Preventing Hospital Acquired Pressure Ulcer

Name of Green Belt(s): Maurice Espinoza, Sonia Ramos LaneName of Champion: Karen Grimley

Date: 7/21/2011

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Problem Statement

What is the problem? The number of patients at UC Irvine Medical Center with a Hospital Acquired Pressure Ulcer (HAPU) is above the mean when benchmarked against the Collaborative for Nursing Quality Indicators (CalNOC) and the National Database of Nursing Quality Indicators (NDNQI). This potentially results in decreased patient satisfaction, increased length of stay (los), increased risk of infection and increased mortality rates.

How do we know it is a problem? Prevalence is above the mean when benchmarked against national databases.

What data to we have on baseline performance? Prevalence data is collected monthly and benchmarked against national databases.

What “pain” does it cause? (impact to patient and/or bottom line):

• This potentially results in decreased patient satisfaction, increased length of stay (los), increased risk of infection, increased mortality rates, increased cost to the patient and organization and increased negative publically reported data.

•

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Why is this important?

• Include Voice of the Customer (VOC): HAPU is considered a Patient Safety “Never Event” and can lead to increased cost, morbidity, length of stay, etc.

• Why this, why now? (“Burning Platform”): HAPU has been an initiative for a long time at this organization. We have shown significant improvement but have not been able to reach the next level.

• What will happen if we don’t fix this? Not fixing the

problem potentially results in decreased patient satisfaction, increased length of stay (los), increased risk of infection, increased mortality rates, increased cost to the patient/ organization and increased negative publically reported data.

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Project CharterProject Name: Pressure ulcers Prevention Champion: Karen Grimley

Belt: Sonia Ramos Lane RN/Maurice Espinoza RN Master Black Belt: Laura WinnerProblem Statement:The number of patients at UC Irvine Medical Center with a Hospital Acquired Pressure Ulcer (HAPU) is above the mean when benchmarked against the Collaborative for Nursing Quality Indicators (CalNOC) and the National Database of Nursing Quality Indicators (NDNQI). This potentially results in decreased patient satisfaction, increased length of stay (los), increased risk of infection and increased mortality rates.

Project Goal:To decrease the prevalence of hospital acquired pressure ulcers at UC Irvine Medical Center in the SICU below the CalNOC median and mean prevalence for similar institutions by the 4th quarter 2011.

To decrease the rate of hospital acquired pressure ulcers in the SICU.

Project Y / Path-Y:Project Y: Monthly prevalence of hospital acquired pressure ulcers in the SICU benchmarked against CalNOCPath Y: Daily incidence of HAPU in SICU measured by number of new HAPU/number of patients in SICUPath Y: daily prevalence of HAPU in SICU as measured by number of existing ulcers/number of patients in SICUPath Y: Number of HAPU that progressed from previously staged pressure ulcer.Path Y: Rate of HAPU in each stage: 1, 2, 3, 4, DTI & unstageable

Scope:Limited to Surgical Intensive Care Unit

Benefits: (Potential)•Decreased incidence of infections •Decreased patient discomfort •Improved patient satisfaction•Decreased length of stay •Improved standing on CalNOC publically reported data

•Decreased mortalityTeam Members:Champion: Karen GrimleyTeam Members:Sonia Ramos Lane, RN, Nursing DirectorSusanne Collins, RN, Critical Care ManagerMo Espinoza, RN, Critical Care Clinical Nurse SpecialistVarsha Shere, RN, Wound Care SpecialistCharlene Miranda-Wood, Nurse Manager

Timeline: Completion DateDefine/Measure April 18, 2011 August 2011Analyze May 2011 September 2011Improve/Control July 2011 February 2012

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Baseline Data for Y:Hospital HAPU

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Baseline Data for Y:SICU HAPU

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HAPU In the SICU

VOCStaging

Identification

Calling DTI too soon

Inconsistency in staging

Documentation used for coding

Not Enough?

Chart Audits:

Need quick follow-up if things are not correct

Need validation that what is being done is correct

Incomplete Hand-off

Consultation

Inconsistent

Inconsistent adherence dietary recommendations

Inconsistent adherence to CWOCN recommendations

Equipment/Supplies

Defective & Not Enough

Positioning aids: Pillowed out,

New Beds: Where did they go?

Positioning Aids not readily available

Support

Documentation complicated and confusing

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HAPU In the SICU

VOCPrevention

Knowledge Deficit

Improper positioning

Turning technique

Not Enough?

