CLAXTON-HEPBURN MEDICAL CENTER PI ACTIVITY REPORT SUBMITTED BY: KAREN COLE, BSN, RN, CWOCN, CDE DEPARTMENT NAME: WOUND OSTOMY CONTINENCE SERVICES MANAGER NAME: LAURA SHEA OPPORTUNITY TO IMPROVE: REDUCE HOSPITAL ACQUIRED PRESSURE ULCERS STAGE II OR GREATER BY 20% BASELINE PERFORMANCE: 1.4% TEAM MEMBERS (BY TITLE & NAME) : KAREN COLE, RN, CWOCN JOY WALKER,PT SHANNON BOBB,RN NINA YOUNG,RN JENNIFER WRIGHT,RN JENNIFER CHAMBERS,RN DAWN DOBBS, LPN MELANIE MURDOCK, CNA GOAL: 1.1% TIME FRAME TO COMPLETE: 1 YEAR PI ACTIVITY ALIGNS WITH THE FOLLOWING STRATEGIC GOAL(S): You goal must be a SMART goal: Specific. Measurable. Attainable. Realistic. Timely People Service x Safety/Quality Growth Financial ROOT CAUSE: MISSED IDENTIFICATION OF PRESSURE ULCERS ON ADMISSION, LACK OF EARLY IDENTIFICATION OF “AT RISK” PATIENTS COMING FROM THE EMERGENCY ROOM; NOT ALL BEDS HAVE PRESSURE REDISTRIBUTION MATTRESSES- NEED TO MOVE PATIENTS FROM ONE MATTRESS TO ANOTHER, DIFFICULTY USING HOVER MATT FOR VERTICAL TRANSFERS, PRESSURE RELIEF CUSHIONS DISAPPEAR, EXPENSE OF OFF LOADING BOOTS, SKIN TEAM NOT MEETING REGULARLY, BRADEN SCORE NOT UTILIZED FULLY. PROCESS IMPROVEMENT SELECTED: BETTER IDENTIFICATION OF “AT RISK” AND “PRESENT ON ADMISSION” FROM ED TO FLOORS. REVIEW OF DOCUMENTATION SCREENS TO HIGHLIGHT “AT RISK” PATIENTS. RE-INSTITUTE SKIN TEAM. EARLY IDENTIFICATION OF “AT RISK” PATIENTS AND IMPLEMENTATION OF PRESSURE ULCER PREVENTION STRATEGIES INCLUDING PRESSURE REDISTRIBUTUION MATTRESSES. IMPLEMENTATION PLAN (DATE / MONITOR PLAN):MONTHLY TRACKING OF ALL PRESSURE ULCERS AND REPORT TO NURSE MANAGERS AND NURSING SERVICE. TWICE A YEAR PREVALENCE AND INCIDENCE STUDY. CHECK RESULTS: (TABULAR, GRAPHIC DISPLAY) 2012 Hospital Acquired Pressure ULcers Number of patients 25 20 15 hospital acquired 10 pressure ulcers 5 0 stage II stage IV DTI Pressure Ulcer Stage IMPROVEMENT? Incidence rate for pressure ulcers stage II or greater in 2012 was 1.6% Incidence rate for pressure ulcers stage III or greater was 0.5% NEXT STEPS Steps taken in 2012- change over to all pressure redistribution mattresses and additions to hover matts, setting up storage rooms at each end of med/surg for storage and education on the hovermatts came in the 4th quarter. Incidence for October, November and December of hospital acquired pressure ulcers stage II and greater was 0.8% and 0.3% for stage III and greater. Steps to be taken in 2013- continue to work with skin team to identify areas of need. Two members are putting together a poster education board on dressing types and in April pressure ulcer treatment will be included as one of their monthly competencies. Reports to nurse managers, nursing administration and PI will continue monthly. Prevalence study will be completed on all units in March.