Kicking it Up a Notch

Clinical/House-wide Process Improvement Project

Title: Kicking it Up a Notch

Authors: Monica Tweddell RN, BSN, CWOCN

                Robin Gooding RN, WCC, OMS

Purpose: The purpose of this project was to enhance the “S” portion of the Skin Bundle to create a standardized process for skin inspection beginning at the time of admission or patient transfer between units. The goal was to decrease our hospital acquired pressure injuries that are reported on a monthly basis to the quality management team. The hospital acquired pressure injury rate in the first quarter of 2012 was at 2.23 %, this prompted the introduction of “kicking it up a Notch” as a new practice. Continuing with monthly skin checks house-wide shows the rocky but steady decrease in the decline of hospital acquired pressure injuries thru 2015 at last quarter ended at 0.51%.

Intervention: A house-wide practice was introduced in the first quarter of 2013. Our practice of taking a photo of wounds when a patient was admitted was increased by “Kicking it Up a Notch”.  Kicking it Up a Notch targeted the nurse who was admitting a patient with the task of advising the patient that the current practice was to take a photo of their sacral area even if there was no skin impairment.  This practice was also extended to patients being transferred within units. The photo requires 2 RN verification signatures. Included in this new practice was the addition of a sacral dressing if the patient met a specific prevention criteria along with a support surface.

 

Evaluation: Pressure injury data is collected by the Wound and Skin Team on a monthly basis. The data collected is communicated with the quality team on a quarterly basis for dissemination and reporting to the NDNQI.