Chart Audits:

Need quick follow-up if things are not correct

Need validation that what is being done is correct

Incomplete Hand-off

Consultation

Inconsistent

Inconsistent adherence dietary recommendations

Inconsistent adherence to CWOCN recommendations

Equipment/Supplies

Defective & Not Enough

Positioning aids: Pillowed out

New Beds: Where did they go?

Positioning Aids not readily available

Support

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Early Waste Identification DOMOWIT• Defects:

– Positioning devices (pillows) are not effective

– Some mattresses need replacing

– Incomplete hand-off from other departments

– Inconsistent shift hand-off

– Inconsistent documentation of progression and plan

– CWOCN recommendations not verified by MD

– inconsistent implementation of dietary recommendations

– Inaccurate staging

– Poor turning technique, Positioning not always of pressure points

– Inconsistent use of maxi-slide

• Over-production

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Early Waste Identification DOMOWIT• Over-processing: Documentation

• Motion

• Over-production

• Waiting: – Positioning devices not readily available

– Orders not verified

• Inventory: – Not enough positioning devices

• Transportation

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S I P O CSupplier Inputs Process Output Customer

Patient RN Report Admission to SICU Documentation RNFamily H&P Referrals Ancillary ServicesRN Physical Assessment MDMD Braden Scale

Nursing Admission Assessment Form completion

RN Sensory Preception Physical Assessment & Braden scale/Computer Entry Plan of Care InitiatedMoisture Referrals Ancillary ServicesActivity WOCNMobilityNutritionShear and Frictionpt HxAssessment

RN RN Qshift Assessment For Pt's with Skin Intact but "At Risk for Breakdown" -Plan of Care initiated

Skin Remains intact PatientMD Braden QshiftAncillary Services Manage Incontinence

Minimize PressureMinimize Friction & ShearMobiltiy/ActivityManage NutritionPt/Caregiver EducationEvaluation of InterventionsDocumentationMD Orders

Nursing Policy & Procedure S-101 -Skin Care Protocol: Prevention & Treatment of Pressure Ulcers

Prevention Protocol algorithm Implement Nursing Interventions; MD orders per Ancillary Services recommendations and continue with

Plan of Care/Interventions.

Skin remains intact Patient

RNAncillary ServicesMD

ACTUAL SKIN BREAKDOWNRN/WOCN Assessment of Stage MD Notification Form; Enter Incident Report; Initiate

POC:ActualPU Form; MD Notification MD

MD Measurements/Photos Manager Notification ManagerTreatment Protocol Algorithm WOCN Notification RN

Treatment Initiation WOCN

RN Assessment ReassessmentTreatment; Daily Assessment if poss;Daily

Documentation; Weekly Assessments & MeasurementsWound Healing or Progressing (Not Healing) Patient

WOCN New Orders Change in TreatmentMD

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MeasureMEASURE

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Cause and Effect MatrixMEASURE

Rating of Importance to Project (low 0- high 10) 6 3 101 2 3

Process Step Process Inputs Assessment Planning Intervention TotalAdmission to SICU RN Report 3 0 0 18

H&P 0 0 0 0Physical Assessment 9 1 3 87

Braden Scale 9 1 3 87Nursing Admission Assessment Form completion 9 0 0 54

Braden Accuracy 9 1 3 87Sensory Preception 3 1 9 111

Moisture 3 1 9 111Activity 3 1 9 111Mobility 3 1 9 111Nutrition 3 1 9 111

Shear and Friction 3 1 9 111For Pt's with Skin Intact but "At Risk for

Breakdown" - Plan of Care initiatedRN Qshift Assessment 9 1 3 87

Braden Qshift 3 1 1 31Manage Incontinence 3 1 9 111

Minimize Pressure 3 1 9 111Minimize Friction & Shear 3 1 9 111

Mobiltiy/Activity 3 1 9 111Manage Nutrition 3 1 9 111

Pt/Caregiver Education 0 0 1 10Evaluation of Interventions 9 1 3 87

Documentation 9 9 9 171MD Orders 0 0 3 30

Implement Nursing Interventions; MD orders per Ancillary Services

recommendations and continue with Plan of Care/Interventions.

Implementation of Prevention Protocol algorithm 9 9 9 171

ACTUAL SKIN BREAKDOWNMD Notification Form; Enter Incident Report; Initiate POC:ActualPU Form;

Assessment of Stage 9 1 9 147

Measurements/Photos 9 0 0 54Treatment Protocol Algorithm(implimentation & consistency) 9 3 9 153

Reassessment daily/weekly 9 1 9 147New Orders 0 0 9 90

TargetUpper Spec

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