Strengthen Patient Care by Reducing Hospital Acquired Pressure Ulcers (HAPU) Nihar Bhatia Head Quality Assurance & Fortis Operating System and Prateem Tamboli, Facility Director, Fortis Escorts Hospital Jaipur Keywords: HAPU Hospital Acquired Pressure Ulcers Ab s t r a c t The cost of treating hospital-acquired pressure ulcer (HAPU) places a significant burden on not only Patients but also to healthcare facilities. Such unplanned expenses potentially include increase in Hospitalization, prolonged medication, increase in Specialized care, Occupancy of Indoor (At times Intensive Care), increased staffing, Parenteral and Nutritional support, laboratory tests, and more treatment expenditures. The development of pressure ulcers (PUs) is associated with the quality of health care. Hence, higher rates of PU development (PUD) may signal overall poor care by the healthcare system. When pressure ulcers are detected early, they are treatable. If left untreated, pressure ulcers can develop into the later stages of the condition, resulting in fatal complications like increased Length of stay, Pain, Infection, Mortality & Morbidity. It also adds to the cost of treatment depending on the stage. Considering it as a major healthcare concern, prevention of HAPU was taken up as an Improvement project by the Fortis Escorts Hospital, Jaipur. Based on data regarding monthly occurrences of HAPU during 2012-2013,our Quality & Nursing team investigated contributory factors and reviewed current tools and standards of practices related to pressure ulcer prevention. Strategic plans were developed to reduce the incidence of HAPU. Such strategies include the application of Lean Six Sigma tools like Poka Yoke, Ishikawa, Pareto approach to monitor & prevent occurrence of HAPU in the hospital. Follow-up monitoring revealed no HAPU occurrence from February 2013 till date. Hence, pressure ulcer prevention strategies as found effective in reducing incidence during a 1-year period have been approved as standards of practices for the unit. Introduction The National Pressure Ulcer Advisory Panel (NPUAP) defines a pressure ulcer as localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. The development of hospital-acquired pressure ulcers is a great concern in healthcare today. Pressure ulcer treatment is costly, and the development of pressure ulcers can be prevented by the use of evidence-based nursing practices. The incidence rates of pressure ulcers vary greatly with the health care settings. There is ample evidence that the majority of pressure ulcers occur relatively early in the admissions process normally within the first 2 weeks. With the increased acuity of elderly patients admitted and decreased lengths of stay in hospital, new data suggest that 15 % of elderly patients will develop pressure ulcers within the first week of hospitalization. Pressure ulcer is a Strengthen Patient Care by Reducing Hospital Acquired Pressure Ulcers (HAPU) 43
generally preventable complication of immobility. The awareness for prevention of pressure ulcers (PU) and for early detection increased in the last decades. The impact of these changes in awareness and in prevention on the prevalence of PU is unclear. The development of a stage III or IV pressure ulcer is now considered a Never event. This change has resulted in an increased focus on preventive strategies and institutional scrutiny of pressure ulcers that develop in patients after hospital admission. The actual cost of pressure ulcers is not known because it is unclear what costs were included in estimates, such as nursing care costs, material costs,etc. Occurrence of HAPU s in the hospital after all possible best nursing care lead us to take up the project. The study was carried out on 332 admitted patients with Braden score less than 15 falling under risk category of acquiring HAPU. Many clinicians believe that pressure ulcer development is not simply the fault of the nursing care, but rather a failure of the entire heath care system hence, a multidimensional approach was used by the team to customize the interventions for the patients under risk category to address unique needs of the patients. Various interventions were planned based on Analysis of incidences of different case mix, age, site & areas of occurrence. Presentation Multiple studies of the prevalence and incidence of pressure ulcers have been done. Typically, the hospital assesses all patients skin to determine if each patient exhibits the physical signs of a pressure ulcer, and if so,at which stage such the pressure ulcer gets manifested. Prevention of PUs is certainly not new, but it is an area of heightened focus at jaipur, when it was realized that preventing HAPU will significantly impact clinical outcomes. Lean Sigma Management principles in healthcare have been very effective in improving care and reducing the chance of patient safety errors. Application of the same encourages sustainable, long-lasting improvement, through setting up measurement systems and then consistently tracking and feeding back performance. Various interventions were planned based on Pareto Analysis to identify the 20% causes resulting into the problem i.e. occurrence of HAPU. Root Cause analysis or ISHIKAWA was used to derive the probable cause & their solutions. Control charts were used to find incidences of different Case mix, Age, Site, Areas of occurrence 44 Nihar Bhatia
