Acute Myocardial Infarction (AMI) Core Processes​	Infection Prevention: Surgical Site Infection (SSI)​
Catheter-Associated Urinary Tract Infection​	Medication Reconciliation (Prevent Adverse Drug Events)​
Central Line Bundle​	Pressure Ulcer Prevention​
Falls Prevention​	Rapid Response Systems​
Governance and Improvement​	Surgical Safety Checklist​
Hand Hygiene​	Surgical Complications​
Heart Failure Core Processes​	Venous Thromboembolus (VTE)​
High-Alert Medication Safety​	Ventilator Bundle​
Infection Prevention: MRSA​	​

 

 

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Use this table to quickly find a mentor for the prevention of pressure ulcers with demographics similar to your own, or use 'ctrl+f' in your web browser to search for specific key words on this page.

 

 

Name	Location	Teaching	Urban / Rural	Pediatric	Bed Size
Baystate Medical Center	Springfield, MA	Teaching	Urban	no	636
Claxton-Hepburn Medical Center	Ogdensburg, NY	no	Rural	no	129
Hazleton General Hospital	Hazleton, PA	no	Urban	no	150
Holy Spirit Hospital	Camp Hill, PA	no	Urban	no	320
Morristown Memorial Hospital	Morristown, NJ	Teaching	Urban	no	588
The Nebraska Medical Center	Omaha, NE	Teaching	Urban	no	548
OSF Saint Francis Medical Center	Peoria, IL	Teaching	Urban	no	710
Onslow Memorial Hospital	Jacksonville, NC	no	Rural	no	162
Owensboro Medical Health System	Owensboro, KY	no	Rural	no	400
Robert Wood Johnson University Hospital at Rahway	Rahway, NJ	no	Urban	no	275
Sherman Health	Elgin, IL	no	Urban	no	250
Trinitas Regional Medical Center	Elizabeth, NJ	Teaching	Urban	no	341

 

 

Baystate Medical Center – Springfield, MA
Availability Status: Available to answer requests
Licensed Beds: 636
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: January 1995
Mentor Contact Name: Stephanie Calcasola

Mentor Contact Email: Stephanie.Calcasola@baystatehealth.org
Mentor Contact Phone: 413-794-2531

 

Additional Information:

 

Sustained assessment completion on admission rates = 100%

 

 

 

 

 

 

Mentor designation - 3/13/07
Information updated - 6/10/11

 

 

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Claxton-Hepburn Medical Center - Ogdensburg, NY
Availability Status: Available to answer requests
Licensed Beds: 129
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: January 2004
Mentor Contact Name: Karen Cole, RN, BSN, CDE, WOCN
Mentor Contact Email: kcole@chmed.org 
Mentor Contact Phone: 315-393-3600 ext. 5337

 

 

Additional Information:

The Braden at-risk assessment is completed on admission and every 12 hours. The screen to complete is automatically added to the care plan and compliance is not an issue. In 2012, we are working with the Emergency Department to complete this on patients who are being admitted to earlier identify patients who need pressure ulcer prevention measures.

Our intensive care unit has 100% pressure redistribution beds; acute Rehab Unit has about 50% and Med/Surg 50%. The nurse manager has budgeted for additional pressure redistribution mattresses for 2012 and plans to work towards all beds having pressure redistribution mattresses over the next 5 years.

See raw data and prevalence rate info.

Top five factors contributing to the success of our pressure ulcer prevention strategies:

1. Materials management supervisor who puts the patient above profit: Over the last three years, we have been able to make all of our beds in the intensive care unit pressure redistributing mattresses and have added 5-10 new pressure redistribution mattresses and pumps in our med/surg units and Acute Rehab unit. Devices for off-loading heels and gel cushions for chairs have been purchased and staff always have enough pillows to position patients.

2. Administative support: Senior management has supported staff to use rental services for specialized mattresses as needed and supported the role of the certified WOCN to provide education and monitor effectiveness of processes.

3. Physicians have become involved in the process and are assessing skin breakdown and have increased their knowledge base for its prevention and treatment. Having a wound care center has increase the number of physicians who are knowledgeable about modern wound care treatments and they have provided grand rounds for the physicians on pressure ulcer prevention and management.

4. Direct care staff has a low turnover rate and many of them have come from Nursing Home backgrounds and their awareness of pressure ulcer prevention is high.

5. Having a WOCN on staff dedicated to the tracking and management of pressure uclers that is located on the medical surgical unit allows for accessiblity for evaluations early in the admission process or during the hospital stay to initiate or evaluate treatment and prevention strategies.

With the increase in awareness of pressure ulcer prevention, the process has now come to involve all levels of staff from the physician, nursing staff and support staff and these staff members are now involving family members in the process. 
 
