Sample Aggregate Review - Root Cause Analysis Stage 3 or 4 Pressure Ulcers Acquired After Admission (Adverse Event type 17)

Transcription

1 Lack f effective multidisciplinary cllabratin n pressure ulcer Lack f clinical practice/knwledge Limited patient and family pressure ulcer educatin Lack f staff cmpetency related t pressure ulcer Decisin tls t determine risk, interventins, equipment chices, etc., nt available, nt adequate, nt understd, nt utilized, and nt agreed upn Cnvene a multi-disciplinary team including Nursing and Assistive Staff, Medical staff, Pharmacy staff, Materials Management staff, Patient Care Services, Nutritin Services, Physical Therapy, and Respiratry Therapy Representatives t wrk n pressure ulcer strategies fr the entire medical facility. New Multi-disciplinary Pressure Ulcer Preventin Wrkgrup (PUP) with sub-grups frmed Grup meets n a mnthly basis Partners identified: Nursing/Assistive Persnnel Materials Management Pharmacy Nutritin Physical Therapy Respiratry Therapy Patient Care Services Medical Staff Meeting agendas: Entire Team: review f all plicies and prcedures related t skin assessments, practices re: treatment chices, practices related t equipment chices Subgrup: dcumentatin f pressure ulcers and determine agreements fr dcumentatin parameters Subgrup: develp plans t assess staff cmpetency related t pressure ulcer and ptimal learning mdality Subgrup: Develp and apprve patient and family educatin plan fr pressure ulcer Subgrup: review plicy/prcedure fr special prblem pressure ulcers: Nare pressure ulcer Mnthly meeting with minutes All plicies, prcedures fr pressure ulcer assessments, interventins, and dcumentatin updated and apprved. Onging gals are met. Reductin in pressure ulcers Measured quarterly and reprted t Medical Facility Quality Imprvement Cmmittees: Q1: July 1-Sept. 30 Q2: Oct. 1-Dec.1 Q3: Jan. 1-March 31 Q4: Apr. 1-June 30 DOH (March 2011) Page 1 f 5

2 Heel pressure ulcer Lack f clinical practice/knwledge Lack f staff cmpetency related t pressure ulcer Details abut patient risk factrs fr skin breakdwn and hw t determine pressure ulcer staging nt clearly understd by ICU nurses Educatin prgram develped t enhance knwledge f pressure ulcer rick factrs and staging Unit Resurce RN Cmpleted skin runds n new admissins in partnership: 1. MS CNS, WO CNS and day shift RN (N=47) within 4 weeks 2. ICU Unite RN participatin weekly; skin runds include: a. Head t te skin assessment b. Discussin and implementatin f pressure ulcer strategies c. Wund management principles as applicable t individual patient issue d. Wund dcumentatin 3. Cmpleted skin assessments n new admissins t Med/Surgical ICU n 15/17 days schedules 4. Cnduct daily skin runds with ICU RNs (date and nging) ICN RN participate in skin runds Target 70% (33) ICU RNs Wrkshp participatin by RNs Target 48 RNs can participate in tw wrkshps in 2008 Dates: 51% (24) f ICU RNs participated in Skin Runds Wrkshp 1: 70% r 17 RNs attended n Wrkshp 2: 80% r 19 RNs attended n ICU Skin Summit was held n Educatin Prgrams: 1. Tw 8-hur wund wrkshps scheduled ver the next 3 mnths DOH (March 2011) Page 2 f 5

