Reducing Incidence of Hospital Acquired Pressure Ulcers at Henry Ford West Bloomfield Hospital (HFWB)

Purpose:
In May,2010 to April,2011, Henry Ford West Bloomfield hospital noted that the hospital acquired pressure ulcers have consistently been above the national benchmark. A team of clinical skin innovators (CSI) was created to spearhead innovative strategies to decrease HAPU by 50% and sustain.

Significance:
Data analysis identified improper documentation, incorrect identification and a general lack of education in evidenced based nursing practice regarding the treatment and prevention of pressure ulcers among nursing staff, was directly contributing to the high prevalence of HAPU at HFWB.

Strategy and Implementation:
1.Creation of CSI(Clinical Skin Innovators): West Bloomfield, a team of staff nurses who are NDNQI Pressure Ulcer certified, data collection trained based on NDNQI standards, in depth knowledge on current research based, continuous best practice evaluation in pressure ulcer care and prevention. 2.CSI designed and implemented: PU Treatment Options poster, PU vs. Other wounds poster, 6Ps revival with "You got caught" cookie incentive and product use demonstrations through skills fair and rolling educational cart. 3.Monthly skin audits initiated as recommended by NDNQI allowing for dynamic changes in implementations according to real-time data in conjunction with LEAN/PDCA. 4.Partnership with: a)nursing administration in promoting "just culture” when coaching staff in assessment and documentation b)Information Srvcs regarding electronic data application streamlining process for faster reporting and action optimization c)nursing governance to engage nursing staff in safety mentality.

Evaluation:
Monthly surveys showed decline close to 80% of HAPU and sustained for 12 months. Monthly graphs reflected cost savings reduction of reimbursement denials for every HAPU. The highest savings is $520,000.

Implications for Practice:
2RNs skin assessment on documentation. Knee high ted hose replaced thigh high. Limb position during surgery enhanced. Nurses influenced doctors to reference PU Treatment Option poster. Staff nurses' integration of assessment data with the family promoted engagement. 6Ps culture change.