Elsevier

Apollo Medicine

Volume 9, Issue 3, September 2012, Pages 282-286
Apollo Medicine

Article on Quality
Project zero towards nursing never events - reduction of hospital acquired pressure ulcers

https://doi.org/10.1016/j.apme.2012.06.007Get rights and content

Abstract

Hospital-acquired pressure ulcers (HAPU) or bedsores – also called pressure sores or pressure ulcers – are injuries to skin and underlying tissues that result from prolonged pressure on the skin. Bedsores most often develop on skin that covers bony areas of the body, such as the heel, ankles, hips or buttocks.

People most at risk of bedsores are those with a medical condition that limits their ability to change positions, requires them to use a wheelchair or confines them to a bed for prolonged periods.

Bedsores can develop quickly and are often difficult to treat. Several care strategies can help prevent some bedsores and promote healing.

Section snippets

Epidemiology

Pressure ulcers are lesions caused by unrelieved pressure that results in damage to the underlying tissue. Generally, these are the result of soft tissue compression between a bony prominence and an external surface for a prolonged period of time. The consequences of pressure-induced skin injury range from non-blanchable erythema of intact skin to deep ulcers extending to the bone. The ulcer imposes a significant burden not only on the patient, but the entire health care system.

It is

The pressure ulcer that took down Superman

It is now fairly known that it was in fact a pressure ulcer that took the life of Christopher Reeve – the Superman. Nearly 9 years following his spinal cord injury, he developed a wound that became severely infected. He died in October 2004 following a cardiac arrest at the age of 52 (Fig. 1).

Red flag

Pressure ulcers increased to 29 (number of patients) in August 2011 from an average of 7 per month.

Grade 1 ulcers were not even identified for some time and they turned into grade 2.

Inadequate hand offs related to pressure ulcers.

Lack of nursing care due to lack of knowledge about pressure ulcers.

Skin care was documented but not given/inadequately given on the ground.

Aim: to reduce the hospital-acquired pressure ulcers to near zero & sustain the same.

Objectives: initial skin assessments, timely

Numerator statement

Number of patients developing pressure ulcers/bedsores after 24 h of admission into the hospital.

Inclusions

All in-patients.

Exclusions

Patients admitted with pressure ulcers/bedsores and all out-patients.

The prevalence of HAPU is operationally defined as the number of patients with HAPUs divided by numbers of patients observed.

Data collection & analysis: HAPU team, pressure ulcer prevention audit tool, monthly analysis & presentation to the HAPU team.

Initiatives:

Daily rounds by the ICN, ANS, back care Nurse.

HAPU

Percentage compliance:

Prior: No standards protocols in place. 50% skin care was found.

Target: 99% compliance to skin care & 1 case per 1000 hospital discharges.

Achieved: 100% compliance & zero cases per 1000 hospital discharges were found without a single HAPU.

Benefits: timely patient assessments, set processes & protocols, team formation.

Conflicts of interest

All authors have none to declare.

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