Nancy Scozzari RN, CWOCN

History of Bedside Process Mapping Serious Safety Event (SSE) Hospital Acquired Pressure Ulcers (HAPU) were identified through Charges Chart Review Risk Management Patient Safety Net SSE meeting Involved Quality, Risk, Social Worker, and Skin/ Wound team member

Process of SSE Meeting The Skin/Wound team would be notified of list of patients on a select Monday of the month Team would perform an extensive chart review to verify HAPU The SSE meeting would occur on the following Wednesday SSE meeting once a month Length of time varied, usually 4 hours

SSE Process Changed 3/12 Quality Reports were developed to pull information from the EHR Drill Down Tool was developed Meeting became weekly Unit Leadership and Nutrition became involved Skin and Wound Team verification of HAPU

Drill Down Tool 2012 2012 Hospital Acquired Pressure Ulcer (HAPU) Drill Down Tool (revised 5.22.12 CEB) Name (person completing drill down tool) Unit/Date Completed Patient Name EDP/HAR Age Sex BMI and Weight Admit Date HAPU Identifcation Date HAPU Centralized Verfication Date HAPU Stage and Body Site Location Review Period (ID date through 5 days prior) DEMOGRAPHICS (Skin & Wound Team to Complete) Source in EHR: Patient Summary/Nursing Overiew PRESSURE ULCER DOCUMENTATION (Skin & Wound Team to Complete) Source in EHR: Doc Flowsheet/Skin Integrity

Drill Down Tool 2012 cont. INTERVENTIONS from HAPU ID date/time through 5 days prior (All to Complete) Multiple Sources in EHR Patient admission/unit location/census information. (Ex. In ED on 1/10 1211-1324, Admitted to MIU 1/10 @ 1324 MIU, to 1S on 1/12 @ 1722, discharged from 1S on 1/13 @ 0834) Source: Patient Summary/Census History Report Was the unit compliant with the Skin Bundle if Braden < 18 (Y/N)? If missed, list staff initials and title. 1. Moisture management/skin observation documentation q2hr in bed or q1h in chair 2. Nutrition consult and evaluation completed within 72 hours if Braden nutrition subscore 1 or 2 or pt seen in last 7 days if LOS >7 days. 3. Pressure Relief/Redistribution q2 hrs in bed or q1hr in chair Sources: Nutrition Notes and Patient Summary/Bundle Audit Report Admission Total Braden Score: Total Braden Score on ID date: Braden Nutrition Subscore on ID date: Total Braden Score 24 hrs prior to ID date: 1. 2. 3. Was the pt on the appropriate bed surface (Y/N)? Refer to Bed Algorithm E60-5A Source: Patient Summary/Bundle Audit Report

Drill Down Tool 2012 cont. Were the pt's heels elevated if the HAPU was identified on heels? Source: Patient Summary/Bundle Audit Report Was appropriate device care provided if applicable? (Ex. trach care q8hrs/2-4hrs & PRN for 1st 72hrs post-op, bundle foley care q24hr, collar care q12, ace wraps removed & skin inspected per MD order, etc.) Provide resources if applicable. Source: Doc Flowsheet/Intervention-2 Was the Lift Team following this patient? (Lift Team criteria: pt weight >200lbs and high-risk unit) Source: Patient Summary/Nursing Overview

Drill Down Tool 2012 cont. STAFFING FACTORS (Unit Leadership to Complete) Sources: Unit Report Sheets/Schedules and FlexWork Were there any contributing staffing factors? 1. Staffing adequate 2. Skill mix appropriate 3. Appropriate resources available 4. Other (inexperienced/unknowledgeable staff, SNP, SLAT, travelers, students, orientees, non-core staff, etc) 5. List staff initials and title of those involved with deviation for follow-up OTHER (Unit Leadership & Patient Safety to Complete) Sources: Patient Summary/Nursing Overview/Hospital Problem List; MAR; Admission/Medical History and Tobacco Use; MD Progress Notes and H&P Notes; SoftMed; Doc Flowsheet/PIT Resp Flowsheet Comorbidities/Risk Factors (Ex. Ventilator use, vasopressor use, OR time/surgery > 3hrs in last 7 days, EMT transportation > 3 hours, history of PUs, stroke, paralysis, smoker, shock, sepsis, ESRD, bowel/bladder incontinence with no rectal tube or foley, end of life, etc.) This material is intended to be confidential and privileged medical review committee materials pursuant to NCGS 131E-76, 131E-95, 131E-97.2, and 90-21-22A, and or other applicable Federal and State Law. This information should not be reproduced, distributed or shared outside of the medical review committee activities.

Drill Down Tool Changed 11/12 Similar patients, eg those with mucosal HAPUs related to NG tubes, will be process mapped at the same time regardless of service line/unit The unit(s) will be responsible for completion of the Process Map, using the Drill Down Tool for reference.

This material is intended to be confidential and privileged medical review committee materials pursuant to NCGS 131E-76, 131E-95, 131E-97.2, and 90-21-22A, and or other applicable Federal and State Law. This information should not be reproduced, distributed or shared outside of the medical review committee activities. Last revised 8/21/13 CMW

Process Changed to Bedside 7/13 The Skin and Wound Team will be responsible for initiating the bedside process mapping and will contact unit leadership when the HAPU is verified The clinical unit leadership will determine the time that will work best for the unit Completed drill downs should be available and shared at the time of bedside process mapping Action plans should be implemented immediately

Case Study A 79 year old male admitted for fatigue and decreased LOC. Past medical history: ORIF one month ago and MI. According to the daughter, he has not been able to eat much for the past 3 days. Upon admission labs reveal dehydration, low albumin, increased WBC s. A skin swarm was performed by two RN s and an Unstageable pressure ulcer was noted to the sacrum upon admission. The admission Braden Score was 15. A NG tube was placed in the left nare on 10/22 for feeding until swallow study could be performed.

Mucosal Pressure Ulcers Pressure ulcers that are found on mucous membranes with a history of a medical device in place at the location of the ulcer.

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