Improving Identification and Documentation of Pressure Ulcers at an Urban Academic Hospital

Abstract

Background A two-year quality improvement campaign at a single teaching hospital was launched to improve the identification, documentation, and treatment of pressure ulcers (PUs) after Centers for Medicare & Medicaid Services (CMS) declared severe hospital-acquired PUs are “never-events.” Method The campaign included (1) reference materials, (2) new documentation templates, (3) staff education, and (4) hospital-wide mattress replacement. An ongoing retrospective chart review of frail older patients determined the presence of PU documentation, which provider (nurse or physician) documented the PU, and which descriptors (stage, size, or location) were used. Results The campaign significantly increased the proportion of PUs completely documented by nurses from 27% to 55% following mattress replacement and resident education (OR 3.68, p = 0.001, 95% CI: 1.68–8.08). A similar improvement was observed for physician documentation increasing from 12% to 36% following the same interventions however this change was not statistically significant (OR 2.11, p = 0.12, 95% CI: 0.82–5.39). These improvements were short-lived due to the implementation of electronic medical records (EMR) for nursing notes. Although the percentage of PUs completely documented by nurses decreased following EMR implementation, it increased in the following months, above the pre-campaign baseline as nurses adapted to the new documentation system. However, after EMR implementation, complete PU documentation by physicians fell to a nadir of 0% and did not recover. Discussion A multi-component campaign to improve the quality of PU documentation by both physicians and nurses can yield positive gains. However, these improvements were short-lived due to EMR implementation, which acutely worsened documentation of PUs. This emphasizes the importance of frequent and repeated interventions to sustain quality improvement successes.

Using a Lean Six Sigma Approach to Yield Sustained Pressure Ulcer Prevention for Complex Critical Care Patients

“…15,17 As opposed to solely stressing individual nursing tasks, our unique study utilized LSS as a structured team-based process improvement approach advocated by other studies as necessary for sustainable prevention. 21,22,30 Our intervention addresses commonly reported root causes of persistently high UAPU rates: poor adherence to documentation, gaps in communication, and lack of continual commitment to reaching the benchmarks. 20 This study provides concrete examples of how LSS can be used to successfully implement key elements of a systematic approach to pressure ulcer preventionVstandardizing documentation tools that are incorporated into existing clinical practices, using visual aids for patient sitting time, maintaining appropriate levels of vital equipment, and widespread staff engagement and education, especially of physicians.…”

“…18,19 Rather, these guidelines need to be 1 factor in a systematic approach to HAPU prevention, implemented by a multidisciplinary care team. [19][20][21][22] This project aimed to develop and test a multidisciplinary process, as opposed to individual tasks, to reduce the incidence of unit-acquired pressure ulcers (UAPUs) in ICUs.…”

Úlceras Por Pressão, Prevenção Primária E Educação: Revisão Integrativa De Estudos

“…Rantz et al (2012) lecionam que, além dos cuidados restritos ao ambiente hospitalar, a intervenção com enfoque na qualidade do cuidado em lares de idosos demonstrou melhora significativa na qualidade do atendimento, bem como nos índices de UP. Dahlstrom et al (2011) asseveram o exposto e relatam que, para manter o sucesso e melhoria da qualidade na prevenção e tratamento de UP, são de fundamental importância as intervenções frequentes e repetidas, independentemente do local onde o paciente se encontra -domicílio ou hospital.…”

An evaluation of nursing documentation of acutely admitted older home-living medical patients in a Danish hospital

“…[17] In general, studies which have investigated congruence between patient records and patient-reported symptoms conclude a low agreement. [18,19] Studies on nursing documentation in elderly patients have been focused upon structured documentation of: functional ability, [20] nutrition, [21] pressure ulcers, [22,23] delirium, [7] and dementia. [24] In Denmark, nursing reports contain the possibility to document both structured and unstructured, such as free text notes.…”