Wendy Abbott, NPI; Jean Addis, ANIV; Jewel Almazan, ANI; Barbara Bratton, NP; Irwin Chew, RN; Kristy Clabby, RN; Angela Collins, RN; Carol Costello, RN; Shelley Diane, CNS; Patricia Dillon, RN; Mara Durkin, RN; Monica French, RN; Cynthia Fialho, RN;
Alicia Ford, RN; Courtney Gates, RN; Jerlynn Gacula-Ordaz, RN; Krista Hoffman, RN; Nancy Lee, ANI; Alexandra Lewis, RN; Linda Lefrak, CNS; Alicia Leung, RN; Ekaterina Malinovskaya, RN; Erin Matsuda, RN; Amber Mason, RN; Mary Moore, NPI; Andrea
Mostny, RN; Zynthia Natividad, RN; Julie Nishida, RN; Mary Nottingham, RN; Katie O’brien, RN; Maura O’day, NP; Ruth, Palmeri, RN; Susan Peloquin, NP; Lisa Purser, ANIV; Christine Shannon, RN; Kathryn Shannon, RN; Sarah Snyder, RN; Sonia Salinas,
RN; Lai Saephan RN; Lisa Tsang, RN; Curtis Wong, RN; Nicole Zellers, RN
Identified Problem
Reducing patient harm during hospitalizations is an
important national safety initiative. As part of this
initiative, UCSF BCH hospital has endeavored to
reduce hospital-acquired pressure ulcers (PU) to
ZERO.
In FY 2012 the BCH rate incidence rate was 0.81 and
the pressure ulcer prevalence rate was 1.68.
DEFINITIONS:
Prevalence = Percentages are calculated: [Number of
Pressure Ulcers present on Prevalence Study Day]
divided by [Number of patients reviewed on Prevalence
Study Day. Prevalence is performed quarterly.
Incidence Rates = Rates are calculated: [Number of
reported pressure ulcers] divided by [Unit Patient Days
for the month] multiplied by [1,000]
Measured outcomes
Results
• Prevalence Rates ZERO for 6 Quarters!
• Incident Rates and Prevalence rates correlate
• 40% reduction in Incident Rate
• 100% reduction in Prevalence Rate
• Improved compliance with prevention bundle
from 75 to 90% in 2 years
No more Boo-Boos
Initiative Goal
Prevent hospital-acquired pressure ulcers by reducing
prevalence by 10% in fiscal year 2014
Steps taken to enact the initiative
• Maintain a minimum of one skin champion in each unit
• Audit compliance with prevention bundle monthly
• Provide biannual BCH PU prevention/intervention class
• Review every pressure ulcer to identify gaps for
improvement in care especially device related pressure
ulcers
• Recommend changes and additions to skin care products
• Complete PU prevalence study quarterly
Sustaining the Change
• Maintain stakeholder commitment: RN, RT, MD,
Families/patients
• Continue to complete PU prevalence study quarterly
• Continue to provide biannual BCH PU
prevention/intervention class
• Continue to analyze each occurring PU
• Develop electronic record PU risk report
• Continue to improve audit tool and audit
performance
• Continue to evaluate new skin/wound care products