Nursing Leadership UPMC St Margaret. Nursing Quality Report April 2013
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1 Nursing Leadership UPMC St Margaret Nursing Quality Report April 2013
2 FY13 FALLS
3 FY13 UNIT FALLS FY13 FALLS BY UNIT 3B ICU IMC 4B 4AR 5B 5A 6B 6A TOTAL Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr-13 May-13 Jun-13 TOTAL UNIT FALLS
4 FY13 TOTAL FALLS RATE
5 FY 13 FALLS / INJURY
6 FY13 FALLS / INJURY SEVERITY
7 FY13 Falls Root Cause Analysis
8
9 PLEASE DO NOT REMOVE THESE ITEMS FROM THE PATIENT ROOMS CLEAN WITH HOSPITAL APPROVED DISINFECTANT
10 Weekly Falls Huddle
11 Safe Patient Handling April 9 April 11 April 17 MAY 1 May 13 May 14 Department Safe t y Coach Lis t Due Share Point De ve lope d Polic y To EMG Me c hanic al Lift s arrive Safe ty c oac hes St art vide o t raining Safe t y Coac h Training Equipm e nt De live ry t o t he unit s
12 HAPU Rate FY 2013 PU rate continues to out perform NDNQI benchmark targets
13 March 21, 2013 Pressure Ulcer Prevalence Findings Per Unit
14 Pressure Ulcers - Hospital Acquired FY 2013 Months highlighted in orange were reported to NDNQI
15 Pressure Ulcers - Unit Acquired FY 2013
16 Upcoming Skin Prevalence Dates April 18, 2013 will be reported to NDNQI
17 UPMC Equipment Depot Goal: To identify opportunities in equipment rentals that can be filtered through the equipment depot. Total System rental costs for FY2012 = 22 million and FY2013 to date 9 million System Rental Costs : Critical Care beds: Currently spend $578K A VAT team is currently working on determining a system standard product. Awaiting final decision Sizewise Products: Currently spend $431K in rentals. Currently providing low air loss mattresses, rental beds (low beds) and over bed tables
18 UPMC Equipment Depot Identified issue with receiving notification of patient discharge: Rental costs keep accruing until Equipment Depot receives notification Equipment Depot working on resolving the issue Equipment Depot not able to generate daily report of beds in use in hospital Each hospital needs to develop process until issue is resolved Quality nurse making rounds Monday Friday to identify equipment in hospital until issue is resolved CPAP/Bipap equipment: Next area being developed by the Equipment Depot Currently in negotiations with Phillips to purchase CPAP/Bipap. Proposal: 38 units FY13, 45 units FY 14, 49 units FY 15. Unsure if this is in addition to our current stock or to replace broken /obsolete units. UPMC SMH currently owns and rents Respiratory Owns 15 Bipap/19 vents Rents 0-6 BIPAP per month Rents 0-6 Vents per month
19 Skin Care Initiatives Baza Cleanse & Protect Use to clean incontinent patients Protects skin Decreases odor by decreasing the bacteria count Use with the soft cloths Can soften soft cloths with warm water then spray Baza on cloth Baby wipes will be phased out over the next several weeks
20 Skin Care Initiatives Gentle Rain Body Wash Is a moisturizing body wash and shampoo Will be replacing baby shampoo and Dial soap Can be used for Foley Catheter care system approved 2 oz bottles will be stocked for ease of use Used with wash cloths Inservices will be conducted once in stock on units
21 HEN-PU Initiative Recognition ICU and 6A recognized as top performers of the HEN-PU initiative for process measures ICU and 6A recognized for 100% compliance with the process measures of completing skin and risk assessments within 24 hours admission (July 2012 through January 2013) ICU recognized for 100% compliance with the process measure of implementing interventions within 24 hours for a patient identified as at risk for developing a pressure ulcer (July 2012 through January 2013) February 2013 both units were recognized for achieving 100% compliance with the 3 Process Measures
22 HEN-PU Initiative Heel Pressure Ulcer Treatment resulted from the Heels Up Initiative on the pilot unit 6A Added the pressure ulcer cards on the unit in March 2013
23 All Specimen Labeling Errors FY 2013
24 CMS VTE Core Measure VTE 1: Prophylaxis by HD 2 Numerator Denominator Rate (%) # Variances Jan' % 12 Feb' % 20 Variance Review #Variances Nursing Omission* Delay* Jan' (83%) 2 8 Feb' (65%) 4 9 * Mechanical Prophylaxis Documentation 24
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