Section 7. Tools and Resources (continued)

Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care

5A: Unit Log

Background: The main purpose of this tool is to summarize the results of the daily comprehensive skin assessments for pressure ulcers on all patients. The form can be completed by registered nurses and nursing assistants.

Reference: Developed by Boston University Research Team.

Instruction: Complete the form for all patients with information on the number of pressure ulcers present and the stage of the deepest ulcer. Use the standardized skin inspection form, using one form for each month.

  1. On the first of each month list the current unit census.
  2. When a patient is discharged:
    • From the facility, write DC and draw a line from the last day to the end of the month.
    • Within the facility, write the room number transferred to and draw a line through the remainder of the month.
  3. When a patient is admitted:
    • Add the name to the sheet.
    • Draw a line from day 1 to the date patient was admitted to the unit.
  4. A patient may be on any unit multiple times during a month.
    • Treat each time the patient leaves as a discharge or transfer.
    • Treat each time a patient is readmitted to a unit as a new admission.
  5. Record each day the results of the comprehensive skin assessment. Include whether the patient has an ulcer, the number of different ulcers, and the stage of the deepest ulcer.

Use: At the end of the month, use this log to calculate your pressure ulcer prevalence and incidence rates. Examine the rates and identify trends over time. Share the results with your unit staff and administrative leadership. For all Stage III and IV pressure ulcers, consider doing a root cause analysis to find out what led to their occurrence.

Unit Log

Month   Days            
Patient NameAdmission DateAdmission NumberRoom Number12345678910111213
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 

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5B: Preventing Pressure Ulcers Data Tool

Background: This tool can be used to measure key processes of care by abstracting medical records data.

Reference:Adapted from materials available at the Montana Rural Healthcare Performance Improvement Network Web site. Available at: http://www.mtpin.org/index.php?p=documents&category_id=118&lp=archivedstudies&lcat_id=20.

Instructions: Complete the form by following the case inclusion and exclusion criteria outlined below:

  • Cases to Include:All inpatients admitted to the unit
  • Cases to Exclude: All newborns and hospice patients; all patients with a length of stay (LOS) less than 24 hours (observation less than 24 hours, same day surgery, emergency department and other ambulatory care patients).

Use: Use the reviewed data to evaluate key processes of care, such as performance of the daily comprehensive skin assessment or individualized care planning. Define a performance target for each key process and analyze if that target is met. Share the findings with the unit staff and leadership.

Date: ______________________________
Unit: _____________________________ MR# Number: ________________

1. Date of admission (mm/dd/yy): ______ - ______ - ______

2. Admitted to:             _____ acute care ____ obs > 24 hr _____ intensive care _____ swing bed  
_____other (STOP ABSTRACTION; not a qualifying case)

3. Admitted from:        _______ home   ______ LTC or SNF facility   ______ assisted living facility
_______ other acute care hospital   ______ other

4. Length of stay (LOS):  _____ equal to or greater than 24 hours; LOS in days = _______ days
_____less than 24 hours (STOP ABSTRACTION)

5. Did the patient receive a facility-approved pressure ulcer risk assessment within 24 hr of admit?
____ No (skip to question 9)
____ Yes

6. Does the risk assessment tool include a Braden Scale or modified Braden Scale score?
_____ No
_____ Yes

7. Was the patient identified on admission as being at risk for pressure ulcer development?
_____ No
_____Yes; complete the following table:

QuestionAnswer
For at-risk patients, are the following interventions documented:YesNo
a. Consult to wound team  
b. Skin inspected daily  
c. Patient repositioned every 2 hours or 'up ad lib'  
d. Pressure redistributing device in place within 24 hours of risk identification  
e. Nutrition assessment completed within 24 hours of risk identification  
  • Nutrition assessment includes dietary consult
  
  • Nutrition assessment includes admit and weekly weight recorded
  
f. Provider orders special diet within 24 hours of risk identification  
g. Barrier cream applied if moisture issues identified  
h. Information given to patient and family  

