Project Zero Towards Nursing Never Events - Reduction of
Hospital Acquired Pressure Ulcers
Apollo Medicine 2012 September
Volume 9, Number 3; pp. 282e286

Article on Quality

Project zero towards nursing never eve...
Project zero towards nursing never events

Article on Quality

Fig. 1 Common pressure ulcer points.

PLAN

A
C
T

PDCA Cyc...
284

Apollo Medicine 2012 September; Vol. 9, No. 3

Loria and Margaret

Fig. 3 Cause & effect diagram for HAPUs.

Aim: to ...
Project zero towards nursing never events

Article on Quality

285

Fig. 4 Pressure ulcer prevention pathway.

METHODOLOGY...
286

Apollo Medicine 2012 September; Vol. 9, No. 3

Loria and Margaret

Benefits: timely patient assessments, set processes...
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Project Zero Towards Nursing Never Events - Reduction of Hospital Acquired Pressure Ulcers

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Hospital-acquired pressure ulcers (HAPU) or bedsores e also called pressure sores or pressure ulcers e are
injuries to skin and underlying tissues that result from prolonged pressure on the skin. Bedsores most often develop on skin that covers bony areas of the body, such as the heel, ankles, hips or buttocks. People most at risk of bedsores are those with a medical condition that limits their ability to change positions, requires them to use a wheelchair or confines them to a bed for prolonged periods. Bedsores can develop quickly and are often difficult to treat. Several care strategies can help prevent some bedsores and promote healing.

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Project Zero Towards Nursing Never Events - Reduction of Hospital Acquired Pressure Ulcers

