Reducing the rate and cost of Hospital Acquired Pressure Injuries by improving access to incontinence care products

Purpose: Improving implementation of wound care recommendation for incontinence care by increasing access to products and decreasing time to implementation by removing over the counter incontinence products from pharmacy stock and placing into unit Omnicell.

Problem Statement: Based on the Hospital Acquired Pressure Injury (HAPI) data, the Community Living Center (CLC) associated with a large healthcare system had a higher than average amount of HAPI’s at 13.86% as compared to systems national average of 9.52%.

Method: An interdisciplinary team launched in 2017 and a retrospective chart review was completed on 14 patients who developed HAPI during the time frame of January 2016 through December 2016. The results showed that 13 out of 14 patients had urine and/or bowel incontinence. Further review found a significant delay from the time incontinence care recommendations where placed to the time of implementation. The team worked with pharmacy and logistics to place over the counter incontinence care products in logistic and into the Omnicell on the unit. Education on the new products was performed on all shifts and pilot lasted from December 2017 through February 2018.

Data Analysis: A value stream map was completed to determine the key processes which noted an average process lead time (PLT) of 17.08 hours pre-pilot. A significant decrease in PLT was noted post pilot from 17.08 hours to 2.87 hours.

Conclusion: There was a significant decrease in PLT from an average of 17.08 hours to 2.87. Also noted a decrease in cost per HAPI from average of $32.264 to $8,824 per patient and a decrease in rate of HAPIs from 13.86% to 7.01%. Finally, in the pre-pilot group, 7 of 14 HAPI were stage 3 & 4s and in the post pilot group only 1 HAPI was a stage 3 the remaining 7 were stage 1 & 2.