• Courtney Vose, Robert X Murphy, David B Burmeister, Charlotte Buckenmyer, Carolyn L Davidson, Tami J Meltsch, Ginger Holko, Elizabeth Karoly, and Bernadette Glenn Porter.
• Patient Care Services, Lehigh Valley Health Network, Allentown, Pennsylvania, USA. Courtney.Vose@lvh.com
• Jt Comm J Qual Patient Saf. 2011 Mar 1;37(3):131-7.

BackgroundPressure ulcers (PUs) are a critical concern, endangering patients and requiring significant resources for treatment in Stage II/IV. The Centers for Medicare & Medicaid Services (CMS) denies reimbursement in cases where a more complex diagnosis-related group (DRG) is assigned as a result of hospital-acquired conditions such as a PU that could have been reasonably prevented.ImplementationAn interdisciplinary PU present-on-admission (POA) team developed an algorithm to support the early identification of PUs for units participating in the process. This approach standardized work, resulting in consistent (1) skin assessment, (2) physician notification, (3) reporting of findings in the patient safety reporting system, and (4) communication to receiving units. Computer-entry tools were developed and completed for six months by the patient care services unit-based process improvement councils; these councils made possible immediate "loop closure" for either positive feedback or needed reeducation with the nursing staff.ResultsThe total number of PUs recognized and reported after implementation of the process improvement initiative--from April 1, 2008, to March 31, 2009--increased to 1,103--an increase of 36.3% in PU reporting when compared with the same period the year before. This initiative has yielded 100% effectiveness in identifying Stage III/IV PUs POA and in preventing hospital-acquired Stage III/IV PUs. The success of the project has helped to ensure high-quality patient care and protection of precious fiscal resources.ConclusionsThe data suggest that the identification of all PUs that are present at time of admission is clinically feasible.

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