Under Pressure - Efforts to Reduce Hospital Acquired Bed Sores

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Clinical PI

Thomas Best
Quality Analyst
University of Chicago Medical Center

Follow an academic medical centers journey to enhance the prevention, diagnosis, and treatment of pressure ulcers. The results of innovative technological and educational improvements are presented, along with many poignant lessons the multidisciplinary team learned throughout the clinical performance improvement process.

This presentation describes significant efforts at the University of Chicago Medical Center (UCMC) to enhance the prevention, diagnosis, and treatment of pressure ulcers. Before the project began, these activities were ripe for clinical performance improvement. For example, 2007 baseline data suggested that only 47% of patients received a timely skin assessment upon admission. Other aspects of pressure ulcer care and prevention were also in need of sustainable improvement.

To address these deficiencies, a multidisciplinary team of physicians, nurses, and clinical quality analysts brainstormed and implemented various interventions. The team implemented standardized wound care methods and documentation in late 2007. Starting in late Spring of 2008, they researched and implemented new patient support surfaces throughout all adult care centers. In light of a national focus on pressure ulcer prevention, the team also assessed the increased bed days for patients with pressure ulcers, as well as the cost effectiveness of care improvements. Quality improvement techniques such as affinity diagramming and root cause analysis will be demonstrated in their application to clinical quality improvement. The presentation will conclude by sharing the results and sustainability of the interventions, as well as the lessons learned by the team.