Improving Identification and Documentation of Pressure Ulcers at an Urban Academic Hospital

Abstract

A two-year quality improvement campaign at a teaching hospital was launched to improve the identification and accurate documentation of pressure ulcers (PUs) after the Centers for Medicare & Medicaid Services (CMS) changed reimbursement regarding hospital-acquired PUs. The campaign consisted of (1) reference materials, (2) new documentation templates, (3) staff education, and (4) hospitalwide mattress replacement. The campaign significantly increased the proportion of PUs completely documented by nurses from 27% to 55% following mattress replacement and resident education (odds ratio [OR] 3.68; p = .001; 95% confidence interval [CI]:1.68-8.08). A similar improvement was observed for physician documentation, increasing from 12% to 36% following the same interventions; however, this change was not statistically significant (OR 2.11; p = .12; 95% CI:0.82-5.39). These improvements were short-lived because of the implementation of electronic medical records (EMRs) for nursing notes. Although the percentage of PUs completely documented by nurses decreased following EMR implementation, it increased in the following months to above the precampaign baseline as nurses adapted to the new documentation system. However, after EMR implementation, complete PU documentation by physicians decreased to a nadir of 0% and did not recover. A multicomponent campaign to improve the quality of PU documentation by both physicians and nurses can yield positive gains. However, these improvements were short-lived because of EMR implementation, which acutely worsened documentation of PUs. This emphasizes the importance of frequent and repeated interventions to sustain quality improvement successes.