When Audrey Gudmundsson, manager of medical services, started on the medical floor at St. Charles in 2013, the unit was averaging seven stage III hospital-acquired pressure ulcers—also known as bed sores—each year.
“It was a problem for this unit,” Gudmundsson said, not only because the hospital wasn’t being reimbursed by Medicare for treatment related to these cases, but also because it meant patients may not have been getting the best care.
“We were a big contributor to hospital-acquired pressure ulcers—the HAPUs—in the organization,” she said. “Being one of the largest units in the hospital with a high-risk population, we have a great opportunity to impact those conditions.”
Gudmundsson was determined to tackle the problem head-on. But first, she had to find out where the HAPUs were coming from and why they were occurring. Were patients actually acquiring this condition in the hospital? Or did they already have it upon admission? Her research revealed it was the latter.
“Essentially we were acquiring them from other units or facilities, but we got dinged for them because we weren’t doing a skin assessment upon admission,” she said. “They already had skin breakdown (usually only stage II), but it wasn’t being properly documented.”
The medical unit gets the majority of its patients—about 90 percent—from the Emergency Department, while a small percentage are direct admissions from doctor’s offices or transfers from the IMCU or ICU.
The medical unit could dramatically reduce its HAPUs, Gudmundsson theorized, by simply performing skin assessments on all of its patients and performing the appropriate documentation within 24 hours so the condition would not be considered hospital acquired.
So Gudmundsson asked charge nurses to team up with the floor nurses to perform full skin assessments on every patient admitted to the unit. But with an average of 14 patients admitted per day, the workload quickly became overwhelming. Skin assessments, as a result, weren’t being performed on every patient, and HAPUs were being missed.
“We started out too broad,” said Gudmundsson, who received her IHI Open School training after this first cycle of process improvement. “We realized we needed to shrink it down and do a small test of change.”
For her second cycle of process improvement, Gudmundsson and her team zeroed in on just the patients who were transferred from the IMCU or ICU.
Narrowing their focus reduced the patient load significantly—to about three to five patients a day—making it possible for the nursing teams to successfully perform skin assessments on 100 percent of the designated patients.
“We were catching all of the transfers,” she said. “We were finding multiple HAPUs on admissions and contacting physicians in the appropriate amount of time. Our HAPUs dropped significantly, from an average of eight stage II cases a month to three.”
However, to get the number of stage II HAPUs to zero, or close to, the unit’s nurses would still have to find a workable way to perform assessments on all admissions. This led to the development of a team approach, in which two floor nurses pair up to conduct skin assessments together.
“That’s when we really saw our rates decrease,” Gudmundsson said, with the monthly average number of stage II HAPUs dropping to one; for stage III cases, there were often none at all.
In the third cycle, Gudmundsson and her team focused on using Braden risk scores to better identify patients who were considered high risk for developing pressure ulcers, and proactively working to prevent them.
The fourth cycle, the final cycle, was focused on sustainment. For a year and a half, the medical unit has not had a stage III HAPU, which Gudmundsson credits to the IHI methods for process change and sustainment.
Incorporating the IHI concept of “small tests of change” into her approach to process improvement helped Gudmundsson more narrowly focus her initiatives, and to speed up the process of evaluating the results and making adjustments.
With the first cycle, she said, “we went too big for too long—that’s when we really got the information that we were missing the mark. Consequently, that’s when the IHI concepts really took hold for me.”