1. Confidential for Quality Improvement Purposes Only Hospital Acquired Pressure Ulcer Reduction Project Jodi Blaszczyk RN, BSN, CWOCN, Skin Care Liaison Committee, Judy McHugh RN, MSN

2. 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%

3. Confidential for Quality 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.

4. Confidential for Quality 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

5. Confidential for Quality Improvement Purposes Only NDNQI Survey Team Training & Staging Acute Rehab & ICU Admission Ulcer Documentation Greater than 4 Linen Layers Skin Survey Re Education Inter-Rater Reliability Stage 1 Back to Bed Save Our Skin Manager Meeting Agenda Item Reduce Linen Layer Non Plastic Adult Briefs Daily Braden Scoring New EPIC RN Documentation

6. Confidential for Quality Improvement Purposes Only

7. LIMIT LINEN LAYERS Target goal 100% linen layers 3 or less –Extra linen layers wrinkle causing increased pressure –Too many linen layers decrease effectiveness of Atmos-Air Mattress Replacement System Milne, CT, et al. Wound, Ostomy, and Continence Nursing Secrets, Philadelphia, 2003, Hanley & Belefus, Inc.

8. Confidential for Quality Improvement Purposes Only 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

9. Confidential for Quality 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.

10. Confidential for Quality 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.

11. Confidential for Quality Improvement Purposes Only Analysis of Data-Reducing Linen Layers Linen layers 3 or less in past 2 quarters > 90% Some improvement seen Need to continue with education.

12. Confidential for Quality 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