Getting Results from Wound Care Monitoring

An aggressive wound care program has been in place since 1983 at our hospital. We have a wound care committee headed by WOCNs and staffed by nurses from every in-patient unit, excellent education, and excellent procedures.

However, as a Magnet facility, we participate in quarterly NDNQI wound care audits showing HAPU prevalence in the 3% range. With all our effort why did we have such a high rate?

How did we attack the problem?:

• We instituted bi-weekly audits using our "Pressure Ulcer Audit Tool".
• We developed the "Wound Care Audit Communication Tool" to document risk reductions missed.
• We use a spread sheet to gather data from the Wound Care Audit Communication Tool and present the results to unit managers.
• Using a remediation letter, managers notify nurses non-compliant more than 5 times in a 3 month period to complete the online NDNQI Pressure Ulcer Training module.
• We created the "Golden Bandaid Award" for o We had wound care representatives assist with Prevalence Studies giving them insight into their efforts impacts.

Lesson's Learned:

• Monitoring tools allowed determination of what risk reduction factors were being used or ignored. Seeing what floors and which nurses needed follow up education and could target remediation.
• Wound care representatives did not audit their own floors. This reduced bias and social pressure from co-workers.
• Educational opportunities rather than punishment as remediation resulted in more willing participation from nurses and managers in problem areas.
• Holding people accountable for their actions and rewarding them for jobs well done drove compliance.

Results:

NDNQI audits for the first two quarters after the program was put in place showed SJH had no HAPU's: the first time we achieved such excellent results.