occur. And this ultimately allows us to complement the care provided by the entire interprofessional team in pressure ulcer management. This is a brief overview of our physical therapist role. I do appreciate my opportunity to promote the involvement of physical therapy in patient management. Thank you. Thank you so much, Debbie. Yes, it's one thing that I think that we have heard about loud and clear on this webinar is that we need a multidisciplinary approach. So once, so thank you for that. Absolutely. And I'm so excited that Robin has now joined us. Robin, are you there? I am. Can you hear me? I can. I can. Thank you so much for joining us today. Robin, why don't you just give us a little bit about your background and then tell us what you guys are doing at Kaiser. Thank you. I appreciate that. So I'm Robin Betz. I'm the Vice President of Quality, Patient Safety, Clinical Effectiveness and Regulatory Services for Kaiser Permanente in Northern California. In our health plan, we have over 4.4 million members that we serve and are responsible to deliver on this quality and safety. And so I'm grateful for the opportunity to share. Donna asked me to take kind of a global approach like what's contributing to harm, especially during COVID and what can we do about that? So really, when you think about human performance, we all perform in three performance modes, skill-based, rule-based and knowledge-based performance. And there's many things going on during COVID that are creating failures in these performance modes. We have novel conditions, a new disease that we're treating, lots of distractions, and also changes in our practice as we look at suppression tactics. So we might have new isolation protocols. Maybe two nurses aren't at the bedside, giving a report and one staying outside the room to reduce traffic and preserve PPE. And all of these things set up and disrupt our standard work. We also really miss our visitors, our patient family members who are content experts regarding their family members' normal baseline and their conditions. They're also a help in hand and keep people from getting out of bed and on their own without asking because someone's right there and says, hey, can you get me that magazine? And that family member will go get that for them instead of them getting out of bed, thinking that they're okay and forgetting that there may be new medications that might impact their balance. So there is also restrictive visibility as we try to isolate the virus itself. And so we're keeping doors closed so we're trying to position IV pumps and urinary catheter bags so that we can look at them through visual windows versus going into the room. Again, reducing that traffic, but all of that disrupts our standard work and we have to now design new standard work as potential failures are exposed or become a reality. So if you wanna go the next slide, we'll talk a little bit about a solutioning, understanding these conditions. You know, you have to think, how can we organize ourselves in such a way that we can quickly detect, understand design and then laterally deploy improvement when we see drift or new challenges emerging in our novel and rapidly changing environment. So as you know, recently, the Patient Safety Movement Foundation and really with under the direction of Donna, they created a framework of safe and reliable care. And there's a lot of guidance around how you make that happen in your organization. It's really built on high reliability science, but people often say, well, what does it look like in that action? I know what the principles are and they're laid out here in every highly reliable organization. These five principles exist, but what does it look like in action? And just so you know, those principles create what they call a collective mindfulness around quality and safety. They're obsessed with it. So let's talk a little bit about what does preoccupation with failure looks like? So if you'll just click the button, that would be great. So you actually proactively monitor for failure. You do quick drill downs on every safety event and address the contributing factors. Use your frontline teams that say, what happened? How did we fail in this one time? Use your data trending and analytics. I have my wonderful risk management team that are monitoring any event that's reported that's associated with COVID and every week we look at the summary and then we can manage how we respond. In the beginning it was around PPE and understanding what's the right thing to wear. Now it's more about exposure and concerns about exposure. And so now we're managing our responses based on our trends. We're also piling and that's called the virtual healthcare companion where we have video access and audio access in the room and actually a staff that are monitoring those cameras so that the patient can dial up anytime that they need something and connect with a real person. And so we're hoping to see how that works and spread. So there's just a lot of ways that we can continuously anticipate by increasing our detection. And then reluctance to simplify if you wanna click the button there. Really not rushing to judgment but really doing a good root cause analysis and embrace human factor science. There's so many reasons why people do things. It's not always that they need to be reeducated. It's that we change something. We had a recent incident where we quit having two nurses at the bedside for that handoff. One would stay outside the room and they would communicate with each other. And that disrupted the way that we do our safety checks before we leave the room and hand the patient off. So we've had to go back and say, you know what, it's worth the expense of the PPE to have two people in the room at handoff. So really looking at what was the factors that contributed to the failure. And then deference to expertise. This is my favorite. If you wanna click the button, this is where you defer to the person most knowledgeable. So how do you get that front-line knowledge about why things happen? Sometimes the person most knowledgeable is not the highest educated in the room. It's the person who's closest to the work, closest to the family. So connecting with family through virtual technology so we can ask them questions about what's normal and is this different and get their input. Front-line ideation and solutioning. So good ideas is if you have huddles every morning with your team, find out what's working today or what happened yesterday and what was a good solution and capture those ideas and laterally deploy them with everyone. Peer to peer coaching. There's great ways that we can coach each other and encourage each other to do