Spotlight on Comanche County Memorial Hospital’s Pressure Injury Prevention Program
Posted on: 12/20/19
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| Jay Johnson (right), OHA board chairman, presents an Excellence in Quality Award to Comanche County Memorial Hospital leaders Debbie Cofer, RN, BSN, CPHQ, administrative director of quality (left); and Rebecca Luscher, RN, BSN, WSC (center). Other Wound Care Team members not pictured are Kristina Kriz, RN, BSN, and Tania Huitt, RN, WCC. |
Over the next several weeks, the Clinical Initiatives Corner will feature each of the Excellence in Quality Award submissions to highlight and share successful quality initiatives. Each week, we will describe how the problem was identified, the improvement goal(s), interventions and outcomes. Please feel free to use this information, duplicate interventions, and share with your staff.
The 2019 Excellence in Quality Award in the 101-300 bed category was presented to Comanche County Memorial Hospital, Lawton.
Debbie Cofer, RN, BSN, CPHQ, administrative director of quality, submitted the following information about the hospital’s Pressure Injury Prevention Program.
Identifying the Problem: Patients were developing pressure injuries during their hospital admission, resulting in unnecessary pain, suffering, and potential hospital acquired condition penalty.
The Goal: Decrease hospital acquired pressure injuries by 50% in a year on all hospital units from January 2018 to present.
- Reduce the number of Hospital Acquired Pressure Injuries (HAPI) within the facility by:
- Developing and utilizing a nurse-driven protocol based on the Braden Scale, and
- Hospital-wide mattress replacement with pressure reducing mattresses.
Interventions:
- Nurse-driven policy incorporating Braden Scale assessment was created;
- Surface audit of all hospital bed mattresses conducted, new mattresses researched and ordered.
- Teaching literature and posters displayed on each unit;
- Team coordinated with materials department to order, maintain stock and provide prevention products on each unit;
- Ongoing education plan created and conducted for direct care staff.
The Outcome:
- Incidence of hospital acquired pressure injuries decreased hospital wide from 37% in first quarter 2018 to 0.8% in second quarter 2019.
- “Never events” (defined by Medicare as stage 3, stage 4, and unstageable pressure injuries for which cost for treatment is not reimbursable by Medicare) were decreased by 57% in calendar year 2018.
Comments: The Pressure Ulcer Prevention Program is an ongoing project, incorporating teamwork, strategic planning for mattress replacement, and sustainability through ongoing training and monitoring.