Background • Process to determine why a problem happened in the first place, so it wont happen again • Correcting the symptom alone is a waste of resources • Be aware of bias – Intentional and unintentional
• Finding the root of the problem is not easy work – But if the latent source of the problem can be found you can get rid of the problem 2
Starting with the pressure ulcer • Is this wound a pressure ulcer? – Was it due to pressure? – Was it due to shear?
• Is this wound on a previously healed PrU? • When was this wound discovered? – What size, stage, location? – Due to a medical device? On mucous membrane?
• What was risk score – Was it accurate? – Did a prevention plan stem from the score?
Determining the timing of the ulcer development • Stage at time of initial discovery – Stage I --- likely began in last 12-24 hours – DTI --- purple tissue without epidermal loss likely began 48 hours ago • Important because – you might not have had this patient 48 hours ago – Turning may have been impossible » OR cases
– Stage II --- likely began in last 24 hours – Stage III-IV --- began at least 72 hours ago
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Examine the location of the ulcer at discovery • Pressure ulcers skin on top of buttocks cleft • Patient was supine at time of pressure – This is a DTI that occurred in the OR
Ulcer location • This patient’s head was elevated when pressure applied – DTI nearer to sacrum
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Location of pressure ulcer • This patient was lying on his side when DTI developed – Ulcer on the side of heel
RCAs continued • If due to pressure, what preventive practices were carried out? – Turning? How often? What angle was the patient off the surface? • If the patient could not be turned was the surface upgraded?
– Were heels elevated? Was elevation continuous? – Was the surface upgraded due to high risk? • Was the patient turned regardless of the surface? • Is the surface working?
– Was the patient repositioned hourly in a chair? • Was a chair cushion used? • Was the cushion working?
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RCAs continued • If due to microclimate… • Was the skin kept clean and dry? – Was incontinent urine and stool quickly removed? • Was the method of skin cleansing nonabrasive? • Was the skin protected against next exposure?
– Was the skin moisturized? – Was an incontinent brief removed for several hours each day? – Was a low air loss or microclimate surface used?
RCAs continued • If due to shear… • Was the body areas subjected to shear protected? – Dressings on sacrum in HOB up patients? – Padding in chair if patient slouches or is in recliner chair
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RCAs continued • If due to protein calorie malnutrition – Was the patient hydrated and fed at the dietician’s recommendations? • • • •
Were supplements consumed? Was swallowing addressed? If not, was the deviation explained? E.g., Advanced Directives
Looking at Human Roots • Difficult aspect– beware of bias • Consider competing priorities – What is the unit of origin • Predominately in ICU? – How many actually started in OR? ER?
A closer look at hemodynamic instability • Defined as volatile blood pressure and/or oxygen saturation with movement – It is not simply the use of vasopressive meds – Concerns arise when document shows patient moved for diagnostics or care, but cannot be turned • Can turning be done slowly? • Can heels be elevated?
– Was surface upscaled to reduce pressure, shear and microclimate? – When on lateral rotation surface • Was patient turned at all? • Did bed do all the turning?
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Human Factors • Educators spend little • Leads to stripe time on bedside care appearance to pressure ulcers – Do not expect new grads to be able to along buttocks “see” when a patient cleft can be turned or “how” to actually turn the patient
• If hospital pillows are thin, when combined with inadequate turning…
Considering Nonadherence • Pressure ulcer prevention must become a lifestyle for some patients – Find ways to help them adapt
• If nonadherence is present – Document it factually – Document what you told them and what they did – Be certain your awareness of nonadherence and the documentation appears in the record before the ulcer starts
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Using RCA data • Classify as quality improvement to reduce discovery • Use the location and stage at discovery to find the timing of the ulcer – What was happening to patient at that time? • Was pressure ulcer prevention possible? • If yes, was it carried out? Documented?
What are the latent roots in your pressure ulcer prevention system? • Over reliance on beds – Creating narrow ulcers along gluteal cleft
• PrU prevention not a priority – “We are saving lives, we can’t worry about skin” – Under appreciation for seriousness of ulcers
• Lack of expectation for complete skin assessment – Ulcers beneath medical devices – Ulcers found at more advanced stages 20
