Running Head: PREVENTING HAPU

Quality Improvement Process: Hospital-Acquired Pressure Ulcer Prevention

Tyler Nickels
Ferris State University

PREVENTING HAPU

Quality Improvement Process: Hospital-Acquired Pressure Ulcer Prevention

Quality management and improvement is an essential part in nursing.
These processes are set in place to provide better, more effective patient
care, improve quality care of patients and to improve patient and staff safety.
Yoder-Wise (2015) defines quality improvement as, an ongoing process of
innovation, prevention of error, and staff development that is used by
institutions that adopt the quality management philosophy (p. 362). Quality
improvement is evaluated and analyzed often, usually monthly to determine
how effective the process is. Changes will be made as needed to help reach
the goal of the process. The quality improvement process being introduced is
to prevent hospital-acquired pressure ulcers (HAPUs).
Clinical Need
Pressure ulcers are acquired from reduced blood flow to the skin, if
remaining in one position for an extended length of time, they can also be
acquired from friction, rubbing or sheering of the skin. Pressure ulcers are
grouped by severity stage I is the earliest stage, while stage IV is the worst.
Stage IV presents with fullthickness tissue loss with exposed bone, tendon,
or muscle (Hinkle, 2014, p. 171). Stage IV is difficult to heal and often
packed with gauze and/or a wound vacuum. According to Padula, (2015)
HAPUs are expensive, In the United States, costs for HAPUs range from
$500 to $70,000 per patient, totaling an estimated $11 billion annually
(p.246). Medicare will not be responsible for theses payments if the pressure
ulcer is acquired within the hospital and a stage III or higher. The hospitals

PREVENTING HAPU
are then responsible for these payments; this is done to promote
improvement in the health care system (Health care purchaser toolkit: Hospital
acquired condition payment policy, 2009). It is important to reposition patients to
prevent pressure ulcers. Developing a quality improvement process for
HAPUs will improve patient care and prevent any related comorbidities.
Interdisciplinary Team
A team of nurses, nurse techs and a manager will be developed
on the unit to prevent ulcers acquired within the hospital. Representatives of
nutrition, physical therapy and occupational therapy will be included to help
educate staff and determine most effective way to prevent HAPUs. There will
be two nurses for the day shift and two for the night shift along with a nurse
tech on each shift. The purpose for having nurses and nurse techs on each
shift is to implement and encourage the prevention of HAPUs for both shifts.
The nurse manager has an important role in this team. They will be
responsible to guide the teams in collaborating and to communicate with
staff on the unit, meeting with the staff on progress of improvement set in
place, sharing benchmarks with other units, communicates performance
priorities, and uses data to measure effectiveness of improvement (YoderWise, 2015, p. 365). Having a well-established team of nurses and
communicating with the manager is important in implementing change to a
units process.
Data Collection

PREVENTING HAPU
Gathering data regarding the quality improvement process is important
in determining what changes need to be made. The team will perform
monthly skin audits to evaluate any presence of pressure ulcers acquired on
the unit. An article in The Joint Commission Journal on Quality and Patient
Safety discusses process measures for determining the percent of pressure
ulcers present on admission, percent of patients reassessed daily, percent of
at-risk patients, and the percentage of patients identified being at risk who
are at risk (Duncan, 2007, p. 609). Measuring these develops an
understanding of who is at risk or has a pressure ulcer on the unit. The team
will also be responsible for determining if staff is providing appropriate
interventions to prevent HAPUSs.
Yoder-Wise (2015) provides methods used to analyze and present
include flow charts, line graphs, histograms, Pareto charts, and fishbone
diagrams (p. 369). A flow chart will be developed to better assess staging.
After the team completes auditing, it will be gathered and a line graph will be
created for every month for each process measure. The results will be shared
at the staff meetings and posted in the break room for staff.
Standard of Care
After data is collected a goal will be determined to improve the process
reflecting on evidence-based care, it is to involve a standard of practice and
a measureable patient-care outcome (Yoder-Wise, 2015, p. 369). Having zero
HAPUs is the goal to strive for but meeting this goal requires a standard of
care and staff to adhere to it. The overall goal of this improvement process is

