Pressure Ulcer Prevention Improvement - Juran Institute

A Quality Case StudyDetailed solutions/action items included:• Assessment of skin (head-to-toe Braden risk assessment) performed within eight hours ofadmission and once a shift thereafter.• Braden scores documented using the computerized, enhanced Braden Risk Assessmenttool with interventions for at-risk patients.• Use visual identifiers for at-risk patients—those with Braden score of 18 or less (bluepillow case and magnet on door frame turned to S.O.S - Save Our Skin).• Chair waffles for patients that are chair bound or require assistance from bed to chair.• Five pillows are stocked in each patient’s room for use in re-positioning.• Breathable pads for incontinent patients are used only one at a time; no overlaying pads,and linen Chux will be eliminated.• No diapers in bed or sitting in a chair.• Patient sitting in a chair is limited to one hour or less, unless patient is able to repositionself or ambulate independently.• Braden cards and Braden Quick Reference clipboard sheets provided for nursing staff.• New mattresses purchased enterprise-wide with pressure redistribution technology, whichmistake-proofs the use of waffle mattresses.• Wound care hotline via Spectralink phone and dedicated e-mail established for nursingstaff resource for at-risk patients.• In-process metrics are included in charge nurse report each shift to verify patientsreceived a Braden score, confirm patients at-risk, and ensure any pressure ulcers aredocumented (community-acquired or hospital-acquired).• Standard wound care order set created for pressure ulcer prevention and treatment.• “Save our Skin” Champions made available on each unit.Upon implementation of the 14 solutions, immediate and statistically significant improvementwas observed (Fig. 1).All Rights Reserved, Juran Institute, Inc. 4