3 2. Planning fr three additinal wund wrkshps in 2009 Lack f cnsistency in staging f pressure ulcers Lack f clinical practice/knwledge Details abut patient risk factrs fr skin breakdwn and hw t determine pressure ulcer staging nt clearly understd by PUP nurses Imprve cmpetency f staging pressure ulcers: 1. PUP RNs 2. Med-Surgical and Cardi ICU RNs Inpatient Nurse Unit Resurce RN RNs determine pressure ulcer staging accurately using the NDNQI Pressure Ulcer Staging Guidelines Med-Surgical Cardi ICU RNs cmplete NDNQI Pressure Ulcer Staging Cmpetency by Validate accurate pressure ulcer assessments by cnducting side by side pressure ulcer assessments and teaching abut treatment strategies with each wuld cnsult request r event reprt frm all inpatient units Add a staging cnsistency parameter t daily tracking sheet t cmpare staging cnsistency Review event reprts fr staging and cnsistency with WO CNS and the MS CNS assessment f wund Cmpletin f NDNQI Pressure Ulcer Staging Training annually 2 PUP RNs frm participating inpatient units (N=22). Target: 100% by 186 RNs frm 2 ICUs frm ICU. Target: 100% by 3 mnths Review pressure ulcer staging and dcumentatin Target 90% cnsistency between 2 PUP RNs frm each participating unit and Unite Resurce RNs quarterly Daily Tracking Sheet updated Review all pressure ulcer event reprts fr staging and cnsistency by Wund/Ostmy and Medical/Surgical Clinical Nurse Specialists Sample size: all patients seen fr wund cnsult requests and with reprts fr Stage 3-4 pressure ulcers acquired after admissin Duratin: Onging Target fr Cmpliance: 90% cnsistency f pressure ulcer staging between WOI CNS and staff 100% f 22 PUP RNs cmpleted training n 100% f 186 ICU RNs cmpleted training n Update cmplete 100% cnsistency in reprting fr quarter ending DOH (March 2011) Page 3 f 5

4 Lack f dcumentatin f cmplete pressure ulcer assessment n admissin and nging Lack f clear agreement regarding dcumentatin parameters Incnsistent r incmplete dcumentatin f skin assessments Cmplete and accurate pressure ulcer and staging dcumentatin Inpatient Nurse Assistant Nurse Unit Resurce RN Onging assessment f pressure ulcers t evaluate apprpriateness f treatment Cnduct daily nline audit f presence f pressure ulcers with stage and lcatin included in admissin dcumentatin. Nurse Manager, Assistant Nurse Manager r Unit Resurce Nurse RN will fllw-up with assigned RN t ensure dcumentatin is cmpleted. Daily nline audit f pressure ulcer presence with stage and lcatin included in admissin dcumentatin. Sample Size: All inpatients Duratin: Onging Target fr cmpliance: 100% f all patient charts shw dcumentatin f pressure ulcer presence n admit including stage and lcatin 100% f Admissin dcumentatin includes cmplete pressure ulcer findings fr quarter ending Lack f identified ptimum learning preferences f nurses Lack f awareness f pressure ulcer risk factrs Ineffective prcess used t update RNs abut pressure ulcer risk factrs Identify ptimum learning preferences thrugh an nline needs assessment survey PUP Wrk Grup Online survey re: RN needs assessment review and apprved by PUP Data cmpleted: 1. Pilt survey cmpleted by entire PUP Wrk Grup (N=11) 2. Medical/Surgical Specialty Unites (N=23) & Orthpedic Inpatient Unit (N=6) 3. ICU Units (N=94) 4. All inpatient nursing units (N=132) Cmpletin reprt f nline survey Duratin: 2 weeks Target: 30% cmpletin f nline survey PUP Wrk Grup target: 3 Medical/Surgical Specialty Units and Orthpedic Unit target: 21 ICU Unit Staff target: 28 All inpatient nursing units target: 94 55% 6 PUP nurses cmpleted survey n 30.4% 21 RNs cmpleted survey n RNs cmpleted survey n 20% 63 RNs cmpleted survey n DOH (March 2011) Page 4 f 5

5 Variability in Pressure Ulcer Preventin Practices Decisin tls t determine risk, interventins, equipment chices, etc., nt available, nt adequate, nt understd, nt utilized, and nt agreed upn Develp and implement best practices fr: 1. Prducts 2. Equipment 3. Heel pressure ulcer 4. Nares pressure ulcers Pressure Ulcer Preventin (PUP) Wrk Grup Subgrup: Investigate the use f alternative devices in additin t the standard use f pillws Cnduct Literature review Subgrup: Chse prducts Rke Bt fr heels Securement prduct that wrks fr NG and feeding tubes (Statlck Tube) Evaluate current practices Develp best practices prcedure Develp educatinal psters and distribute t all units Cnduct trials fr each prduct at separate times Chse units Identify staff champins Final recmmendatins t Prduct Cmmittee Mnthly meeting with minutes All plicies, prcedures fr prducts and equipment updated and apprved All plicies, prcedures fr heel and nares pressure ulcer assessments, interventins, and dcumentatin updated and apprved Reductins in pressure ulcers measured quarterly DOH (March 2011) Page 5 f 5