It is found that the highest number of HAPU occurs in Surgical patients with the Sacrum as the major site among the patients of age of 40-60 years. To prevent HAPUs, following strategic interventions have been instituted in the hospital: 1. Risk assessment: Every admitted patient is assessed for Hospital Acquired Pressure ulcers. 2. 4Ps Protocol: Using the concepts from Maslow's Hierarchy of Needs, the team standardized, organized, and bundled 4 evidence-based Nursing Practices based on 4 Ps (i.e. Pain, Position, Possessions & Potty) into a two hourly round aimed at preventing pressure ulcers, enhancing patient comfort, reducing hospital-acquired pneumonia, and improving patients/ families' satisfaction with their care. 3. Partners in care: Using the concept of "Partners in Your Care involving patients & family by explaining why the patient is at risk and how the patient and family can help in prevention. 4. Champions: They are drawn from supervising teams that included one expert nurse for each floor from education who made rounds on all the patients in the unit daily. They would examine patients from head to toe, document/measure all pressure ulcers, and educate primary nurses/nurse assistants on the plan/products needed for the patients wound care based on their assessments 5. Visuals: Visual posters to keep reminding the staff for turning & positioning of patients every two hourly & pocket size Braden score cards for continuous education. 6. SKIN Drive: Generating awareness on prevention drive on S-Skin Selection, K-Keep Turning, I-Incontinence Management, N-Nutrition 700% % Frequency 600% 500% 400% 300% 200% 100% 40% 0% Evidence of turning and positioning 415% 347% 228% 229% 177% 124% 82% 42% 42% 51% 52% 59% 59% 68% Appropriate weight Patient assessment of Skin assessment Heels Elevation Evident supervision After surgery Equipment/material pressure relieving Braden Scale assessment and Braden constraint mattress Scale documented Functional Criteria 615% 515% 100% 100% Nutritional Adherence to assessment prescribed diet Strengthen Patient Care by Reducing Hospital Acquired Pressure Ulcers (HAPU) 45
SKIN Drive Surface Selection Keep Turning S K N I Nutrition Incontinence Management All these mentioned above are found to have brought a significant improvement by Reducing Pressures Ulcers by 89%. Preventing preventing extra stay of 3.5-5 days of Patients and thus saving approx Rs. 1.38 Crore per year. Reduced chances of Nosocomial Infections that are normally as a result of long stay Improved efficiency, quality of patient s experience & health outcomes Setting up of new benchmark which further enhances the scope of patient care Employees are more elevated to work for Patient Centricity & Safety Positive feedback have resulted in high morale Increased ownership for delivering the patient care Satisfied patients promote global image of Indian healthcare industry Lessons learnt There were various challenges faced in implementation but those have been addressed appropriately through 1. 2. 3. 4. 5. Optimum utilization of resources Adequate allocation of resources Team work Staff motivation Patient feedbacks 46 Nihar Bhatia
6. 7. Close monitoring of process Continuous improvement through periodic meetings Conclusion A project is successful only if it is scalable & sustainable. The strategic interventions as indicated above have not only helped in identifying the causes of HAPU but also helped preventing 96.98% patients from developing HAPU with Braden scores less than 15. Evidence-based study shows that the most effective approaches include keeping the wound moist, appropriate repositioning, using support surfaces, and proper nutrition. Learning from each incidence has been shared and as a result, it has impacted on the care of patients throughout the hospital.. Since the introduction of this approach, incidence of grade 3 and 4 pressure ulcers has been consistently made zero & there has been 89% reduction in incidence of occurrence of HAPU. Patients experience is improved through reduction of pressure ulcers. Success in this process seems to be related to the data-driven Lean Sigma approach & evidence based Nursing care. Acknowledgements The team likes to thank Mr. Prateem Tamboli, Facility Director of the hospital for his leadership and continuous support to this project.the teaml also likes to thank Dr. Shrikant Swami, Medical Suptd. & Ms. Jiji Mol, Chief of Nursing, teams of Nursing supervisors & of Nursing Education. The team also acknowledges support of Ms. Kirti, Team Leader Quality Assurance for facilitating communication, monitoring analysis and data collection and of all others who directly & indirectly supported this project. Reference National Pressure Ulcer Advisory Panel (NPUAP) NCBI National Centre for Biotechnology Information IHI - Institute of Healthcare Improvement NHS National Health Service WOUND CARE: Reducing Hospital-Acquired Pressure Ulcers Nursing Centre.com AHRQ Agency for Healthcare Research & Quality. Strengthen Patient Care by Reducing Hospital Acquired Pressure Ulcers (HAPU) 47