Project Zero Towards Nursing Never Events - Reduction of Hospital Acquired Pressure Ulcers

Project zero towards nursing never events - reduction of hospitalacquired pressure ulcers

Gaurav Loriaa,b,*, Jammala Saritha Margaretc

ABSTRACT

Hospital-acquired pressure ulcers (HAPU) or bedsores e also called pressure sores or pressure ulcers e areinjuries to skin and underlying tissues that result from prolonged pressure on the skin. Bedsores most often developon skin that covers bony areas of the body, such as the heel, ankles, hips or buttocks.People most at risk of bedsores are those with a medical condition that limits their ability to change positions, requiresthem to use a wheelchair or confines them to a bed for prolonged periods.Bedsores can develop quickly and are often difficult to treat. Several care strategies can help prevent some bedsoresand promote healing.

Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved.

Keywords: Bed sores, Clinical pathways, Back care, Bundles

EPIDEMIOLOGY

Pressure ulcers are lesions caused by unrelieved pressurethat results in damage to the underlying tissue. Generally,these are the result of soft tissue compression betweena bony prominence and an external surface for a prolongedperiod of time. The consequences of pressure-induced skininjury range from non-blanchable erythema of intact skin todeep ulcers extending to the bone. The ulcer imposesa significant burden not only on the patient, but the entirehealth care system.

It is universally considered nursing’s greatest challengesand is among the most costly, most prevalent and mostwidely endorsed of all nursing sensitive quality measures.

THE PRESSURE ULCER THAT TOOK DOWNSUPERMAN

It is now fairly known that it was in fact a pressure ulcerthat took the life of Christopher Reeve e the Superman.

Nearly 9 years following his spinal cord injury, he devel-oped a wound that became severely infected. He died inOctober 2004 following a cardiac arrest at the age of 52(Fig. 1).

THE STUDY

Red flag

Pressure ulcers increased to 29 (number of patients) inAugust 2011 from an average of 7 per month.

Grade 1 ulcers were not even identified for some timeand they turned into grade 2.

Inadequate hand offs related to pressure ulcers.Lack of nursing care due to lack of knowledge about

pressure ulcers.Skin care was documented but not given/inadequately

given on the ground.

aCoordinator Quality, bNational Head Quality, cExecutive Quality, Apollo Hospitals, Hyderabad, India.*Corresponding author. email: gaurav_l@apollohospitals.comReceived: 18.6.2012; Accepted: 29.6.2012; Available online: 14.7.2012Copyright � 2012, Indraprastha Medical Corporation Ltd. All rights reserved.http://dx.doi.org/10.1016/j.apme.2012.06.007

Apollo Medicine 2012 SeptemberVolume 9, Number 3; pp. 282e286 Article on Quality

Fig. 1 Common pressure ulcer points.

ACT

PLAN

CHECK

PDCA Cycle for HAPUs

DO

Fig. 2 PDCA cycle.

Project zero towards nursing never events Article on Quality 283

Aim: to reduce the hospital-acquired pressure ulcers tonear zero & sustain the same.

Objectives: initial skin assessments, timely care, setprocesses & protocols.

Priority aims:d Decrease the incidence of pressure ulcerdevelopment

d Assess all patients for risk of developing a pressureulcer

d Skin assessment/inspection of patients’ from head-to-toe

d Patient-specific pressure ulcer prevention care plandocumentation in the medical record

d Patient & family education for prevention & careof pressure ulcers.

Process: PDCA methodology (Fig. 2) was adopted anda cause and effect diagram (Fig. 3) for the increased numberof bedsores was designed.

The team sought to deliberately identify the challengesand imperatives to the prevention of pressure ulcers.

Indeed, the team spoke to many doctors and nurses overand over again and listed down the initiatives.

d Optimal assessments e ensuring accurate staging(interdisciplinary approach)

d Simplify urgent interventionsd Provide a 360� approach to patient care/prevention

of pressure ulcersImplementation: pressure ulcer bundles, HAPU clinical

pathway, Braden scale, pressure ulcer prevention (PUP)team, back care protocols.

Pressure ulcer prevention tool included:d Complete head-to-toe assessment of the patientd Risk assessment using Braden scaled Order Nutritional Consultd Turn and position patients every 2 hd Use moisturizers.

Key tasks: daily monitoring & rounds, immediatereporting of any HAPU to the HAPU team.

