Pressure Ulcer Prevention Improvement - Juran Institute

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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
# Patients 1st Braden > 8 hrs from AdmitA Quality Case StudyFigure 1 – Control chart of number of patients with a Braden score completed more than eighthours after admission. The chart demonstrates a significant downward shift in this metric andreduced variation after solutions were implemented.C Chart of Braden > 8 hrs from admission220200Education Completed1Feedback Implemented180160140120100UCL=137.7_C=106.8806010/22/200810/26/200811/2/200811/9/200811/16/200811/23/200811/30/2008Date of Weekly Discharge Patient Summary Report12/7/2008LCL=75.8In addition, the overall pressure ulcer incident rate in October 2008 compared to the baseline ofJuly 2007 showed a statistically significant difference in rate from 18% to 8%.Incidence Rates X N Sample p Incident RateJuly 2007 15 83 0.18 18%October 2008 10 120 0.08 8%Test for difference = 0 (vs. > 0): Z =1.98p-Value = 0.024Control:The control phase provides tools and methodology necessary for an organization to meet thechallenges of maintaining and sustaining improvements to the process. The pressure ulcerprevention team used the following tools:• Control Plan – provides roadmap of action plans for maintaining and sustaining processimprovements.• Communications plan – describes how and when information of process changes will bedisseminated to staff throughout hospital and affected areas.• Training Plan – outlines the schedule for training staff of new process changes.• New and revised policies and procedures – provide guidance regarding how processesare to be completed.After the process was fully implemented and in place for several more months, the team learnedthat their target incident rate of 5% and a sigma level of 3.2 had been achieved.All Rights Reserved, Juran Institute, Inc. 5
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Pressure Ulcer Prevention Improvement - Juran Institute

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