1. Reduction of Nosocomial Pressure Ulcers on 5 NEW Rehabilitation Unit S ave O ur S kin Confidential: Quality Improvement Material

2. Team Membership Physicians Acute Rehab Nurses Skin Liaison Nurse Patient Care Techs Physical Therapists Occupational Therapists Administrative Assistant Center for Clinical Effectiveness Confidential: Quality Improvement Material

3. National benchmarking data demonstrated an increase of hospital acquired pressure ulcers on 5NEW. Documentation Issues Nurses not consistently documenting skin assessment upon admission No EPIC field to document healed ulcers Staff Issues Need for increased education regarding appropriate toileting Patient Issues Prolonged sitting in chairs Wearing ill-fitted shoes Problem Identified Confidential: Quality Improvement Material

4. Aim Statement Reduce the incidence of nosocomial pressure ulcers on 5 NEW to zero. Confidential: Quality Improvement Material

5. Obtained physician/administrative support for project. In serviced all staff on Save Our Skin (S.O.S) Program. –Skin assessment tools –Use of Braden Scale –Identification of pressure ulcer –Patient and family education S.O.S program piloted initially 3/03/08 including patient, family & staff. Solutions Implemented Rapid Cycle #1 1 st & 2 nd Quarter 2008 Confidential: Quality Improvement Material

6. SOS Project Implementation Analysis of Outliers Confidential: Quality Improvement Material

7. SOS Project Implementation Analysis of Outliers “Back To Bed” Reinforced

8. Drill down 7 outlier cases for September 2008 to identify trends, common variables. Reeducate staff on S.O.S initiative. Engage Physical Therapy staff in initiative. Schedule patients “Back To Bed” Monitor incidence of nosocomial pressure ulcers on 5NEW. Report outcomes to key stakeholders and staff. Solutions Implemented Rapid Cycle #2 3 rd & 4 th Quarter 2008 Confidential: Quality Improvement Material

9. SOS Project Implementation Analysis of Outliers “Back To Bed” reinforced 2 PU healed prior to discharge

10. Confidential: Quality Improvement Material Loyola 5 NEW Goal: 0% Confidential: Quality Improvement Material

11. Solutions Implemented Rapid Cycle #3 1 st Quarter 2009 Monitoring healed pressure ulcers Epic improvement: document type of cushion for chair depending on type of pressure ulcer (chair, gel, roho) Encourage participation of Dietary Department in S.O.S. Confidential: Quality Improvement Material

12. Next Steps Monitor outcomes of S.O.S program Measure number of nosocomial pressure ulcers that are treated and resolved prior to discharge. Monitor number of pressure ulcers Present on Admission that are treated and resolved prior to discharge. Track admission source to 5 NEW. Improve notification of healed ulcers to physicians. Determine loss of revenue to Rehab due to a nosocomial pressure ulcer. Spread S.O.S. program to other hospital units. Confidential: Quality Improvement Material

13. Celebrate Success Staff celebrated the success of the November initiative and positive reinforcement given. Initiative continues, partnership with Physical Therapy grows. In order to maintain project sustainability, monitoring and information sharing among disciplines continues. Goal of zero nosocomial pressure ulcers achieved in November, December and January. Presented program to hospital board in January 2009 Issued a press release to consumer and trade publications on December 16 th, 2008. S.O.S. posted on Loyola’s Website. Article published in Advance for Nurses on February 16 th, 2009. Confidential: Quality Improvement Material