Hospital-acquired Pressure Ulcer Project

Hospital-acquired Pressure Ulcer Project

This is an individual assignment. Using your assigned case study, create the action plan components of your QI project using the Indicator Worksheet.* After your fishbone diagram (i.e., cause-effect diagram) is created, you will identify items to be changed. List these as steps or key pieces that your clinical practice guideline or systematic review suggests be in place to improve outcomes (i.e., indicators) in “process or indicator” column. In the “what data will be collected” column, identify how you will measure the change (e.g., audit, documentation in system, etc.). Under “plan for improvement,” take out each indicator and create plan by identifying 1) what the indicator is; 2) why it is key for improving outcomes; 3) operational definition; 4) numerator/denominator for ratio/percentage; 6); data collection method, and 7) goal for indicator (this is not the outcome; it is specific to indicator, a benchmark; for example, 100% compliance). Hospital-acquired Pressure Ulcer Project


These are components that must completed as part of your final QI Report of Project. Together, these tasks directly relate to course objective “use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems.”

*item found in QI Project Resources

You should include the following:

  • Submit completed Indicator Worksheet
  • Example of how to do the tables:

All patients on med-surg unit B with a catheter in place will have the type of catheter documented in their chart.

Numerator: Patients in unit B with a silver tipped catheter in place.

Denominator: All patients in unit B with a catheter in place.

The benchmark is 100% compliance, 0 CAUTIs

The intervention table could look something like the following:






And so on…

Silver tipped catheter


Document type of catheter inserted in each patient

The evidence shows that the silver tipped catheters have less risk of infection

When patient is admitted to unit


Because there is a well-established, significant body of evidence demonstrating best practices for CAUTI prevention, we know that there are other interventions besides insertion of silver tipped catheter to be considered. Your case studies also contain nursing problems for which a well-established body of evidence exists in support of best practices. Do the above steps for each intervention that you identify.

Structure or Process Indicators

List the steps or key pieces that your clinical practice guideline or systematic review suggest that should be in place to improve outcomes (these become your indicators): Hospital-acquired Pressure Ulcer Project

Process or Indicator What data will be collected

Plan for Improvement

Indicator: ____________________________________________________________________________________________________

This is key to improving outcomes because:

Operational definition:



Data collection method


Goal for this indicator:


Our HAPU rates on Unit A have risen significantly over the past 6 months. We have a Wound and Skin Care Nurse (WSCN) who has training in wound care. This nurse does not have a Master’s degree or specialty certification in this area but does have a lot of experience. The Wound and Skin Care Nurse is scheduled to work from Monday through Friday, 8a-5p. The WSCN nurse visits every unit and asks about each of our patients. If we identify someone as having a red spot or a potential area of breakdown, we let her know during her rounds.

The WSCN visits patients daily if they are on a computer-generated list of patients at risk for skin breakdown. The list is created when a box is checked in the computerized charting skin assessment area that asks if the patient is on bed rest or is unable to move independently. If a ‘yes’ is checked then the patient’s name is automatically placed on the list. In addition, the computerized Braden Scale is added to the patient’s documentation. The WSCN downloads the list every morning. If someone is identified at risk during the day shift the WSCN does not know about it until the next day.

The WSCN spends a lot of time on our unit. We sometimes have a problem when a patient needs to be seen by the WSCN but do not appear on the list. The nurses do not see the list, only the WSCN nurse. Our current process is to perform the Braden Scale upon initial admission assessment, then once a day if the patient is noted to be at risk, usually during the midnight shifts. The information is entered into the electronic chart (documentation system). We can track the patients’ progress and see what treatments are given to the patient. For the most part, the WSCN does all the treatments unless we are given specific instructions about an individual patient. We are not aware of what evidence supports any of the treatments. Because we have a WSCN, the direct care nurses are not familiar with how to care for the patient with skin breakdown unless the WSCN provides specific directions. We need to know what the best practices are for caring for a patient with a HAPU, including nurse driven care versus what the WSCN does for the patient.

Hospital-acquired Pressure Ulcer Project