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Multifaceted Approach Leads to Lasting HAPU Gains

Using a step-by-step approach, Truman Medical Centers, in Kansas City, Mo., decreased hospital-acquired pressure ulcers (HAPUs) by 78 percent through a variety of interventions throughout 2012. The two-hospital system, a level I trauma center with 41 percent of its discharges covered by Medicaid, sustained a consistently low HAPU rate into 2013 by ensuring the new processes were implemented reliably.

Starting with the basics, the team in early 2012 made turn clocks and turn teams a standard of practice for all nurses at its Hospital Hill and Lakewood campuses. In mid-2012, the team developed a protocol, modeled after C. Tod Brindle’s work, for the use of sacral and heel pressure ulcer prophylaxis for patients with intact skin who scored less than 15 on the Braden Scale, which predicts pressure ulcer risk.

The protocol outlined how to apply, maintain, and change prophylactic dressings, and corresponded with emerging evidence that protective dressings can be an effective component of HAPU prevention strategies. In critical care units, the system also used the protocol for patients on ventilators or vasopressors, or who were hemodynamically unstable.

The team phased in the protocol one unit at a time, starting with Hospital Hill’s critical care units, then moving to its telemetry units and medical-surgical units, and finally spreading to all of the Lakewood campus’ units by the end of 2012. As the protocol was instituted, the team trained a wound care champion on each unit who was available to answer process-related questions in real-time.

Following implementation, the team audited front-line nurse compliance, using lapses as learning and training opportunities. Compliance rose from 50-60 percent to 80-90 percent between the first audit in January 2013 and the last audit in March 2013.

In September 2013, the team coupled an environmental study with their pressure ulcer prevalence survey. They found 52 devices that could cause HAPUs in one day of rounding, leading them to retrospectively analyze their 2012 and 2013 HAPU data. They found that 33 percent of HAPUs in 2012 and 32 percent in 2013 were caused by devices, and that oxygen tubing was the leading device that contributed to the condition.

This finding prompted Truman to replace its oxygen tubing with a safer material and further assess how it could improve or replace other devices to increase safety.

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