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AIM Statement:
Achieve zero deep tissue injury, stage 3, stage 4, and unstageable pressure injuries on non ICU units by 09/30/17.
To prevent the continued growth of HAPI volume, a project team came together to understand existing barriers, brainstorm & test possible solutions and ultimately improve processes to prevent HAPIs.
PLAN:
- Held a benchmarking call with the Mayo Clinic to identify their best practices for HAPI prevention
- Researched evidence based improvement strategies from various reputable institutions (ex. WOCN, AHRQ and AMA)
- Defined project scope by eliminating the ICU from the target population since they had recently undergone improvement efforts and focused staff training specific for their population
- Reviewed baseline HAPI data to begin identifying possible opportunities and root causes
- Surveyed unit staff to determine staff perception of HAPI prevention practices/processes
- Developed project timeline to achieve project aim by desired date.
DO:
- Held a workout event at our hospital with a team of more than 20 registered nurses and patient care technicians to map existing processes, analyze current data and define issues/barriers
- Increased National Database of Nursing Quality Indicator (NDNQI) prevalence study intensity from quarterly to monthly
- Implemented a HAPI event drilldown form/process to begin learning more about why the HAPI may have occurred
- Established skin champions for each unit: 2 RNs for days and 2 RNs for nights
- Developed a pilot turning team process to identify at risk patients and ensuring appropriate interventions are in place.
STUDY:
The team will continue:
- monitoring pilot turning team/identify at risk patient progress on the select unit.
- performing monthly NDNQI Prevalence Study to monitor progress.
ACT:
Once the pilot has shown to be effective and we have proven the interventions are producing the desired results, we will begin to spread the interventions to all other units.
Conclusion:
August 2017, our monthly prevalence study identified Zero HAPIs.