Pressure Ulcer Prevention (PUP)

Purpose:
Improving quality patient care and decrease cost of hospital acquired pressure ulcers was key focus in 2009. A team was formed in January 2009 to reduce the number of hospital acquired pressure ulcers. Goals: 2009- rate at 2.7 or less, 2010- reduction by 25%, and 2011 reduce an additional 6%.

Significance:
In 2009 multiple strategies were successfully implemented to reduce incidence of hospital acquired pressure ulcers. In 2010 a 73% cost avoidance and 69% reduction in incidence of Stage III, IV, US and SDTI pressure ulcers was realized.

Strategy and Implementation:
Hospital Pressure Ulcer Prevention Team (PUP) formed January 2009, with multidisciplinary representation, using a PDSA approach. Since that time team has utilized staff surveys, literature reviews of best practices and piloting process changes. We have experienced successful implementation and as well as opportunities for improvement for future endeavors. Key successful initiatives are implementation of standardized incontinence protocol and products, Skin Resource Manual and monthly mini RCA's using Pressure Ulcer Tracking form for all hospital acquired pressure ulcers. For 2012 the PUP team continues to evaluate trends and patterns which resulted in removing Buck's Traction from preprinted order sets as device was found to increase risk for heel ulcers.

Evaluation:
Overall pressure ulcer rate (number): 2009: 2.4 (167), 2010:0.6 (42), and 2011: 0.6 (45). Stage III, IV, US, SDTI pressure ulcer rate (number): 2009:1.21(83), 2010: 0.36 (24), 2011: 0.32 (22) NDNAI: Our facility has been in the 10th percentile for all units except one since 4th quarter 2010.

Implications for Practice:
1)Multidisciplinary team, 2)Literature and best practice review, 3)Mini RCA's identifying trends, 4)Stakeholders being involved in design processes, and 5)Education on assessing skin and skin care ensuring validity of assessments, documentation, and data evaluated for improvement purposes.