Reduction of Nosocomial Pressure Ulcers on 5 NEW Rehabilitation Unit
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Transcript of Reduction of Nosocomial Pressure Ulcers on 5 NEW Rehabilitation Unit
Reduction of Reduction of Nosocomial Pressure Nosocomial Pressure
Ulcers Ulcers on 5 NEWon 5 NEW
Rehabilitation UnitRehabilitation Unit
Save Our
Skin
Confidential: Quality Improvement Material
Team Membership
• Physicians• Acute Rehab Nurses• Skin Liaison Nurse• Patient Care Techs• Physical Therapists• Occupational Therapists• Administrative Assistant• Center for Clinical Effectiveness
Confidential: Quality Improvement Material
National benchmarking data demonstrated an increase of hospital acquired pressure
ulcers on 5NEW.
•Documentation Issues•Nurses not consistently documenting skin assessment upon admission•No EPIC field to document healed ulcers
•Staff Issues•Need for increased education regarding appropriate toileting
•Patient Issues•Prolonged sitting in chairs•Wearing ill-fitted shoes
Problem Identified
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Aim Statement
Reduce the incidence of nosocomial pressure ulcers on 5 NEW to zero.
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• Obtained physician/administrative support for project.
• In serviced all staff on Save Our Skin (S.O.S) Program.– Skin assessment tools– Use of Braden Scale – Identification of pressure ulcer– Patient and family education
• S.O.S program piloted initially 3/03/08 including patient, family & staff.
Solutions Implemented
Rapid Cycle #1 1st & 2nd Quarter 2008
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Num
ber
of N
osoc
omia
l Pre
ssur
e U
lcer
sSave Our Skin: Nosocomial Pressure Ulcer Incidence
5 NEWOctober 2007-September 2008
Octob
er 2
007
(N=5
2)
Nov
embe
r 20
07 (N
=49)
Dec
embe
r 200
7 (N
=50)
Janu
ary 20
08 (N
=48)
Febr
uary
200
8 (N
=57)
Mar
ch 2
008
(N=5
1)
April
2008
(N=4
7)
May
200
8 (N
=55)
June
200
8 (N
=53)
July 200
8 (N
=47)
Augus
t 200
8 (N
=49)
Sept
embe
r 200
8 (N
=53)
0
2
4
6
8
10UCL
Mean
SOS Project Implementation
Analysis of Outliers
Confidential: Quality Improvement Material
Num
ber
of N
osoc
omia
l Pre
ssur
e U
lcer
sSave Our Skin: Nosocomial Pressure Ulcer Incidence
5 NEWOctober 2007-December 2008
Octob
er 2
007
(N=5
2)
Nov
embe
r 20
07 (N
=49)
Dec
embe
r 200
7 (N
=50)
Janu
ary 20
08 (N
=48)
Febr
uary
200
8 (N
=57)
Mar
ch 2
008
(N=5
1)
April
2008
(N=4
7)
May
200
8 (N
=55)
June
200
8 (N
=53)
July 200
8 (N
=47)
Augus
t 200
8 (N
=49)
Sept
embe
r 200
8 (N
=53)
Octob
er 2
008
(N=5
1)
Nov
embe
r 20
08 (N
=49)
Dec
embe
r 200
8 (N
=53)
0
2
4
6
8
10UCL
Mean
SOS Project Implementation
Analysis of Outliers
“Back To Bed” Reinforced
• Drill down 7 outlier cases for September 2008 to identify trends, common variables.
• Reeducate staff on S.O.S initiative. • Engage Physical Therapy staff in initiative.• Schedule patients “Back To Bed” • Monitor incidence of nosocomial pressure
ulcers on 5NEW.• Report outcomes to key stakeholders and
staff.
Solutions Implemented
Rapid Cycle #23rd & 4th Quarter 2008
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Num
ber of
Nos
ocom
ial P
ress
ure
Ulc
ers
Save Our Skin: Nosocomial Pressure Ulcer Incidence5 NEW
October 2007-March 2009
0
2
4
6
8
10
UCL
Mean
SOS Project Implementation
Analysis of Outliers
“Back To Bed” reinforced
2 PU healed prior to discharge
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Ra
te5 NEW Nosocomial Pressure Ulcer Rate
Academic and National BenchmarksMulti-Line - individuals
Nosocomial RateAcademic 75% PercentileBenchmarking Rehab MeanAcademic 10%
2 Q 200
6
3 Q 200
6
4 Q 200
6
1 Q 200
7
2 Q 200
7
3 Q 200
7
4 Q 200
7
1 Q 200
8
2 Q 200
8
3 Q 200
8
4 Q 200
8
0
5
10
15
20
25
30
Loyola 5 NEW
Goal: 0%
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Solutions Implemented Rapid Cycle #3
1st Quarter 2009 • Monitoring healed pressure ulcers• Epic improvement: document type of cushion
for chair depending on type of pressure ulcer (chair, gel, roho)
• Encourage participation of Dietary Department in S.O.S.
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Next Steps
• Monitor outcomes of S.O.S program• Measure number of nosocomial pressure ulcers that
are treated and resolved prior to discharge.• Monitor number of pressure ulcers Present on
Admission that are treated and resolved prior to discharge.
• Track admission source to 5 NEW.• Improve notification of healed ulcers to physicians. • Determine loss of revenue to Rehab due to a
nosocomial pressure ulcer. • Spread S.O.S. program to other hospital units.
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Celebrate Success
• Staff celebrated the success of the November initiative and positive reinforcement given.
• Initiative continues, partnership with Physical Therapy grows.
• In order to maintain project sustainability, monitoring and information sharing among disciplines continues.
• Goal of zero nosocomial pressure ulcers achieved in November, December and January.
• Presented program to hospital board in January 2009• Issued a press release to consumer and trade publications
on December 16th, 2008.• S.O.S. posted on Loyola’s Website.• Article published in Advance for Nurses on February 16th,
2009.
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