  1. 1. Project Zero Towards Nursing Never Events - Reduction of Hospital Acquired Pressure Ulcers
  2. 2. Apollo Medicine 2012 September Volume 9, Number 3; pp. 282e286 Article on Quality Project zero towards nursing never events - reduction of hospital acquired pressure ulcers Gaurav Loriaa,b,*, Jammala Saritha Margaretc ABSTRACT Hospital-acquired pressure ulcers (HAPU) or bedsores e also called pressure sores or pressure ulcers e are injuries to skin and underlying tissues that result from prolonged pressure on the skin. Bedsores most often develop on skin that covers bony areas of the body, such as the heel, ankles, hips or buttocks. People most at risk of bedsores are those with a medical condition that limits their ability to change positions, requires them to use a wheelchair or confines them to a bed for prolonged periods. Bedsores can develop quickly and are often difficult to treat. Several care strategies can help prevent some bedsores and promote healing. Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved. Keywords: Bed sores, Clinical pathways, Back care, Bundles EPIDEMIOLOGY Pressure ulcers are lesions caused by unrelieved pressure that results in damage to the underlying tissue. Generally, these are the result of soft tissue compression between a bony prominence and an external surface for a prolonged period of time. The consequences of pressure-induced skin injury range from non-blanchable erythema of intact skin to deep ulcers extending to the bone. The ulcer imposes a significant burden not only on the patient, but the entire health care system. It is universally considered nursing’s greatest challenges and is among the most costly, most prevalent and most widely endorsed of all nursing sensitive quality measures. THE PRESSURE ULCER THAT TOOK DOWN SUPERMAN It is now fairly known that it was in fact a pressure ulcer that took the life of Christopher Reeve e the Superman. a Nearly 9 years following his spinal cord injury, he developed a wound that became severely infected. He died in October 2004 following a cardiac arrest at the age of 52 (Fig. 1). THE STUDY Red flag Pressure ulcers increased to 29 (number of patients) in August 2011 from an average of 7 per month. Grade 1 ulcers were not even identified for some time and they turned into grade 2. Inadequate hand offs related to pressure ulcers. Lack of nursing care due to lack of knowledge about pressure ulcers. Skin care was documented but not given/inadequately given on the ground. Coordinator Quality, bNational Head Quality, cExecutive Quality, Apollo Hospitals, Hyderabad, India. Corresponding author. email: gaurav_l@apollohospitals.com Received: 18.6.2012; Accepted: 29.6.2012; Available online: 14.7.2012 Copyright Ó 2012, Indraprastha Medical Corporation Ltd. All rights reserved. * http://dx.doi.org/10.1016/j.apme.2012.06.007
  3. 3. Project zero towards nursing never events Article on Quality Fig. 1 Common pressure ulcer points. PLAN A C T PDCA Cycle for HAPUs D O CHECK Fig. 2 PDCA cycle. 283
  4. 4. 284 Apollo Medicine 2012 September; Vol. 9, No. 3 Loria and Margaret Fig. 3 Cause & effect diagram for HAPUs. Aim: to reduce the hospital-acquired pressure ulcers to near zero & sustain the same. Objectives: initial skin assessments, timely care, set processes & protocols. Priority aims: d Decrease the incidence of pressure ulcer development d d d d Assess all patients for risk of developing a pressure ulcer Skin assessment/inspection of patients’ from headto-toe Patient-specific pressure ulcer prevention care plan documentation in the medical record Patient & family education for prevention & care of pressure ulcers. Process: PDCA methodology (Fig. 2) was adopted and a cause and effect diagram (Fig. 3) for the increased number of bedsores was designed. The team sought to deliberately identify the challenges and imperatives to the prevention of pressure ulcers. Indeed, the team spoke to many doctors and nurses over and over again and listed down the initiatives. d Optimal assessments e ensuring accurate staging (interdisciplinary approach) d Simplify urgent interventions d Provide a 360 approach to patient care/prevention of pressure ulcers Implementation: pressure ulcer bundles, HAPU clinical pathway, Braden scale, pressure ulcer prevention (PUP) team, back care protocols. Pressure ulcer prevention tool included: d Complete head-to-toe assessment of the patient d Risk assessment using Braden scale d Order Nutritional Consult d Turn and position patients every 2 h d Use moisturizers. Key tasks: daily monitoring rounds, immediate reporting of any HAPU to the HAPU team. Team: quality systems, nursing, infection control team, Microbiologists, intensivists. Pilot: one month.
  5. 5. Project zero towards nursing never events Article on Quality 285 Fig. 4 Pressure ulcer prevention pathway. METHODOLOGY CALCULATIONS Inclusions Numerator statement All in-patients. Number of patients developing pressure ulcers/bedsores after 24 h of admission into the hospital. Exclusions Patients admitted with pressure ulcers/bedsores and all outpatients.
  6. 6. 286 Apollo Medicine 2012 September; Vol. 9, No. 3 Loria and Margaret Benefits: timely patient assessments, set processes protocols, team formation. CONFLICTS OF INTEREST All authors have none to declare. FURTHER READING Fig. 5 Trend of pressure ulcers over a period of time. The prevalence of HAPU is operationally defined as the number of patients with HAPUs divided by numbers of patients observed. Data collection analysis: HAPU team, pressure ulcer prevention audit tool, monthly analysis presentation to the HAPU team. Initiatives: Daily rounds by the ICN, ANS, back care Nurse. HAPU team to assigned areas. Pressure ulcer prevention chart in each file. Braden scale as a part of daily assessments in the nursing assessment form. Non compliances reported to the Nursing Director as well as the Microbiologist on a daily basis (Fig. 4). Sustenance: continuous audits, trainings, data analysis. The trend: (Fig. 5). PERCENTAGE COMPLIANCE: Prior: No standards protocols in place. 50% skin care was found. Target: 99% compliance to skin care 1 case per 1000 hospital discharges. Achieved: 100% compliance zero cases per 1000 hospital discharges were found without a single HAPU. 1. Inman KJ, Sibbald WJ, Rutledge FS, Clark BJ. Clinical utility and cost-effectiveness of an air suspension bed in the prevention of pressure ulcers. JAMA. 1993;269:1139. 2. Xakellis GC, Frantz RA. The cost-effectiveness of interventions for preventing pressure ulcers. J Am Board Fam Pract. 1996;9:79. 3. Thomas DR. The new F-tag 314: prevention and management of pressure ulcers. J Am Med Dir Assoc. 2006;7:523. 4. Pressure ulcers prevalence, cost and risk assessment: consensus development conference statement e The National Pressure Ulcer Advisory Panel. Decubitus. 1989;2:24. 5. Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. JAMA. 2006;296:974. 6. Lyder CH. Pressure ulcer prevention and management. JAMA. 2003;289:223. 7. Norton D, McLaren R, Exton-Smith AN. An Investigation of Geriatric Nursing Problems in the Hospital. London, UK: National Corporation for the Care of Old People (now the Centre for Policy on Ageing); 1962. 8. http://www.denvergov.org/AgingandElderCareResources/ AgingandElderCareResources. 9. Berman Audrey, Snyder Shirlee, Kozier Barbara, Erb Glenora. Kozier Erb’s Fundamentals of Nursing: Concepts, Process, and Practice. 8th ed. Pearson Prentice Hall; 2010. 10. Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. http://www.ahrq.gov/research/ ltc/pressureulcertoolkit/. 11. Best Practices for Preventing Pressure Ulcers: The Advisory Board Company. 12. www.nlm.nih.gov/medlineplus/pressuresores. 13. www.ehow.com. 14. http://www.bradenscale.com/images/bradenscale.pdf. 15. http://www.bedsores-pressure-sores.com/preventing_bed_ sores. 16. http://woundconsultant.com/sitebuilder/staging.pdf. 17. http://www.primaris.org/sites/default/files/resources. 18. http://www.nursingassistanteducation.com. 19. http://www.nursingcenter.com/library/JournalArticle.
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