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Marlyn Conti , BSN, MM, CPHQ Patient Safety Initiatives Manager Intermountain Healthcare PowerPoint PPT Presentation


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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

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Marlyn Conti , BSN, MM, CPHQ Patient Safety Initiatives Manager Intermountain Healthcare

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Marlyn conti bsn mm cphq patient safety initiatives manager intermountain healthcare

Intermountain-led CMS Hospital Engagement Network Pressure Ulcer PreventionJune 24, 2014 Affinity Call

Marlyn Conti , BSN, MM, CPHQ

Patient Safety Initiatives Manager

Intermountain Healthcare


Outline for discussion

Outline for Discussion

  • Review of the HEN Pressure Ulcer work

  • “Just-one-thing” Recommendations

  • High performers

  • 2014 plans for improvement:


Overall progress through q1 2014

Overall Progress Through Q1 2014


Intermountain hen 2012 q1 2014 pressure ulcer psi 3

Intermountain HEN 2012-Q1 2014 Pressure Ulcer PSI 3


Intermountain hen 2012 q1 2014 pressure ulcer psi 31

Intermountain HEN 2012-Q1 2014 Pressure Ulcer PSI 3


Intermountain hen 2012 q1 2014 pressure ulcer stage 3

Intermountain HEN 2012-Q1 2014 Pressure Ulcer >= Stage 3


Intermountain hen 2012 q1 2014 pressure ulcer stage 31

Intermountain HEN 2012-Q1 2014 Pressure Ulcer >= Stage 3


Intermountain hen 2012 q1 2014 pressure ulcer stage 2

Intermountain HEN 2012-Q1 2014 Pressure Ulcer >= Stage 2


Intermountain hen 2012 q1 2014 pressure ulcer stage 21

Intermountain HEN 2012-Q1 2014 Pressure Ulcer >= Stage 2


Intermountain hen 2012 q1 2014 pressure ulcer prevalence

Intermountain HEN 2012-Q1 2014 Pressure Ulcer Prevalence


Intermountain hen 2012 q1 2014 pressure ulcer prevalence1

Intermountain HEN 2012-Q1 2014 Pressure Ulcer Prevalence


Just one thing matrix recommendations

Just One Thing MatrixRecommendations


High performing hospital highlight pressure ulcer psi 3

High Performing Hospital Highlight…Pressure Ulcer PSI 3


High performing hospital highlight

High Performing Hospital Highlight…

Pressure Ulcers >= Stage 3


High performing hospital highlight1

High Performing Hospital Highlight…

Pressure Ulcers >= Stage 2

  • *Most Improvement

    • Only 2 Hospitals have

      Reported Q1 2012 and

      Q 1 2014 data


High performing hospital highlight2

High Performing Hospital Highlight…

Pressure Ulcers Prevalence – All stages


Practice survey

Practice Survey

  • Do you have a pressure ulcer prevention team? Yes/No

    • If yes, Is your team multidisciplinary? Yes/No

    • If yes, how frequently do they meet?

    • Do they have resources to collect/interpret/review data?

      • Comments (free text)

  • What tools do you use to assess and properly stage a pressure ulcers? (free text)

    • Posters, fact sheets, etc, other (free text)


Practice survey1

Practice Survey

  • Do you have skin and/or pressure ulcer assessment prompts embedded in your EMR? Yes/No

    • If yes, how often are they reported or prompted

      • Who receives the reports

      • What are the expected actions

    • To determine if reassessing patients at established frequencies

  • What is the one intervention that has had the most impact in reducing pressure ulcers? (free text)

  • What is the most innovative approach to reducing pressure ulcers?


Pressure ulcer scenario

Pressure Ulcer Scenario

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??


Pressure ulcer scenario1

Pressure Ulcer Scenario

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.

  • What this preventable?

  • What would you have done??


2014 plans for improvement

2014 plans for improvement

  • Collect and share best practices across our network hospitals & system in a single document

  • Share practice bundles?


  • Login