Leading Practice: Reduction or Elimination in Hospital Acquired NPU - Terrebonne General Medical Center


AHRMM is developing a repository for leading and proven supply chain practices, case studies, and toolkits that are developed from a Cost, Quality, and Outcomes (CQO) perspective. The following Hospital Acquired Nosocomial Pressure Ulcers (NPU) leading practice was submitted by:

Terrebonne General Medical Center, Houma, LA

Problem Statement: In 2010 Terrebonne General Medical Center’s (TGMC) hospital-wide Nosocomial Pressure Ulcers (NPU) incidence rate per 1,000 patient days was 2.69 our goal was less than 2.0. In 2011, TGMC’s organizational leaders of the governing board, medical staff, and leadership commissioned a performance improvement team to reduce the nosocomial pressure ulcer (NPU) rate occurring within the organization, overall and within the Critical Care Unit to meet the 2.0 goal.

Method: In 2011, TGMC re-organized the Wound Care nurses to report to the Infection Control Manager who reports directly to the Vice President of Nursing. Pressure ulcer prevalence and incidence data began being reported on a monthly basis to the multi-disciplinary Patient Safety Committee. Braden Scale and Pressure Ulcer prevention guidelines were placed on the hospital intranet for ease of staff use and referral.

Means: TGMC’s Nursing Products Committee reviewed the use of sacral dressings for the critical care patients. This product would prevent pressure ulcer development and assist in healing Stage II Pressure Ulcers that are present on admission. This product was trialed on the Critical Care Unit and approved for continued use. Skin cleansing wipes were also recommended and approved for use hospital-wide to treat denuded skin and prevent Stage II Pressure Ulcers due to incontinence. Pressure Ulcer prevention guidelines were changed so that as the patient was assessed for risk using the Braden Scale, the nurse had the capability to order pressure relief mattresses.

TGMC adopted the NDNQI© Pressure Ulcer Module Trainings to educate the nursing staff. These modules were added to the new nurse orientation and the annual competency education. This training was also extended to the certified nurse assistant education. The Wound Care nurse monitored documentation compliance for Braden scale, skin integrity and staging as applicable and would provide one to one education to the staff nurse and Nurse Director as needed.

Date Implemented: Re-organization of the Wound Care nurses - April 2011.
Product changes - Began in September 2011 but continued to evolve through 2013.

Outcomes: Mid 2012, nurses and certified nurse aides began rounding with the Wound Care Nurse reinforcing the importance of pressure ulcer prevention. Wound Care nurses completed an evaluation of each unit to assess the patient population and the barriers that can contribute to skin breakdown.

Nosocomial pressure ulcer incidence rates per 1000 patient days improved as noted below:

Hospital-Wide Rates

2010 2.69 Less than 2.0
2011 2.20 Less than 2.0
2012 0.86 Less than 2.0
2013 0.54 Less than 2.0
2014 0.41 Less than 2.0

Critical Care Unit Rates

2010 9.48 Less than 3.50
2011 6.74 Less than 3.50
2012 3.12 Less than 3.50
2013 2.51 Less than 3.50
2014 1.10 Less than 3.50

Cost Comparison

Product Cost Benefits
#1 Sacral border dressing $9.89 per dressing that is changed every 5 days. Prevents skin breakdown from friction shearing and maceration (incontinence).
#2 Topical cream $12.75 for 3 tubes that would be a 5 day treatment. Does not protect from friction and shearing.
#3 Topical treatment, dressing, and tape $30.40 for a 5 day supply. Used for prevention and treatment. Uses more nurse time and decreases patient comfort.

Tools: Excel spreadsheets are utilized to track nosocomial pressure ulcer rates on a monthly basis. Data is collected hospital-wide and by individual units. Internal benchmarks such as MEAN the 2nd standard deviation are used along with external benchmarks from the Hill-Rom International Pressure Ulcer Survey.

How Does Your Example Address the Issue from a CQO Perspective?

Cost - in reviewing the product options, the product that proved to be the most beneficial was also the product that was the most cost efficient for our patients.
Quality - Nosocomial pressure ulcers can decrease the quality of life for our patients. Implementing a hospital-wide nosocomial pressure ulcer prevention program has increased the quality of care provided to our patients.
Outcomes - Hospital-wide nosocomial pressure ulcer rates per 1000 patient days decreased from 0.54 in 2013 to 0.41 in 2014. The Critical Care Unit rate per 1,000 patient days decreased from a rate of 2.51 in 2013 to a rate of 1.10 in 2014.

Additional Resources:

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