Obtaining Meaningful Use from an Electronic Medical Record: A Multidisciplinary Approach to the Assessment of Pressure Ulcers

While pressure ulcer occurrences continue to drive unnecessary healthcare costs, the implementation of real-time assessments via a daily automated electronic report can lead to increased nurse accountability and enhanced interdisciplinary communication and collaboration. Pressure ulcers are costly, burdensome, and potentially preventable conditions. Despite efforts by organizations to reduce rates and implement evidence-based practice, gaps between research and practice continue to prevail. An interdisciplinary, technological approach can help bridge the existing practice gap. For the past 6 years, quarterly pressure ulcer studies have been conducted in the hospital. However, chart reviews were often retrospective, and did not offer a real-time depiction of the patient condition or documentation status. Quite often, hospital acquired pressure ulcers were only calculated during the quarterly study because no consistent method existed within the medical record to ascertain the current facility acquired rate. The creation of the Daily Pressure Ulcer Report in collaboration with Nursing, Information Technology, Dieticians, and Physical Medicine & Rehabilitation, allows for an automatic assessment of all patients with a documented pressure ulcer via email; in essence making the report widely available, anywhere, and at any time. The results of the Daily Pressure Ulcer Report have since been utilized in Case Study Presentations for all hospital staff to provide education and increase awareness of the ongoing opportunities. Since the creation of the daily pressure ulcer report, it has been incorporated into practice across the facility. Although further progress is targeted, facility acquired rates have decreased by 50%, decreasing from 15% to 8%. Staff engagement has increased and monitoring is now a collaborative effort. The real-time monitoring of documentation and early detection can yield a higher quality of preventive care for patients. The utilization of such a report can be incorporated into shift report, patient leadership rounds, and when establishing an interdisciplinary plan of care.