The growing frequency of pressure ulcers presents healthcare organizations with a considerable dilemma. Reports estimate that prevalence rates for these ulcers surpass 15% of hospital inpatients, and incidence rates range between 7% and 10%. 1 Moreover, "nearly 60,000 U.S. hospital patients are estimated to die each year from complications due to hospital-acquired pressure ulcers, and the average hospital incurs between $400,000 and $700,000 in annual direct treatment costs for hospital-acquired pressure ulcers." 1 Finally, "costs to heal pressure ulcers have been reported from $2,000 to $70,000 per wound," and conservative totals estimate the national cost for treatment between $1.3 and $3.5 billion annually. 2,3
These increasingly high prevalence and incidence rates may illustrate decreased attention to the prevention of pressure ulcers in the healthcare industry, particularly in acute care settings. As the majority of these wounds are preventable, higher figures in an institution may suggest poorer standards of care. Perhaps the increased use of modern technology in recent years has caused caregivers to overlook traditional standards of care, such as frequent patient repositioning. Moreover, a belief that pressure ulcers are unavoidable in debilitated or elderly populations may have permeated common practice. Regardless of the reason, several agencies have included reduction of these rates among their top priorities. Specifically, the American Nurses Association (ANA), as well as the Agency for Healthcare Research and Quality (AHRQ), have established new guidelines designed to better prevent and treat these wounds.
As a result of this revitalized interest in pressure ulcer treatment, OSF Saint Francis Medical Center (SFMC) initiated the implementation of the Six Sigma procedure-a process that allows for increased focus on developing and delivering near-perfect products and services-into its daily operations. 4 SFMC is a 710-licensed bed, multisite, not-for-profit facility located in Peoria, Ill. The facility serves a 37-county area, is Magnet designated, and is a teaching hospital/research institute for the University of Illinois College of Medicine. Further, SFMC offers a Level I trauma center, a full-service emergency department, and admits over 25,000 patients annually.
By incorporating Six Sigma methodologies into SFMC's treatment process, investigators hoped they could improve treatment methods and reduce further incidences of pressure ulcers. This undertaking ultimately led to the development of the Save Our Skin (SOS) project, an effort that boasted an ambitious goal of reducing the number of hospital-acquired pressure ulcers in adult patients by 50% within one fiscal year.
Six Sigma methodology
Created first by Motorola in the 1980s, then popularized by Allied Signal and General Electric (GE) in the 1990s, Six Sigma has proven its worth to organizations seeking to improve productivity, profitability, and quality. 5 According to Six Sigma methodologies, by measuring the number of defects in a process, it's possible to determine systematically the means to eliminate them. 5 Achievement of Six Sigma quality entails that a process produces no more than 3.4 defects per million opportunities, which are defined as a "chance for nonconformance, or not meeting the required specifications." 5
Needless to say, healthcare delivery involves a multitude of contributing factors, which result in a high degree of variation. Subsequently, this variation leads to patient dissatisfaction and increased costs. Therefore, the Six Sigma methodology is an appropriate tool to reduce human variation in a particular process and significantly reduce the amount of unacceptable outcomes. 6 Through a data-focused, decision-making process, Six Sigma utilizes a systematic five-phase, problem-solving process called DMAIC, which entails:
1. Defining the problem and critical customer requirements (CCR).
2. Measuring the performance of identified CCRs.
3. Analyzing the problem to find root causes and determine which have the most impact.
4. Improving the situation by initiating change.
5. Initiating measures to sustain improvements made for long-term control.
While Six Sigma quality may be difficult to achieve in healthcare processes, implementation of the DMAIC problem-solving methodology has proven beneficial in many institutions. Given the clinical and financial costs associated with pressure ulcer development, prevention becomes a likely candidate for Six Sigma attention.
Improvements in cost, performance
The business case developed around the adoption of Six Sigma involved a review of fiscal year 2001 SFMC occurrence reports, which indicated 92 cases of hospital-acquired pressure ulcers. Moreover, an incidence study completed in August/ September 2001 noted that 9.4% (N=265) of the patients assessed on Day 1 were found to have hospital-acquired pressure ulcers, and 10% (N=100) had developed pressure ulcers 6 days later. The medical center's estimated additional cost per case was $3,037.00, and the additional overall cost related to pressure ulcer development was $4,877,000.00. Considering these figures, a reduction in the number of hospital-acquired pressure ulcers by 50% to 5% (3.15% Sigma Level) would reduce overall costs by $2,438,000.00.
