Reduction of Nosocomial Pressure Ulcers on 5 NEW Rehabilitation Unit

1. SaveOur Skin Reduction of Nosocomial Pressure Ulcers on 5 NEW Rehabilitation Unit 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. Problem Identified • 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 Confidential: Quality Improvement Material

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

5. Solutions Implemented Rapid Cycle #1 1st & 2nd Quarter 2008 • 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. Confidential: Quality Improvement Material

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

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

8. Solutions Implemented Rapid Cycle #2 3rd & 4th Quarter 2008 • 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. Confidential: Quality Improvement Material

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

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

11. Solutions ImplementedRapid Cycle #31st 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 inS.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 onAdmission 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 16th, 2008. • S.O.S. posted on Loyola’s Website. • Article published in Advance for Nurses on February 16th, 2009. Confidential: Quality Improvement Material