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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