In addition to cost savings, project developers anticipated significant improvements in patient satisfaction, length of stay/quality, staff awareness of skin integrity issues, and risk management issues. Further, use of the methodology would provide staff, physicians, and managers experience with the new improvement process, as well as create a quality improvement project for staff to discuss and implement in individual units and departments.
In fall 2001, a pressure ulcer prevalence-incidence study, using Nursing Care Quality Initiative (NCQI) guidelines, was conducted at SFMC. Within this context, prevalence is a 1-day "snapshot" count of hospital inpatients with pressure ulcers, whereas incidence is a count of the patients that developed pressure ulcers over the hospital's average length of stay. Throughout the course of this study, the following information was obtained (N=284):
[white diamond suit] Pressure ulcer prevalence was equal to 13%.
[white diamond suit] Sixty-nine percent of patients assessed didn't have documentation of breakdown upon admission.
[white diamond suit] The majority of hospital-acquired pressure ulcers were located on the coccyx, sacrum, and heels.
[white diamond suit] Staff wasn't consistently implementing prevention interventions.
[white diamond suit] The process of getting specialty beds was inefficient and confusing.
[white diamond suit] The medical record process didn't truly reflect pressure ulcer volume.
All of the aforementioned results proved that even with a certified wound/ostomy/continence nurse, staff educational offerings, a skin care policy/protocol, daily skin risk assessment, and the ability to order specialty beds, there was still significant room for improvement in the medical center's prevention and treatment of pressure ulcers.
An analysis of SFMC's pressure ulcer prevalence-incidence study indicated that 9.4% of hospital-acquired pressure ulcers found in the medical center's patient population were due to various contributing factors. Most notably, these factors included incomplete initial skin assessments, underutilization of the existing skin care protocol, incomplete ongoing skin risk assessments, unavailable/incomplete activity orders, and patients not being turned. As a result, Six Sigma team members further validated three specific root causes-accountability, knowledge deficit, and communication deficit.
Identifying potential solutions
Given an internal assessment of the medical center's performance with respect to pressure ulcers, as well as the potential underlying causes, Six Sigma leaders set out to establish a project scope. It was determined that this would include all inpatient adults over age 17, specifically address hospital-acquired pressure ulcers, and begin at admission and end at discharge. Initial gap analyses of incidences of pressure ulcers at SFMC indicated 9.4%/1,606 cases (2.81% Sigma Level); therefore a goal was set at 5%, or 854 cases (3.15% Sigma Level).
Prior to developing solution components, project leaders began considering "quick win" scenarios. As a result, 140 pressure-relieving hospital replacement static air mattresses were distributed among six units, including the neurology ICU and general, orthopedics, intermediate medical-surgical, rehabilitation, and urology. Units were selected based on their close proximity to one another, a higher concentration of decreased mobility patients, and the fact that their pressure ulcer incidence rates were considerably higher than the overall medical center figure.
The mattress is a nonelectric powered, pressure-relieving system that maximizes body weight displacement and minimizes tissue interface pressure. Moreover, it utilizes horizontal air cylinders that allow finer adjustments for enhanced pressure relief, sloped heel sections to reduce heel breakdown, and a multidirectional stretch cover to reduce shear and friction. As a result of purchasing the specialty mattresses, SFMC decreased rental costs by over $100,000, and pressure ulcer incidence decreased by 4% on the units identified (approximately 7% to 11%).
Once the aforementioned quick win was realized, project leaders developed and implemented a five-point solution to the overall problem of hospital-acquired pressure ulcers. This solution was based on identified root causes and benchmarked/evidence-based best practices including, but not limited to, Agency for Health Care Policy and Research Clinical Practice Guideline Number 3 (Pressure Ulcers in Adults: Prediction and Prevention), and the National Pressure Ulcer Advisory Panel. 7 The execution of this solution marked the advent of the medical center's SOS program, which helped to facilitate the solution options detailed in the scenarios listed below:
Solution #1
As surgical patients are under anesthesia for extended periods, they have an increased risk of developing pressure ulcers; therefore, a mechanism was established to ensure that all operating room (OR) patients (i.e., preoperative, intraoperative, post-anesthesia care unit) receive a skin risk assessment. All OR patients are categorized according to risk group to increase care-giver focus on intervention and in turn prevent skin breakdown. Specific processes include:
-Preoperative nurses complete a preoperative skin risk assessment to identify at-risk patients, and complete a skin assessment to identify pre-existing pressure ulcers on admission. An SOS sticker is placed on the at-risk patient's chart to communicate to the intraoperative nurse that intervention is required.
