Transcript Pressure Ulcer NDNQI Surveillance

Hospital Acquired Pressure Ulcer
Reduction Project
Jodi Blaszczyk RN, BSN, CWOCN,
Skin Care Liaison Committee,
Judy McHugh RN, MSN
Confidential for Quality
Improvement Purposes Only
Opportunity/Aim Statement:
• Reduce Nosocomial Pressure Ulcers (PU)
Goal: 0%
• Increase daily Braden Scale Compliance
Goal: 100%
• Limit linen layers 3 or less
Goal: 100%
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Improvement Purposes Only
PLAN
• LUMC participates in quarterly National
Database of Nursing Quality Indicators (NDNQI)
Studies
– Point prevalence performed consists of a one day
study in which head to toe skin assessments for
pressure ulcers, documentation, chart audits, and
number of linen layers are collected.
• Braden Scale Daily* Compliance is monitored
monthly
*as a proxy Braden Scale daily compliance consists of
random audit done 2 times a month.
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Improvement Purposes Only
Solutions Implemented to Reduce PU
• Mandated daily Braden Scale Assessment – May 2008
• Developed cards for Braden Scale low, mod, high risk
guidelines
• Implemented Inter-Rater Reliability Stage 1 ulcers
• Added Pressure Ulcer Prevention to Managers Meeting
Agenda Item
• Expanded Team Turn; Back to Bed; and Save Our Skin
Programs on more nursing units
• Implemented non plastic breathable adult/pediatric briefs
• Ongoing education on reducing linen layers and adult briefs
• Developed Evidenced Based Decision Tree for heel pressure
relief
• Migrated existing Braden Scale CBL to new E-Learning
system – 799 completed
• Filled open Enterostomal Nurse Clinician Position
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Improvement Purposes Only
HW Noso S ki n Ul ce r Ra te
Quarter
1
2 Q 06 Jun
10.3
3 Q 06 Sep
12.1
4 Q 06 Nov
13.9
1 Q 07 Mar
7.3
2 Q 07 May
7.3
3 Q 07 Sep
7.8
4 Q 07 Nov
5.6
1 Q 08 Feb
6.8
2 Q 08 Jun
8.1
3 Q 08 Sep
5.1
4 Q 08 Dec
4.5
Individuals
Temporary: UCL=13.13, Mean=8.07, LCL=3.02 (mR=2)
14
UCL = 13.13
NDNQI Survey
Team Training
& Staging
12
Acute Rehab & ICU
Admission Ulcer Documentation
Greater than 4 Linen Layers
10
Back to Bed
Save Our Skin
Skin Survey
Re Education
8
Me a n = 8 . 0 7
Inter-Rater Reliability
Stage 1
6
Manager Meeting
Agenda Item
New EPIC
RN Documentation
4
Reduce Linen Layer
Non Plastic Adult Briefs
Daily Braden
Scoring
De
c
4
Q
08
Q
3
08
Se
p
Ju
n
08
2
Q
08
Q
1
Q
4
Q
3
Q
07
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2
Fe
b
No
v
07
07
Se
p
M
ay
M
ar
07
Q
1
4
Q
06
Q
3
Confidential for Quality Improvement Purposes Only
06
Se
p
Ju
n
06
Q
2
No
v
LCL = 3.02
HOSPITAL WIDE BRADEN SCALE COMPLIANCE
NUMBER
33
34
35
36
37
38
39
40
41
42
43
44
DATE JAN 08 FEB 08 MAR 08 APR 08 MAY 08 JUN 08 JUL 08 AUG 08 SEP 08 OCT 08 NOV 08 DEC 08
ASSESS
1191
992
1040
503
512
479
485
482
242
210
216
504
CENSUS
1456
1217
1236
585
562
532
527
506
249
220
226
511
1
82
82
84
86
91
90
92
95
97
95
96
99
Individuals
Temporary: UCL=96.31, Mean=90.75, LCL=85.19 (mR=2)
100
Goal = 100%
Braden Scale Rate
UCL = 96.31
95
Me a n = 9 0 . 7 5
90
LCL = 85.19
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08
DE
C
08
V
NO
O
CT
08
08
SE
P
08
AU
G
08
JU
L
08
JU
N
08
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M
AY
08
AP
R
08
M
AR
08
FE
B
JA
N
08
85
LIMIT LINEN LAYERS
Target goal 100% linen
layers 3 or less
100
95
– Extra linen layers
wrinkle causing
increased pressure
90
– Too many linen layers
decrease effectiveness
of Atmos-Air Mattress
Replacement System
85
Line n laye rs 3 or le s s
Milne, CT, et al. Wound, Ostomy, and Continence
Nursing Secrets, Philadelphia, 2003, Hanley & Belefus, Inc.
80
3 Q C 07 4 Q C 07 1 Q C 08 2 Q C 08 3 Q C 08 4 Q C 08
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Centers for Medicare & Medicaid
Services (CMS)
• Pressure ulcer estimated costs = $43,180
per stay
• Reports 257,412 preventable pressure
ulcers occur as secondary diagnosis
• As of 10/1/08, CMS no longer reimburses
hospital for nosocomial pressure ulcers
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Improvement Purposes Only
Analysis of Data - Nosocomial Pressure
Ulcer Rate
• Nosocomial PU rate has decreased with
implementation of Inter-Rater Reliability on
Stage 1 ulcers.
• New EPIC RN Documentation has
assisted in capturing Pressure Ulcers
Present on Admission (POA).
• Further education on documentation is
needed to prevent nosocomial PU rate to
be artificially inflated.
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Improvement Purposes Only
Analysis of Data – Braden Scale
Compliance
• Goal met at 100%.
• Identifying who is at
risk allows for earlier
implementation of a
pressure ulcer action
plan.
• Appear to be meeting
goal of Braden scale
done daily; however,
need to monitor if
sustained over time.
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Analysis of Data-Reducing
Linen Layers
• Linen layers 3 or less in past 2 quarters >
90%
• Some improvement seen
• Need to continue with education.
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Improvement Purposes Only
Next Steps
•
•
•
•
•
•
•
•
•
•
•
•
Continue Targeting nursing units with high Nosocomial rates
Continue stage I inter-rater reliability of skin surveyor
Begin PU prevalence study data collection on portal
Increase turn around time on reports
House wide education on documentation
Educate on Specialty bed & Bariatric selection flowchart
Educate PCTs on reducing linen layers
Subcommittee to evaluate and update: P&P and EPIC
documentation changes
Implement Evidenced –based Decision Tree for Heel Pressure
Relief
Implement low, mod, and high risk guideline cards
Enterostomal nurses meeting individually with managers
Educate on 2009 Skin Care Resources available
Confidential for Quality
Improvement Purposes Only