Establishing a comprehensive networkwide pressure ulcer identification process

Area of Science:

• Healthcare quality improvement
• Patient safety initiatives
• Clinical nursing research

Background:

• Pressure ulcers (PUs) pose a significant risk to patients and incur substantial treatment costs, particularly for Stages II-IV.
• The Centers for Medicare & Medicaid Services (CMS) penalizes hospitals by denying reimbursement for hospital-acquired PUs.
• Preventable PUs impact patient outcomes and hospital financial resources.

Purpose of the Study:

• To develop and implement a standardized algorithm for early identification of PUs present-on-admission (POA).
• To improve the consistency of skin assessments, physician notification, reporting, and inter-unit communication regarding PUs.
• To reduce the incidence of hospital-acquired PUs and associated financial penalties.

Main Methods:

• An interdisciplinary team created an algorithm for PU identification in participating units.
• Standardized processes included skin assessment, physician notification, safety reporting, and communication.
• Computer-entry tools facilitated immediate feedback loops with nursing staff via unit-based process improvement councils.

Main Results:

• Total reported PUs increased by 36.3% (1,103 cases) in the year following implementation compared to the previous year.
• The initiative demonstrated 100% effectiveness in identifying Stage III/IV PUs POA.
• Hospital-acquired Stage III/IV PUs were successfully prevented, ensuring high-quality care and fiscal protection.

Conclusions:

• The developed algorithm enables clinically feasible and effective identification of all PUs present at the time of admission.
• Standardized processes are crucial for improving PU detection and prevention.
• This approach supports both patient well-being and hospital financial health.