1. Device related pressure Ulcer in Cardio thoracic intensive care unit
Heart Hospital

2. CTICU Pressure Ulcer Project Team
Team Leader
Dr. Alejandro Kohn Tuli
Physician
Dr. Hesham Ahmed
Safety Facilitator
Dr. Poonam Gupta
Quality Management
Ms. Kakoli Roy
Mr. Othman Otoum
Nursing Staff
Ms. Shiny Shiju
Ms. Manal Hassan
Dietician
Ms. Aisha Pookunju
Wound Care Nurses
Ms. Sunitha Mathew
Ms. Marife Quinto
Physiotherapist
Mr. Prasobh Jacob
Mr. Syed Ansari
Respiratory Therapist
Mr. Ruzzel Galvez
   

3. DRIVER DIAGRAM Secondary drivers
Formation of multidisciplinary team involving consultants, staff nurses, quality control department, physiotherapist, wound care nurses, dietician and respiratory therapist
Assessment for pressure ulcer should be done immediately after receiving the patient from OR using Braden scale
Documentation of findings.
Reassessment on every turning.
Use visual clues for easy understanding of patient at risk
Proper documentation of patients with high risk and already developed pressure ulcers.
Primary Drivers
Aim/ Primary Outcomes
Measures:
Multidisciplinary team formation, Risk identification and assessment
S - Surface – Clean, use proper mattresses for pressure redistribution
- S- Skin – Regular inspection to check signs of pressure changes , development of skin care bundle
- K – Keep moving – consider mobilizing, positioning every 2 hourly, minimize pressure on bony prominences, sitting time should not exceed more than 2 hours per session, physiotherapist advise for proper technique of mobilization. Consult physician for the patients with “NOT TO BE TURNED” orders.
- I - Incontinence - In patients with incontinence clean and dry surface, use barrier creams
- N – Nutrition – Dietician round for nutrition assessment and advise
Development and Implementation of SSKIN bundle
Reduction in hospital acquired pressure ulcer count to 50 % by Dec 2014
Prevention of device related pressure ulcers
Outcome Measure : CCO11 Pressure ulcer count
Process measure: CCP6 Percent compliance of patients deemed “at risk” receiving the full pressure ulcer prevention bundle
CCP7 Percent of patients receiving daily pressure ulcer risk reassessment
The driver diagram relating to the aim described
Change position of ETT and NGT every 4 hourly, respiratory therapist should be consulted.
Change ETT ties with 2 available types in HH
Education of frontline staff and involvement of patient and caregivers
Education of team members and frontline staff
Mandatory NDNQI certification for all frontline staff
Patient and family education about risk and prevention of pressure ulcers.
Best Care Always • A HMC campaign in collaboration with IHI

4. PDSAs Completed
physiotherapist involvement
Meet adequate nutrition as per patient tolerance
Spread in the unit
Wound care nurses involvement
Start feeding with in 24 hrs of admission to unit.
Education sessions arranged to understand visual clues
Respiratory therapist involvement
Proper place was finalized to place stickers
Dietician rounds for all the patients
Use the box to describe what you are trying to do e.g. raise awareness of risk assessment, develop assessment form, design education. Then do brief not eon what you tested
Dietician involvement in the team
Visual clues designed as per braden score risk category
Multidisciplinary team formation
Multidisciplinary team formation
Introduce visual clue to identify high risk patient
Nutrition assessment for all the patients in CTICU

5. PDSAs Completed
Test spread in Unit
Displaying compliance results on nursing board
Requested Pharmacy Director to made the cream available as pharmacy product
Once patient stable, withdraw the orders
Group education sessions conducted
Trial was conducted on 2 high risk patients with excellent outcome
Reminders in every round to review the orders
One to One nurse education was conducted
Sample creams and sprays were arranged by wound care nurses
Use the box to describe what you are trying to do e.g. raise awareness of risk assessment, develop assessment form, design education. Then do brief not eon what you tested
Nurses will inform doctors to write do not turn orders for hemodynamic ally unstable patients
Baseline data was collected for correct braden scale assessment
Cavillon cream should be used as barrier cream but was unavailable in hospital
Documentation of DO NOT Turn orders from Doctors
Proper assessment by Braden Scale
Use of barrier cream for pressure ulcer

6. PDSAs Completed
Change of ET tie every 24 hrs alternatively with Smith and Hollister
Results will be displayed in OR to increase awareness
To display calendar on notice board so that easily visible to all
Change in ET position every 4 hourly
Patients who already developed pressure sores, is counted in OR
Days without PU is green and with PU is red
Assessment of patient by respiratory therapist upon coming in the unit
Use the box to describe what you are trying to do e.g. raise awareness of risk assessment, develop assessment form, design education. Then do brief not eon what you tested
Immediate assessment of patients received from OR by respiratory therapist to detect signs of pressure ulcers
To display pressure ulcer calendar in unit with day marked with pressure ulcer
Involvement of respiratory therapist for ETT tie and position change
Segregation of pressure ulcer count in unit
Displaying Pressure ulcer calendar in unit

7. Pressure Ulcer mild Risk Pressure Ulcer mild Risk
Pressure Ulcer High Risk
Pressure Ulcer High Risk
Pressure Ulcer moderate Risk
Pressure Ulcer moderate Risk
Pressure Ulcer Alert
Pressure Ulcer Alert

8. Number of stage 2 pressure ulcers in the unit
April – Out of 9, 5 were device related Pressure ulcers
May – Out of 4, 2 were device related pressure ulcers
June – 2 device related pressure ulcers noted
150 days of no stage II pressure ulcer in this microsystem

9. % Weekly Compliance to Pressure Ulcer Bundle

10. Pressure Ulcer Calendar in CTICU November 2014
Stage 2 and More 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU
No HAPU

11. Key Learnings
1- There may be unconventional pressure ulcers in the unit, we have to do detailed study before planning interventions. 2- Multidisciplinary team approach for pressure ulcer is key of success of this project as many healthcare professional are involved in patient care apart from doctors and nurses 3- Introduction of visual cues is important part of the project which helped in identifying patients at risk without seeing the patient files. 4- Barrier creams were not available in the unit. We managed to get 2 samples from wound care and tested it on 2 patients. After getting promising results, now its available in the stock. 5- To share the data with the staff act as motivator for the team.

12. Recommendations and Next Steps
We are planning to extend our project to OR as after data analysis, patients are transferred from OR with oral sores.