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To critically analyze every Hospital Acquired Pressure Ulcer (HAPU) through Intensive Reviews to strategically improve nursing sensitive indicators and reach our goal of zero defects.
Significance:
Just like different substances heat up at different temperatures, patients can develop HAPU despite even the best prevention and excellent nursing care. The exercise of individual Intensive Review connects patient comprehensive data and nursing care together to identify the “boiling point” = HAPU.
Strategy and Implementation:
Intensive Reviews were implemented to detect trends and achieve goal of zero Pressure Ulcer (PU) defects. Monthly Intensive Reviews are performed by the PU Core Indicator team consisting of Educator RN, Risk RN and Wound Ostomy Continence RNs (WOCNs). An Intensive Review is when the team systematically examines and discusses the patient's hospital stay including medical history, contributing factors, sequela and nursing documentation using a uniquely created paper tool. Utilizing this tool, evidence for avoidable vs. unavoidable PU is determined. Intensive Review findings both scorching and refreshing, are communicated to the CNO, Directors, Managers and staff to continue to support our premise that HAPU are a direct reflection of nursing care provided. These results are distributed in graph form and publicized on each unit monthly. The graph illustrates a diagram of PU body site, PU stage, and nursing unit where injury occurred.
Evaluation:
Intensive Reviews have simmered down HAPU Prevalence from 1.7% in 2008 to 0.3% in 2009, and has held gains for three quarters. This process heats up RN awareness for comprehensive skin assessment, documentation and WOCN consultation to avoid reaching the “boiling point”.
Implications for Practice:
Translating data from Intensive Reviews using patient stories and raw numbers has ignited passion in the bedside nurse to prevent HAPUs. Our Intensive Review model has been shared and adopted by other hospitals.