PREVENTING HAPU
to improve the quality of patient care, to do this adherence of staff and
implementing it onto the unit is a must. To meet this, the staff is to complete
an assessment on patients, using a risk scale of pressure ulcers, and prevent
and manage pressure ulcers using the most evidence-based practice.
Implementation Strategies
Agency for Research and Quality (AHRQ) is an organization that works
within the U.S. Department of Health and Human Services to provide latest
evidence based care to improve the safety of health care. AHRQ has
developed recommendations to best care for patient and prevent HAPUs.
These recommendations will be integrated into the standard of care for
quality improvement in HAPUs. Conducting an assessment is the most vital
aspect of preventing HAPUs. AHRQ developed a guideline, Pressure ulcers:
prevention and management of pressure ulcers (2014), which recommends using a risk
assessment scale; the one to be used will be the Braden Scale. Duncan
(2007) discusses using six strategies to implement in preventing pressure
ulcers, these included conducting a pressure ulcer assessment on admission,
daily reassessment for all patients, inspect skin daily, manage moisture,
optimize nutrition and hydration, minimizing pressure (p. 606-608). This
process is educated to all nursing staff on the unit when orienting to
establish the most effective teaching tool. The nursing team will be
responsible for implementing these six prevention methods to staff on the
unit. Implementing these strategies will help to reduce pressure ulcers,
Brunner & Suddarths Textbook of Medical-Surgical Nursing (2014) educates

PREVENTING HAPU
on interventions for pressure ulcers, these include relieving pressure,
positioning the patient, using pressure relieving devices, improving mobility,
improving sensory perception, improving tissue profusion, improving
nutritional status, reducing friction and shear, minimizing irritating moisture
and promoting pressure ulcer healing (p. 170-173). Many interventions are
included in patient care as a part of the nursing process. The nursing team
involved in the quality improvement process will determine if these
interventions are being implemented on the floor.
Evaluation
The nursing team will evaluate the interventions being implemented
on the unit to ensure they are being met, if they are not met there will be
revisions made for the implementations. Data gathered monthly will
determine how well unit staff and department representatives are impacting
the outcome. The manager of the unit is responsible for publicizing the
success of the quality improvement team when change is implemented
successfully met (Yoder-Wise, 2015, p. 374). The manager is also responsible
for evaluating how effective the team has worked together in this process.
Conclusion
Patient care is the center of all quality improvement processes. As this
one presented is the same, preventing pressure ulcers. To best prevent
pressure ulcers a team is to be developed and implement strategies to the
care of patients with a risk for pressure ulcers. These strategies will be
evaluated on a monthly basis to determine the effectiveness and further

PREVENTING HAPU
implementation may be needed. Proper implementation and evaluation will
lead to reducing the number of HAPUs on the unit and may lead to change of
quality improvement process in a hospitals system, thus improving the
quality of patient care throughout the organization.

References
Duncan, K. (2007). Preventing pressure ulcers: The goal is zero. The Joint
Commission Journal on Quality and Patient Safety, 33(10), 605-610.
http://www.in.gov/isdh/files/Preventing_PU_The_Goal_is_Zero_article.pdf
Health care purchaser toolkit: Hospital acquired condition payment policy. (2009). In National
Business of Coalition Health . Retrieved July 31, 2015, from

PREVENTING HAPU
http://www.nbch.org/nbch/files/ccLibraryFiles/Filename/000000001630/HAC
%20Payment%20Policy%20Toolkit%20(final%20version)%20081109.pdf
Hinkle, J., Cheever, L. (2014). Brunner & Suddarths textbook of medicalsurgical nursing. New Delhi, India: Wolters Kluwer.
Padula, W., Makic, M., Mishra, M., Campbell, J., Nair, K., Wald, H., Valuck, R.
(2015). Comparaitve effectiveness of quality improvement
interventions for pressure ulcer prevenetion in academic medical
centers in the United States. The Joint Commission Journal on Quality
and Patient Safety, 41(6), 246-256.
Pressure ulcers: prevention and management of pressure ulcers. (2014). In Agency for
Healthcare Research and Quality. Retrieved July 31, 2015, from
http://www.guideline.gov/content.aspx?id=48026&search=pressure+ulcer#Section434
Yoder-Wise, P.S. (2015). Leading Managing in Nursing (6th ed.) St. Louis, MO:
Elsevier