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Decreasing pressure ulcer risk during hospital procedures: a rapid process improvement workshop.

Authors
  • Haugen, Vicki
  • Pechacek, Judy
  • Maher, Travis
  • Wilde, Joy
  • Kula, Larry
  • Powell, Julie
Type
Published Article
Journal
Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society / WOCN
Publication Date
Jan 01, 2011
Volume
38
Issue
2
Pages
155–159
Identifiers
DOI: 10.1097/WON.0b013e31820ad0fd
PMID: 21326117
Source
Medline
License
Unknown

Abstract

A 300-bed acute care community hospital used a 2-day "Rapid Process Improvement Workshop" to identify factors contributing to facility-acquired pressure ulcers (PU). The Rapid Process Improvement Workshop included key stakeholders from all procedural areas providing inpatient services and used standard components of rapid process improvement: data analysis, process flow charting, factor identification, and action plan development.On day 1, the discovery process revealed increased PU risk related to prolonged immobility when transporting patients for procedures, during imaging studies, and during the perioperative period. On day 2, action plans were developed that included communication of PU risk or presence of an ulcer,measures to shorten procedure times when clinically appropriate, implementation of prevention techniques during procedures, and recommendations for mattress upgrades. In addition, educational programs about PU prevention were developed, schedules for presentations were established, and an online power point presentation was completed and placed in a learning management system module. Finally, our nursing department amended a hospital wide handoff communication tool to include skin status and PU risk level. This tool is used in all patient handoff situations, including nonnursing departments such as radiology. Patients deemed at risk for ulcers were provided "Braden Risk" armbands to enhance interdepartmental awareness.

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