Janet Mullen, BSN, BA, RN, CWOCN, CFCN, University of Pittsburgh Medical Center Passavant Hospital, Wound, Ostomy, Continence Nurse, Pittsburgh, PA, Jessica Johnston, BSN, RN, CWON, University of Pittsburgh Medical Center Passavant Hospital, Wound, Ostomy, Continence Nurse, Pittsburgh, PA, Sheryl Fulmer, BA RN CWON, ET/Wound Skin & Ostomy Department, UPMC Passavant Hospital, Pittsburgh, PA, Lisa Manni, MSN, RN NEA-BC, Nursing Administration, UPMC Passavant Hospital, Pittsburgh, PA, Jenn Linn, BSN RN, Medical / Surgical ICU, UPMC Passavant Hospital, Pittsburgh, PA, Christina Wall, BSN CCRN, Cardiovascular ICU, UPMC Passavant Hospital, Pittsburgh, PA, Constance Pearson, MPM RN CPHQ, UPMC Passavant Retired, Pittsburgh, PA and Glenn Hasulak, MCSD, Information Services, UPMC Passavant Hospital, Pittsuburgh PA, PA
Our acute care non-teaching suburban hospital has a group of registered nurses and nursing assistants “Skin Savers”, who represent their units in monthly skin care meetings and prevalence surveys. However, despite the involvement of the Skin Savers and Wound, Ostomy & Continence (WOC) nurses we were not able to meet the National Data of Nursing quality Indicators (NDNQI) quarterly benchmark for 200-299-bed hospital in three of four quarters. The purpose of this project was to exceed the quarterly NDNQI benchmark through decreasing prevalence by at least 25% within 1 year.
A process to discover the incidence of HAPU was developed between bedside nurse, WOC RNs and Quality Improvement to discover contributing causes of HAPUs and evaluate the pressure ulcer prevention protocol. The process was initiated by staff documenting a pressure ulcer in the electronic record, followed by the WOC RN validating the wound and further assigned the PU to the responsible unit (UAPU). Criteria were established by unit directors, clinicians and WOC RNs by using existing assessment policies.
Data identified the units with the highest UAPU. In April 2014, an intra-professional subgroup was formed to examine the Cardio-thoracic & Medical/Surgical Intensive Care Units who were responsible for over 27% of patients with UAPU. Development of a HAPU follow up form identified both intrinsic and extrinsic causative factors, thus increasing UAPU awareness to unit leadership. The HAPU Follow Up form led us to development of a unit based Mini Root Cause Analysis.
In conclusion, we met the NDNQI benchmark 4/4 quarters. Our baseline average was 2.07 and our average in the last 4 quarters was 1.01 – a 51% improvement, thus exceeding our goal. This project’s ultimate goal was preventing hospital acquired conditions by raising awareness to reduce pressure ulcer occurrence, and to improve clinical practice.
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