the right thing and use common language to do that. There's a lot of tools as some people use TeamSTEPPS and they have a tool called CUS, which I don't like the acronym, but it's voice of concern to help me understand and then trump the safety card. So you would ask, I'm concerned that you're going into that room without your PPE on. And then if they keep going, say help me understand why you would do that. So everyone has a common language and when you start using it, people realize, oh, they're just coaching me and I'm supposed to thank them for watching my back. So, and then engage patient and family in event investigations where it's appropriate. And we've been able to do that. My risk management team just did a wonderful training on how to engage patient and family members in an event investigation because they might have seen something that we could learn from. And then on the other side is the commitment, I mean, the sensibility to operations. How do you build in that daily sensitivity so you know it's going on as a leader? Well, you allow for event escalation through daily huddles every day. We have across our 21 hospitals a tiered huddle and they escalate any new hospital acquired infections that they're investigating. If there was a fall, if there was an employee harm event. And so my safety team were able to capture that, identify early and then begin to react and share learnings or assist them where we can. Data management systems are really important in this process so that you can provide good leading indicator data so that people on their, if you have visual boards in your departments, they can see what they're doing today that contributes to tomorrow. And it's very motivating for individuals, team members to see that what they're doing every day is making a difference. And then leader rounding. I can't emphasize enough how important it is for leaders to get out on the units and to round and look at their visual boards and say, what are you working on? How's that working? And ask questions, but also reinforce what you wanna see and compliment people for the great work that they're doing. And then if you are in the middle of, right now we're surging, we have over 400 patients that we're managing that are COVID positive and some of them are very, very sick. And so we have a command center so that no single hospital operates in an island. We come together, we can shift resources, we support one another because every day we're paying attention to that the needs of each organization. So we build in that sensitivity to the operations through these communication channels. And then a commitment to resilience. And this is where we stay practiced in what we need to do. And so we have standard work, right? So the Patient Safety Movement Foundation publishes apps that are actual patient safety solutions that are actually recipes with best practices around how to mitigate harm. And also one awesome thing that my safety team did was as we begin to see our trends and different challenges with our harm events, they put together a pocket guide that said, here's our standard work but here's what's special with COVID to pay attention to. Incredible resource quickly produced and laterally deployed to all of our nursing staff. And then recognize and reinforce positive behavior. Again, taking advantage of leader rounding. If you don't get with you what you expect you get what you inspect. People care about what their leaders care about. So if you as a leader are rounding and you have a prone patient who's COVID positive who has severe respiratory distress syndrome you can thank the nurse for, oh, I see that your patient's prone. Thank you for using that great spongy dressing to protect their skin while they're prone to secure their devices. Those little things like reinforcing that this is what I wanna see and I so appreciate you doing that really hard wire standard work. And then really that lateral deployment of lessons learned, right? So create ways of doing shared learnings. My risk management team collates events and finds common causes and then shares those in a regular interval so that the teams can learn from each other across our hospitals. If you wanna go to the next slide really looking at this science if you just click one more time those top principles really place these organizations or your organization in a constant state of anticipation. You're always on the lookout for the next potential failure and this allows you to more effectively stay out of trouble. Now on the bottom side, if you click again these are our more containment strategies. So as you implement these principles you're able to quickly contain and minimize risks when things begin to percolate and allow you to more quickly get out of trouble. And that's how you really are able to operational a high reliability organization. So thank you for your time. I know you wanted to leave time for some questions, Donna. So I'll turn it back over to you. Thank you, Robin. I appreciate that and that is so incredibly important to look at pressure ulcers as an error as an event. And I think one of the issues that we have in healthcare is that so many folks don't see a stage one pressure ulcers pressure ulcer as an event that we then need to report. So Robin, that was such a great summary of how leaders can be actively involved in helping to prevent pressure ulcers in your organization. We do have several questions. So I know we're not gonna be able to get to all of these but Debbie, I wonder if you can... There was one question about physical therapists. What's the best way for us to get physical therapists involved in a multidisciplinary team? Well, it depends on the setting you're in but in rehab settings and in hospital settings everybody's extremely visible and there nobody should be inaccessible. So the physical therapist and the nurse should be talking. Nurses should have their eyes out for any potential problems and request referrals to physical therapy or ask the physical therapist what they think. We often will answer questions even on patients where we don't have a referral. That's certainly more in the patient's best interest than waiting until there's a referral for us. So just communication, open communication between health team members, being visible, being available just like with the leadership. Constantly communicating with the team members that are out on the front line. Wonderful, thank you. Donna, can I just add on that? Please, please. Family members and even other providers that might be taking care of a patient should not be afraid to speak up and ask. Ask the, if you're a family member, ask the nurse. If you're a nurse taking care of a