Quality Breakthrough: Reducing Hospital Acquired Pressure Ulcers to Zero

Purpose:
Intent or goal of the strategy was to reduce our hospital acquired pressure ulcers, since there was variation in our patient outcomes, with an ultimate goal of reaching and sustaining zero.

Significance:
Since the average cost of caring for a patient who develops a Stage III or IV pressure ulcer is approximately $63,000, and our data showed variation in our outcomes, this issue was extremely important to address from both a cost and a quality perspective.

Strategy and Implementation:
Our data, submitted through NDNQI for 8 years, showed variation in performance and patient outcomes. A quality improvement team was formed to review our data, and develop an action plan for improvement, with a goal of reducing hospital acquired pressure ulcers (HAPU) to zero. A Skin and Wound Assessment Team was formed and conducts twice weekly rounds on patients with a Braden score of 17 or less, with recommendations for skin management. The team consists of nursing staff, an educator, nutritionist, and wound care specialist, as needed for Stage III or greater. Available skin care products and supplies stocked on the units were reviewed. Education of nursing staff was provided on Braden scoring, appropriate wound management, and pressure reduction surfaces available. Nutritionist referrals are made for dietary supplements and nutritional maintenance. Monthly pressure ulcer results are presented at staff meetings, and unit results are posted on bulletin boards in public areas.

Evaluation:
Since the formation of the Skin and Wound Assessment Team and rounding twice weekly on patients at high risk for developing a pressure ulcer, our results have shown zero HAPU for 30 consecutive months with Stage III or IV, which is also confirmed through the AHRQ Patient Safety Indicator results.

Implications for Practice:
These strategies can be easily transferred to other facilities. A team approach with direct nursing staff involvement in improvement efforts was a driving factor. Open communication and transparency of posting the monthly results has been instrumental in motivating staff and sustaining the results.