Article on QualityProject zero towards nursing never events - reduction of hospital acquired pressure ulcers
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.