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Confidential for Quality Improvement Purposes Only
Hospital Acquired Pressure Ulcer Reduction Project
Jodi Blaszczyk RN, BSN, CWOCN,
Skin Care Liaison Committee,
Judy McHugh RN, MSN
Confidential for Quality Improvement Purposes Only
Opportunity/Aim Statement:
• Reduce Nosocomial Pressure Ulcers (PU)Goal: 0%
• Increase daily Braden Scale ComplianceGoal: 100%
• Limit linen layers 3 or less Goal: 100%
Confidential for Quality Improvement Purposes Only
PLAN
• LUMC participates in quarterly National Database of Nursing Quality Indicators (NDNQI) Studies – Point prevalence performed consists of a one day
study in which head to toe skin assessments for pressure ulcers, documentation, chart audits, and number of linen layers are collected.
• Braden Scale Daily* Compliance is monitored monthly*as a proxy Braden Scale daily compliance consists of random audit done 2 times a month.
Confidential for Quality Improvement Purposes Only
Solutions Implemented to Reduce PU
• Mandated daily Braden Scale Assessment – May 2008• Developed cards for Braden Scale low, mod, high risk
guidelines • Implemented Inter-Rater Reliability Stage 1 ulcers • Added Pressure Ulcer Prevention to Managers Meeting
Agenda Item • Expanded Team Turn; Back to Bed; and Save Our Skin
Programs on more nursing units • Implemented non plastic breathable adult/pediatric briefs• Ongoing education on reducing linen layers and adult briefs• Developed Evidenced Based Decision Tree for heel pressure
relief • Migrated existing Braden Scale CBL to new E-Learning
system – 799 completed • Filled open Enterostomal Nurse Clinician Position
Confidential for Quality Improvement Purposes Only
HW Noso Skin Ulce r Ra te
Confidential for Quality Improvement Purposes Only
2 Q 06 Jun10.3
3 Q 06 Sep12.1
4 Q 06 N ov13.9
1 Q 07 M ar7.3
2 Q 07 M ay7.3
3 Q 07 Sep7.8
4 Q 07 N ov5.6
1 Q 08 Feb6.8
2 Q 08 Jun8.1
3 Q 08 Sep5.1
4 Q 08 D ec4.5
Quarter
1
IndividualsTemporary: UCL=13.13, Mean=8.07, LCL=3.02 (mR=2)
4
6
8
10
12
14
UCL = 13.13
Me a n = 8 . 0 7
LCL = 3.02
HW Noso Skin Ulce r Ra te
Confidential for Quality Improvement Purposes Only
2 Q 06 Jun10.3
3 Q 06 Sep12.1
4 Q 06 N ov13.9
1 Q 07 M ar7.3
2 Q 07 M ay7.3
3 Q 07 Sep7.8
4 Q 07 N ov5.6
1 Q 08 Feb6.8
2 Q 08 Jun8.1
3 Q 08 Sep5.1
4 Q 08 D ec4.5
Quarter
1
IndividualsTemporary: UCL=13.13, Mean=8.07, LCL=3.02 (mR=2)
4
6
8
10
12
14
UCL = 13.13
Me a n = 8 . 0 7
LCL = 3.02
NDNQI SurveyTeam Training
& Staging
Acute Rehab & ICUAdmission Ulcer Documentation
Greater than 4 Linen Layers
Skin SurveyRe Education
Inter-Rater ReliabilityStage 1
Back to BedSave Our Skin
Manager MeetingAgenda Item
Reduce Linen LayerNon Plastic Adult Briefs
Daily BradenScoring
New EPICRN Documentation
Confidential for Quality Improvement Purposes Only
Bra
den
Sca
le R
ate
HOSPITAL WIDE BRADEN SCALE COMPLIANCE
33JAN 08
11911456
82
34FEB 08
9921217
82
35MAR 08
10401236
84
36APR 08
503585
86
37MAY 08
512562
91
38JUN 08
479532
90
39JUL 08
485527
92
40AUG 08
482506
95
41SEP 08
242249
97
42OCT 08
210220
95
43NOV 08
216226
96
44DEC 08
504511
99
NUMBER
DATE
ASSESS
CENSUS
1
IndividualsTemporary: UCL=96.31, Mean=90.75, LCL=85.19 (mR=2)
85
90
95
100
UCL = 96.31
Me a n = 9 0 . 7 5
LCL = 85.19
Goal = 100%
Bra
den
Sca
le R
ate
HOSPITAL WIDE BRADEN SCALE COMPLIANCE
33JAN 08
11911456
82
34FEB 08
9921217
82
35MAR 08
10401236
84
36APR 08
503585
86
37MAY 08
512562
91
38JUN 08
479532
90
39JUL 08
485527
92
40AUG 08
482506
95
41SEP 08
242249
97
42OCT 08
210220
95
43NOV 08
216226
96
44DEC 08
504511
99
NUMBER
DATE
ASSESS
CENSUS
1
IndividualsTemporary: UCL=96.31, Mean=90.75, LCL=85.19 (mR=2)
85
90
95
100
UCL = 96.31
Me a n = 9 0 . 7 5
LCL = 85.19
Goal = 100%
Confidential for Quality Improvement Purposes Only
Confidential for Quality Improvement Purposes Only
LIMIT LINEN LAYERS
Target goal 100% linen layers 3 or less
– Extra linen layers wrinkle causing increased pressure
– Too many linen layers decrease effectiveness of Atmos-Air Mattress Replacement System
Milne, CT, et al. Wound, Ostomy, and Continence
Nursing Secrets, Philadelphia, 2003, Hanley & Belefus, Inc.
Confidential for Quality Improvement Purposes Only
Centers for Medicare & Medicaid Services (CMS)
• Pressure ulcer estimated costs = $43,180 per stay
• Reports 257,412 preventable pressure ulcers occur as secondary diagnosis
• As of 10/1/08, CMS no longer reimburses hospital for nosocomial pressure ulcers
Confidential for Quality Improvement Purposes Only
Analysis of Data - Nosocomial Pressure Ulcer Rate
• Nosocomial PU rate has decreased with implementation of Inter-Rater Reliability on Stage 1 ulcers.
• New EPIC RN Documentation has assisted in capturing Pressure Ulcers Present on Admission (POA).
• Further education on documentation is needed to prevent nosocomial PU rate to be artificially inflated.
Confidential for Quality Improvement Purposes Only
Analysis of Data – Braden Scale Compliance
• Goal met at 100%. • Identifying who is at
risk allows for earlier implementation of a pressure ulcer action plan.
• Appear to be meeting goal of Braden scale done daily; however, need to monitor if sustained over time.
Confidential for Quality Improvement Purposes Only
Analysis of Data-Reducing Linen Layers
• Linen layers 3 or less in past 2 quarters > 90%
• Some improvement seen
• Need to continue with education.
Confidential for Quality Improvement Purposes Only
Next Steps
• Continue Targeting nursing units with high Nosocomial rates• Continue stage I inter-rater reliability of skin surveyor• Begin PU prevalence study data collection on portal• Increase turn around time on reports• House wide education on documentation• Educate on Specialty bed & Bariatric selection flowchart• Educate PCTs on reducing linen layers• Subcommittee to evaluate and update: P&P and EPIC
documentation changes• Implement Evidenced –based Decision Tree for Heel Pressure
Relief• Implement low, mod, and high risk guideline cards• Enterostomal nurses meeting individually with managers • Educate on 2009 Skin Care Resources available
