Why do so many patients develop bedsores – painful pressure ulcers that are hard to heal and often become infected – while under the watch of caregivers?
A special team at the University of Mississippi Medical Center charged with exploring reasons for that hospital-acquired condition, or HAC, came up not just with the scope and causes of the problem, but workable solutions.
“We discovered early on that pressure ulcers are much more complex and complicated than turning a patient every two hours,” said Dr. Janet Harris, professor of nursing and associate dean for practice and community engagement. “And when we really started digging, we saw a lot of heel pressure sores. Our bed frames were old, and patients were rubbing their heels on the frames.”
UMMC is purchasing new bed frames, instructing nurses to prop up patients’ ankles with pillows, pushing the assessment of patients at high risk for ulcers to front-line staff and strengthening collaboration between unit nurses and nurses specializing in wound care.
It’s just one example of aggressive measures to reduce the incidence of HACs so that patients aren’t in harm’s way. Stepped-up documentation, a renewed increase in caregiver and patient education, redoubled vigilance by administration, and added emphasis on shared accountability and responsibility are combining to improve quality of care and patient safety.
As UMMC awaits new financial penalties for patient harm from the federal Centers for Medicare and Medicaid Services, administrators are continuing efforts to pinpoint lapses in patient care and treatment protocol. The initiatives not only identify where the hospital must do a better job, but shine a light on those delivering exemplary care.
Every Tuesday morning at 9, more than two dozen administrators and managers gather in the conference room down the hall from the office of Kevin Cook, chief executive officer of the adult hospitals.
They review a long checklist of quality-control and safety concerns, broken down by category and hospital floor or unit: A door to an external stairway is propped open. A TV on a tall stand is unsafe. A ceiling is leaking.
A few minutes later, checklists in hand, they divvy up into a half-dozen teams and fan out to every floor in University Hospital. The information they gather from talking to frontline nurses and staff will be rolled into an overall unit scorecard issued once a month.
“I can walk into a unit, and they can tell me when they had their last (patient) fall,” Harris said. “They can tell me all of the details with each and every patient.
“Our goal for this year is to be below the expected number of HACs for our patient population. Our goal next year is to be 50 percent below that. Our goal is zero HACs, so we’re chasing zero.”
Teams are in place to focus on not just pressure ulcers, but other serious HACs, including central-line and urinary catheter infections.
“We have a relentless focus on HACs,” Harris said.
When Dr. Elham Ghonim, director of infection prevention, arrived at UMMC in 2009, she was surprised at how many patients had urinary tract infections caused by catheters. It didn’t take her long to trace the problem.
“When I found out how many patients had Foleys (a common catheter) without a doctor’s order for it, I said, ‘No wonder our infection rate is so high,’” Ghonim said. “Now, nurses must wait for a physician to order a Foley.”
A weekly “Safe Journey” meeting takes place “to ensure that patients have a safe journey, with no HACs, during their stay here,” Harris said.
“We go through every incident from the previous week and discuss what the predisposing factors are. For the most part, we’re finding issues with the process more so than with staff causing patient harm.”
For example, she said, if a patient arrives at UMMC with a urinary catheter already inserted, staff has a certain timeframe by which they must test the patient to see if he arrived with an infection.
“If we don’t do that in time, we get dinged for causing that infection,” she said.
Administrators are stressing best-practice guidelines, said Dr. William O. Cleland, recently retired chief medical officer. “How we insert a central (IV) line should be the same for every patient, with strict adherence to the best guidelines.”
Another example, he said, is protocols to reduce the risk of patient falls.
“During admission, patients are given an assessment of their fall risk,” he said. “If it’s high, several things start to happen and a lot of nursing decisions kick in.”
That includes placing alert signs on a high-risk patient’s door, placing the patient on the floor where he or she can be best monitored, and using bed alarms for patients instructed to ask for help before leaving their beds.
Before a surgery, Cleland said, there’s a mandatory “time out” to give full attention to rigorous adherence to procedure. HACs such as surgery on the wrong limb or leaving instruments inside a patient’s body, while rare, should never happen.
“Everyone in the room stops and focuses on everything happening with the patient: marking sites for surgery, making sure patient consent forms are in order,” Cleland said. “We get input from everyone in the room before an incision is made. This has to be done, and it’s highly monitored.”
Documenting standardized, validated data is allowing UMMC to track information on HACs and their frequency. It’s the same information trail used by CMS to measure a hospital’s performance and quality, and to differentiate between patient harm occurring in a hospital and harm that occurred before the patient got there.
Said Dr. John Showalter, assistant professor of medicine and chief medical information officer: “It’s going to allow us to see where our problems are and to address them at the level where it will make a difference, which is at bedside.”
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