UC DAVIS HEALTH
EVIDENCE-BASED PRACTICE

Pressure Ulcer Project
East 5 HAPI Project

Monica Brauer RN, Ka Cheung BSN RN, Anna Marie P. Ebreo BSN CRRN, Lisa Eller MSN CRRN, Chery Leslie BSN RN, Christina Madrona BSN CRRN, Amy Negus BSN CRRN, Aster Sahillu BSN CRRN, Victoria Smith MSN RN, Jacqueline Wicks BSN RN

 
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POSTER - #PI1044

Pressure Ulcer Project - East 5 HAPI Project

Monica Brauer RN, Ka Cheung BSN RN, Anna Marie P. Ebreo BSN CRRN, Lisa Eller MSN CRRN, Chery Leslie BSN RN, Christina Madrona BSN CRRN, Amy Negus BSN CRRN, Aster Sahillu BSN CRRN, Victoria Smith MSN RN, Jacqueline Wicks BSN RN
UC DAVIS HEALTH - EVIDENCE-BASED PRACTICE

Background
East 5 Rehab had its first Hospital Acquired Pressure Injury (HAPI) event in 17 years this fall. In October 2019, a 21-year-old male spinal cord injury patient acquired a pressure ulcer on his right ischial tuberosity and subsequent ulcers on bilateral soles. The Rehab Professional Governance (PG) Council analyzed potential causes associated with this HAPI and contacted the Rehab team for input and collaboration at our December 2019 meeting. Dr. Holly Kirkland-Kyhn and Alex Bonson OT, also met with our council to discuss resources for preventing future HAPI.

Purpose
The purpose of our project was to prevent HAPI events on East 5 Rehab. Hospital acquired pressure injuries are a significant source of morbidity, increasing treatment cost and impact performance metrics associated with reimbursement.

Design & Methods
Our PG Council collaborated on a comprehensive evaluation strategy requiring a pre and post survey to determine current awareness and utility of HAPI resources. A pre-survey was collected from all East 5 Rehab nurses, not currently on PG council. A post- survey was implemented following intervention to determine proficiency and understanding.

Analysis
(View poster)

Implementation Plan
The PG Council educated and implemented use of a .dot phrase. This documentation is included in the nurse's assessment and required for all patients with Braden score of 13 or lower, or those at high risk for pressure injury. A series of in-services were scheduled with a waffle mattress representative for training on its proper use. The representative planned to demonstrate pressure mapping to show the effectiveness of the waffle mattress for preventing HAPI. This was later adapted to a video instruction for staff.

Action
(View poster)

Performance Data
Pre-survey
86% Believe a .dot phrase would be helpful for charting on patients at risk of decubitus ulcers.
36% Believe waffle seat cushions are more effective than Rojo cushions in preventing decubitus ulcers.
13% Know how to effectively use a waffle mattress.
Post Survey
100% Believe a .dot phrase would be helpful for charting on patients at risk of decubitus ulcers.
94% Understand waffle seat cushions are more effective than Rojo cushions in preventing decubitus ulcers.
82% Know how to effectively use a waffle mattress.

Conclusions & Further Study
Our post-survey showed that the in-services increased the nurse's understanding that the waffle seat cushions are more effective than Rojo cushions in the prevention of decubitus ulcers and the nurse's knowledge on how to effectively use a waffle mattress.

Future plans
Future plans include development of a job aid with educational media and video links. Plans also include further consultation with waffle mattress representatives to provide ongoing support and educational materials.

References
1. Kirkland-Kyhn, Holly, et al. "Caring for Aging Skin." AJN The American Journal of Nursing 118.2 (2018):
60- 63.
2. Chou, Roger, et al. "Pressure ulcer risk assessment and prevention: a systematic comparative effectiveness review." Annals of Internal Medicine 159.1 (2013): 28-38.

Funding & Acknowledgements
Thank you to Alex Bonson, OT, Dr. Holly Kirkland-Kyhn, and Joe Ginilo from EHOB for assistance with the in-services. 

Creative Commons License
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

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