Team: quality systems, nursing, infection control team,Microbiologists, intensivists.

Pilot: one month.

Fig. 3 Cause & effect diagram for HAPUs.

284 Apollo Medicine 2012 September; Vol. 9, No. 3 Loria and Margaret

METHODOLOGY & CALCULATIONS

Numerator statement

Number of patients developing pressure ulcers/bedsoresafter 24 h of admission into the hospital.

Inclusions

All in-patients.

Exclusions

Patients admitted with pressure ulcers/bedsores and all out-patients.

Fig. 4 Pressure ulcer prevention pathway.

Project zero towards nursing never events Article on Quality 285

The prevalence of HAPU is operationally defined asthe number of patients with HAPUs divided by numbersof patients observed.

Data collection & analysis: HAPU team, pressure ulcerprevention audit tool, monthly analysis & presentation tothe HAPU team.

Initiatives:Daily rounds by the ICN, ANS, back care Nurse.HAPU team to assigned areas.Pressure ulcer prevention chart in each file.Braden scale as a part of daily assessments in the nursing

assessment form.Non compliances reported to the Nursing Director as

well as the Microbiologist on a daily basis (Fig. 4).Sustenance: continuous audits, trainings, data analysis.The trend: (Fig. 5).

PERCENTAGE COMPLIANCE:

Prior: No standards protocols in place. 50% skin care wasfound.

Target: 99% compliance to skin care & 1 case per 1000hospital discharges.

Achieved: 100% compliance & zero cases per 1000hospital discharges were found without a single HAPU.

Benefits: timely patient assessments, set processes &protocols, team formation.

CONFLICTS OF INTEREST

All authors have none to declare.

FURTHER READING

1. Inman KJ, Sibbald WJ, Rutledge FS, Clark BJ. Clinical utilityand cost-effectiveness of an air suspension bed in the preven-tion of pressure ulcers. JAMA. 1993;269:1139.

2. Xakellis GC, Frantz RA. The cost-effectiveness of interven-tions for preventing pressure ulcers. J Am Board Fam Pract.1996;9:79.

3. Thomas DR. The new F-tag 314: prevention and managementof pressure ulcers. J Am Med Dir Assoc. 2006;7:523.

4. Pressure ulcers prevalence, cost and risk assessment:consensus development conference statement e The NationalPressure Ulcer Advisory Panel. Decubitus. 1989;2:24.

5. Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers:a systematic review. JAMA. 2006;296:974.

6. Lyder CH. Pressure ulcer prevention and management. JAMA.2003;289:223.

7. Norton D, McLaren R, Exton-Smith AN. An Investigation ofGeriatric Nursing Problems in the Hospital. London, UK:National Corporation for the Care of Old People (now theCentre for Policy on Ageing); 1962.

8. http://www.denvergov.org/AgingandElderCareResources/AgingandElderCareResources.

9. Berman Audrey, Snyder Shirlee, Kozier Barbara, Erb Glenora.Kozier & Erb’s Fundamentals of Nursing: Concepts, Process,and Practice. 8th ed. Pearson Prentice Hall; 2010.

10. Preventing Pressure Ulcers in Hospitals: A Toolkit forImproving Quality of Care. http://www.ahrq.gov/research/ltc/pressureulcertoolkit/.

11. Best Practices for Preventing Pressure Ulcers: The AdvisoryBoard Company.

12. www.nlm.nih.gov/medlineplus/pressuresores.13. www.ehow.com.14. http://www.bradenscale.com/images/bradenscale.pdf.15. http://www.bedsores-pressure-sores.com/preventing_bed_

sores.16. http://woundconsultant.com/sitebuilder/staging.pdf.17. http://www.primaris.org/sites/default/files/resources.18. http://www.nursingassistanteducation.com.19. http://www.nursingcenter.com/library/JournalArticle.

Fig. 5 Trend of pressure ulcers over a period of time.

286 Apollo Medicine 2012 September; Vol. 9, No. 3 Loria and Margaret

Apollo hospitals: http://www.apollohospitals.com/Twitter: https://twitter.com/HospitalsApolloYoutube: http://www.youtube.com/apollohospitalsindiaFacebook: http://www.facebook.com/TheApolloHospitalsSlideshare: http://www.slideshare.net/Apollo_HospitalsLinkedin: http://www.linkedin.com/company/apollo-hospitalsBlog:Blog: http://www.letstalkhealth.in/