Intermountain-led CMS Hospital Engagement Network Pressure Ulcer Prevention June 24, 2014 Affinity Call. Marlyn Conti , BSN, MM, CPHQ Patient Safety Initiatives Manager Intermountain Healthcare. Outline for Discussion. Review of the HEN Pressure Ulcer work
Marlyn Conti , BSN, MM, CPHQ
Patient Safety Initiatives Manager
Pressure Ulcers >= Stage 3
Pressure Ulcers >= Stage 2
Reported Q1 2012 and
Q 1 2014 data
Pressure Ulcers Prevalence – All stages
9 M/O female infant with congenital anomalies requiring tracheostomy with an un-cuffed trachplaced. Secretions were very difficult to manage and the MD indicated that re-intubation would be ‘impossible’ for this baby.
Trachties were very tight in order to hold the tube in place.
The first trach change was performed 7 days after the initial placement and a stage IV pressure ulcer was found from the trach ties.
What could have been done??
40 Y/O male, admitted with altered level of consciousness related to hepatic encephalopathy, hypotension and abdominal ascites. Patient had several large volume paracentesisperformed with rapid re-accumulation of fluid.
The decision was made by the physician and the patient's mother to provide comfort measures only and the patient was transferred to inpatient hospice. 4 days after hospice transfer, a stage III pressure ulcer was found on his coccyx.