Think Patient Safety: Examining the Obstacles in Preventing Hospital Acquired Conditions (HAC) Pressure Ulcers (PU)

Purpose:  Analysis and trending monthly PU prevalence HAC rates revealed 300+ bed acute-care hospital consistently out-performed National Benchmarks.  However, HAC PU continued to occur.  A systematic process change evaluating HAC occurrence was developed. Certified Wound Ostomy Continence Nurse (CWOCN) combined existing clinical expertise with WOCN Society Prevention and Management of Pressure Ulcers (WOCN 2010) developing PU HAC debriefing tool (DT). In 2011, CWOCN lead a process evaluating HAC case analysis with 10 Clinical Nurse Specialists (CNS) utilizing DT. The process provided methodology for systematic review/analysis of PU prevention from point of admission, through HAC occurrence and beyond. 

The HAC DT prompted investigators to measure compliance of each step in hospital PU guideline.  The tool concentrated specific data gathering points outlining hospital’s PU Prevention and Treatment Guidelines (PUPTG).  Compliance rates with documentation components of PUPTG were evaluated. The system and process measured compliance rates with assessment/documentation and/or deviations from standard of care. Assigning a numerical value to the compliance rate gave nursing a targeted numerical rating to improve upon.  

In 2012 the CNS and CWOCN coached/mentored the Assistant Nurse Managers (ANM) and Clinical nursing staff to conduct the HAC investigation, presenting findings at the unit level through huddles, staff meetings, and unit based councils.  The goal of this coaching and mentoring was to empower the ANM and/or the Clinical nurse to develop their investigation skills to the point of conducting the HAC investigation chart review independent of the CNS, uncovering obstacles to PU prevention.

Outcome:  Occurrences of HAC PU has continued a steady linear decline.  The HAC investigations are presented at a monthly Multi-disciplinary Pressure Ulcer Prevention Committee.   Action plan is discussed and committee members give input related to overcoming obstacles to PU prevention.  Multiple process modifications have been developed as a result of bedside staff utilizing the HAC DT.