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How One LAC+USC Unit Became a Model in HAPU Prevention

Recognizing the increased risk hospital-acquired pressure ulcers (HAPUs) pose for intensive care unit (ICU) patients, nurses in LAC+USC’s 4A medical intensive care unit (MICU) in 2010 set an ambitious goal: to reduce HAPUs in their unit by 50 percent by the end of that year. After implementing “plan, do, study, act” (PDSA) cycles to pilot improvement strategies, the team surpassed its goal and helped 676-bed LAC+USC achieve an impressive drop in its number of HAPUs.

Hospital-acquired pressure ulcers (HAPUs) are caused when a patient experiences prolonged periods of immobility, putting increased pressure on the skin, soft tissue, bone, and/or muscle. The condition particularly plagues ICUs because severely ill patients have compromised tissue perfusion and limited physical mobility.

In 2010, the 4A MICU started participating in the Transforming Care at the Bedside (TCAB) program, which is built around nurse-driven quality improvement projects. As part of the program, the unit’s nurses used the Institute for Healthcare Improvements’ PDSA model to test four specific HAPU interventions:

  1. visual indicators on the doors of at-risk patients and patients with pressure ulcers;
  2. the “four eyes check,” which involves two nurses assessing and verifying the status of each patient’s skin on admission;
  3. the “safety calendar,” a color-coded calendar that shows which days the unit has a pressure ulcer; and
  4. education for staff about best practices for identifying and treating HAPU or at-risk patients.

In the first 12 months of the project, the team surpassed its goal of reducing its number of HAPUs by 50 percent. The project’s early results had a broader impact, too, causing LAC+USC — where discharges are nearly half Medicaid or Medicare recipients and the patient population is 67 percent Hispanic — to see a 46 percent decrease in its HAPUs housewide.

Prompted by this initial success, the hospital expanded Unit 4A’s project to the rest of its ICUs, where it continued to produce positive results. From the second quarter of 2010 to the third quarter of 2012 — after all of the hospital’s ICUs adopted the project and with continued vigilance on  implementing pressure ulcer prevention protocol in the ICUs and wards — LAC+USC’s quarterly HAPU prevalence dropped by 86 percent, from 87 HAPUs per quarter to just 12.

According to its sponsoring director, the key to the project’s success was that front-line staff initiated, designed, and carried out each strategy, which created a culture of safety, ownership of the project and increased engagement among nurses. Also the facility’s wound care nurses were invaluable resource to front-line staff for their expertise in pressure ulcer management. For example, the nurses presented their successes to leadership, and administered training sessions when the initiative spread to other hospital units.


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