-Intraoperative nurses develop interventions appropriate for the identified patient (i.e., "position aids" to reposition patients and thereby offset pressure on bony prominences) and communicate to the post-anesthesia care unit (PACU) nurse the patient's risk and status. PACU nurses continue to assess at-risk patients and communicate their status to the appropriate floor nurse.
Solution #2
Next, the medical center revised its Skin Breakdown Prevention Protocol, which had been lacking in attention to prevention and wasn't user friendly. The following components were implemented:
-Additional hospital replacement static air mattresses were purchased to decrease caregiver confusion as to which mattress was most appropriate.
-Special music is played over the in-house paging system once every 2 hours to remind caregivers that their patients must be turned. This revision was selected based on benchmark research with other successful institutions.
-SOS signs are placed outside of at-risk patients' rooms as a reminder for caregivers.
-Premoistened, disposable barrier wipes are used to help cleanse, moisturize, deodorize, and protect patients from perineal dermatitis due to incontinence.
Solution #3
The third solution involved the creation and distribution of an easily accessible pressure ulcer "pocket guide" for staff, which contained an abbreviated version of the protocol with helpful tips clearly outlining pressure ulcer prevention methods, as well as moisture management and other general care issues.
Solution #4
Next, an SOS champion was designated for each nursing unit. Typically a staff RN or patient care technician, this person acts as a resource for skin breakdown prevention, and coordination of process control efforts with the unit manager. Additionally, unit SOS champions serve on a "house-wide" team (co-chaired by two certified wound and ostomy care nurses) that meets monthly to evaluate and trial new products for skin care, discuss prevention issues and improvements taken from unit experiences, review quarterly prevalence-incidence results, and attend ongoing educational sessions regarding skin integrity. Lastly, SOS champions are responsible for ongoing data management, which consists of:
-Medical record review for all incidents of pressure ulcer development to determine whether they were avoidable.
-Monthly audit of patient charts when Braden Scale score is 16 or less to ensure compliance with the Skin Breakdown Prevention Protocol.
-Quarterly survey and report of pressure ulcer incidence and prevalence for the designated unit.
-Distribution of quarterly pressure ulcer data to all nursing unit managers, directors, and nurse administrators, allowing staff unfettered access to medical center outcomes.
Solution #5
The last solution implemented by SFMC involved the redefinition of specific roles and responsibilities for the unit "process owners," charge nurses, RN staff, and patient care technicians/nursing assistants. Ultimately, the RN staff is accountable for the prevention of pressure ulcers; however, unit managers are considered process owners, responsible for ensuring compliance, as well as outcomes and the achievement of unit targets for pressure ulcer incidence. Moreover, if quarterly targets aren't met, the process owners and SOS champions are responsible for outcome improvement action plans.
Monitor performance
Once improvements have been made and results documented, it's necessary to continue measuring performance of the process routinely, adjusting operations when data clearly indicate it or when the patients' requirements change. This being the case, project leaders implemented a sophisticated measurement plan in furtherance of the overall project goals. (See "Control phase measurement plan components.")
In recent years, there's been an emphasis on the modern technical aspects of nursing care; however, this project is a direct attempt to refocus efforts on traditional direct nursing patient care. Results proved that by putting Six Sigma methodologies and its subsequent Save Our Skin program into practice, SFMC decreased pressure ulcer incidence by nearly 70%, and increased prevention efforts. Nonetheless, while awareness of pressure ulcer prevention has increased and incidence has decreased because of this project (see line graph), the overall culture change at the medical center remains a work in progress. Therefore, pressure ulcer incidence continues to be a measurement used in organization-wide scorecards and staff bonus programs. As part of a multihospital system, the medical center's improvements have also served as an example to sister facilities, thereby encouraging pressure ulcer incidence to become a systemwide quality indicator.
REFERENCES