patient and you notice physical therapy, ask the doctor that's taking care. Hey, is physical therapy seeing this patient? Is this the time we should be getting physical therapy involved? Don't be afraid to bring it up and ask the questions. Completely agreed. I wish there were more nursing assessments that would trigger an automatic order for physical therapy in patients that are immobile because too many immobile patients are left immobile for too many days before it's identified that they are not getting the movement that they need. I will say that I never considered a physical therapy evaluation with my grandmother ever. I mean, she was getting physical therapy for other kinds of movement while she was in rehab, but honestly did not know that a physical therapist would be someone to look at the pressure ulcer. That's one of our hidden skills. Not everybody's aware that that is a skill that we have. Again, there's really, it sounds like there was some disconnect in the communication because she sounds like obviously a high-risk kind of person and that really should have triggered some thoughts in people's minds that we need to be more proactive and preventative in this type of care. We did have a question from a panelist about getting patients and families involved in an investigation. Robin had alluded to that. And so I wonder, Robin and Lea, I'd love to hear Robin from an administrative standpoint, how do we get patients and families involved? And Lea, from your standpoint, how do we get patients and families involved? Yeah, thanks. So you have a responsibility to disclose to the patient when there's harm anyway, and usually they know, right? And so in that process, you can ask questions, especially if probably, I think there's some that offer more insights than others like a fall. I remember we had a patient fall and it was an elderly woman who was so proud of herself because she could always do it. She was a ballerina. She could always do a pirouette. She had hip surgery and she said she couldn't wait to do a pirouette again. And she decided she was gonna do one and they told her not to and that it would be a risk. So right in front of her, right in front of them, right after they said, please don't do that, she did it anyway. And that's a great opportunity to say how could we have been more clear and just dive into the questions about what made her think that she could do that? Maybe on a carpeted floor, you don't have as much resistance as you do when you have those little sticky socks on that prevent falls. And there's a lot of things that we can learn from a patient about why they made the decisions that they did. And so it's just being inquisitive and saying we want to learn from you and how can you teach us? How could we have been more clear in our messaging or how could we have, what did you see that you think could have helped us been more careful or what didn't we listen to? So there's just a lot that we can learn from our patients and the family members. Leah, from your perspective. I think it's important for people to understand when you work in healthcare, you may lose this perspective and that is how bewildering the healthcare environment is to a patient or family. It is a completely unknown territory. It's a place where you feel like everything is going on around you and everybody else seems to know what they're doing, what they're talking about. They speak a different language. They speak clinical language that is bewildering in and of itself. And they clearly know what they're doing. They know all about this. And for us as patients and families, it's foreign territory. We don't understand any of it. And it is also a moment of extremely high stress. It's a moment we aren't going to forget in our lives. It may be a routine day for personal works in healthcare, but for a patient or family, it's an extraordinary moment in their life that gets written in their biography. I mean, it is the moment when my grandmother faced the end of her life. That's a huge moment in my life, any bewildering environment that I don't understand. And so, and I work as a healthcare advocate. So I don't work in the healthcare environment every day, but I work as an advocate and it was extremely difficult for me to assert what she needed. First of all, I didn't completely know what she needed. And second of all, I couldn't translate what was going on and who was supposed to be in charge of what. So it was a continual battle for me. And I felt like I was trying to be nice because I knew I was going to be there all the time and I didn't want anyone to be mean to my grandmother. So you can add that in. Anyway, it was bewildering. And so I came out of it feeling like it is a far more difficult job for a patient or their family to advocate on their own behalf than I thought until I've gotten the middle of it and realized how bad it was. And then we got a nurses aid and I, not everyone can afford this obviously, but anyone who can afford to find to put some pennies together and make it happen to have a 24-hour nurse in a rehab center, which is ridiculous that that's needed. That is the number one best thing that happened in the care of my grandmother because they could be there, they could make sure she was turned and they could advocate and they weren't as bewildered by the environment. So anyway, so I wish I had better answers, but just to give people a sense of how difficult it is to advocate I think is important for people who work in healthcare to be aware of. Thanks Lea. Well, we are four minutes past the hour, but we still have so many questions. I feel like we probably need to answer a lot of these questions on electronically because there's no way we're gonna get to them all. So we will do that after we complete this webinar. So we'll maybe calling on some of our panelists to answer those questions with me. One comment from the audience from Sujin said, imagine how this would be for patients in caregivers with language barriers. So absolutely. I mean, we're talking about folks with social disparities as Daria mentioned with access to nutrition as well as just being able to understand what's happening. So again, a plug for coordinated care across the continuum of including patients and families and in their care so that they can be active participants. Thank you all so very much for joining us today. We always enjoy having, being able to host a monthly webinar like this. And so thank you very much. I hope everybody has a wonderful holiday. Thank you, Donna. That was great. Thanks for inviting us to participate. Absolutely, I appreciate it. Thank you. Yeah, thank you. Thank you. Have a great day, everybody. Yeah. Be safe, everyone.