8. Was the patient identified on admission as being at low risk for pressure ulcer development?
_____ No
_____Yes; complete the following table:

QuestionAnswer
For patients with low risk on admission, was the following completed?YesNo
  • Documentation of daily skin inspection
  
  • Documentation of risk assessment daily
  

9. If the patient did not have a pressure ulcer identified on admission, did the patient develop one or more pressure ulcers during the hospital stay?
____ Ulcer present on admission
____ No
____ Yes; stage(s)___________________; complete the following table:

QuestionAnswer
For patients developing pressure ulcer during this admission, are the following interventions documented as completed?YesNo
a. Provider notified of pressure ulcer prior to end of shift  
b. Consult to wound team  
c. Skin inspected daily  
d. Patient repositioned every 2 hours or "up ad lib"  
e. Pressure redistributing device in place within 24 hours of risk identification  
f. Nutrition assessment completed within 24 hours of risk identification  
  • Nutrition assessment includes dietary consult
  
  • Nutrition assessment includes admit & weekly weight recorded
  
g. Provider orders special diet within 24 hours of risk identification  
h. Barrier cream applied if moisture issues identified  
i. Provider order for wound care on the chart within 24 hours of notification  
j. Wound care implemented as ordered  
k. Pressure ulcer assessed for healing, worsening as ordered  
l. Patient and family notified of skin problem  

12. Was the patient discharged with one or more pressure ulcers? 
____ No
____ Yes; stage(s)___________________

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5C: Assessing Comprehensive Skin Assessment

Background: This sample protocol illustrates how to evaluate the performance of a comprehensive skin assessment.

Reference: Developed by Boston University Research Team.

Sample protocol for assessing performance of comprehensive skin assessment

  1. Take a sample of records of patients newly admitted to your unit within the past month. As few as 10 records may be sufficient for initial assessments of performance.
  2. Identify medical and nursing notes from the first 24 hours of hospitalization. These should include the admission nursing assessment, physician�s admission note, and subsequent nursing progress notes.
  3. Determine whether there is any documentation of a skin examination. This might include mention of any lesions or specific mention that none are present.
  4. Determine how comprehensive the initial skin assessment was. Is there specific mention of all five dimensions of the assessment: temperature, color, moisture, turgor, and whether skin intact.
  5. Calculate the percentage having any documentation of skin assessment as well as having a comprehensive exam.

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5D: Assessing Standardized Risk Assessment

Background: This sample protocol illustrates how to evaluate the performance of standardized risk assessment.

Reference: Developed by Boston University Research Team

Sample protocol for assessing performance of standardized risk assessment

  1. Take a sample of records of patients newly admitted to your unit within the past month. As few as 10 records may be sufficient for initial assessments of performance.
  2. Identify nursing notes from the first 24 hours of hospitalization. This should include the admission nursing assessment, subsequent nursing progress notes, or any notes specifically documenting pressure ulcer risk assessment.
  3. Determine whether there is any documentation of the completion of the standardized risk assessment. This may include a Braden Scale, Norton Scale, or other system. Completion should be indicated by the assignment of an actual score.
  4. Calculate the percentage having the actual score completed.

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5E: Assessing Care Planning

Background: This sample protocol illustrates how to evaluate the performance of care planning.

Reference: Developed by Boston University Research Team

Sample assessment of care planning performance

  1. Take a sample of records of patients newly admitted to your unit within the past month who have an abnormal standardized risk assessment. As few as 10 records may be sufficient for initial assessments of performance.
  2. For each patient, determine on which dimensions of the standardized risk assessment there was a score that was not normal.
  3. Identify the care plans prepared shortly after admission.
  4. Determine whether each abnormally scored dimension of the standardized risk assessment is addressed in the care plans.
  5. Calculate the percentage of abnormally scored dimensions of the standardized risk assessment that are addressed in the care plan.
Page last reviewed April 2011
Internet Citation: Section 7. Tools and Resources (continued): Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. April 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcertoolkit/putool7c.html