Explanations for turning schedules and off-loading are part of daily care. Families are now more aware of the processes and are more involved with staff in accomplishing these goals. Changes in documentation support patient and family education and are included in the pressure ulcer prevention protocols. Most of our skin breakdown has been identified to have occurred with patients on hospice and so we will include family education in this group in our goals for 2012.

 

All patients have the Braden Risk Scale completed on admission and every 12 hours thereafter.  New flow chart documention now allows the nurse to see this information over a course of days allowing for easier identification of changes in status.  Changes in documentation now also allows the WOCN to view all patients on the units risk on one screen.

 

All beds in the ICU now have a pressure redistribution mattress with pumps.  Over the last 3 years, 20 beds with pressure redistribution mattresses have been placed on our med/surg and acute rehab units, including one that is suitable for bariatric patients.  Off loading of heels has become routine for all bed-ridden patients.

100% of patients admitted to ICU, ARU, and med/surg had Braden Scores completed on admission and daily.

 

With the increase in awareness of pressure ulcer prevention, the process has now come to involve all levels of staff from the physician, nursing staff and support staff and these staff members are now involving family members in the process. 

 

Explanations for turning schedules and off-loading are part of daily care.  Families are more aware of the processes and are more involved with staff in accomplishing these goals.  Changes in documentation support patient and family education and are included in the pressure ulcer prevention protocols.

 

Mentor designation - 7/7/07
Information updated - 4/10/12

 

 

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Hazleton General Hospital – Hazleton, PA
Availability Status: Available to answer requests
Licensed Beds: 150
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: May 2004
Mentor Contact Name:  Andrea Andrews, RN, Director of Quality/Case Management
Mentor Contact Email: aandrews@ghha.org
Mentor Contact Phone: 570-501-4744

 

Additional Information:

Keys to success:

 

Implementation of an Interdisciplinary Skin and Wound Team has been instrumental in helping Hazleton General achieve success.  Members of the team include RNs, LPNs, dieticians, physical therapists, home care RNs, medical staff, and our Wound Ostomy Nurse chairs the meeting.  Each nursing unit has an RN or LPN on the team.  These nurses have been trained by the Wound Ostomy Nurse to act as a resource person on each unit, deal with questions, and offer pressure ulcer prevention strategies and consultation on skin and wound care.  All staff nurses have been educated, but these resource nurses receive additional monthly education and feedback regarding their unit PI measures.  These resource nurses and the Wound Ostomy Nurse also then share information with the staff on the units.

 

Our certified Wound Ostomy Nurse offers mentoring, guidance, and consultation for staff in addition to direct patient care.

 

Staff buy-in, administrative support, and physician involvement were also keys to our success, as well as collaboration with ancilllary departments.

Key Challenges:

 

Elderly population - Our wound and ostomy nurse communicates with skilled nursing facilities when patients are admitted to try to maintain similar wound care, unless otherwise indicated.

 

Have mainly RNs and LPNs do the turning and repositioning of these compromised patients.

 

If a patient is at risk for pressure ulcers with a Braden scale of 18 or less, the staff addresses skin integrity issues on the plan of care.  Nursing interventions include inspection of skin, every shift, proper management of moisture and cleansing of skin, nutritional iterventions, turning and repositioning every 2 hours, use of support surfaces as indicated, and heels elevated from bed surface while in bed.

 

If a patient does have a pressure ulcer on admission, correct wound care is ordered as based on wound assessment.

The wound and ostomy nurse is consulted on all patients at risk for pressure ulcers on admission.  The patient is screened to assure correct interventions are in place and ongoing. The wound and ostomy nurse also assesses and recommends wound care on all patients admitted with pressure ulcers.

 

All patients receive pressure ulcer admission assessment, utilizing the Braden scale.  This is also assessed on every shift.  If a pressure ulcer is present on admission, wound photos are taken with measurements documented.  Wound and skin assessments are done each shift.

 

If a patient is noted to be at risk for pressure ulcers, skin integrity is addressed on the plan of care.  Interventions for the at-risk patient include the following five components: 1) Daily inspection of skin for pressure ulcers; 2) Proper management of moisture, including both cleaning and moisturizing skin; 3) Optimization of nutrition; 4) Repositioning every two hours; and 5) Use of pressure-relieving surfaces.  However, skin inspection is done on every shift as opposed to daily. 

Percent of Patients Receiving Daily Pressure Ulcer Risk Reassessment:
100% of the patients receive pressure ulcer risk reassessments - this is done on every shift.

Pressure Ulcer Incidence:
Our facility uses the International Benchmarks set during HillRom's Annual Pressure Ulcer Prevalence Study. We report Facility Acquired Pressure Ulcer Prevalence in place of Incidence. In 2011, our Facility Acquired Pressure Ulcer Prevalence ranged from 1% - 3%. (This compares to a range of ​2% - 5% in 2010.) The benchmark is 5%.

 

Pressure Ulcer Prevalence:

First Pressure Ulcer Prevalence study was done in 2004. Our prevalence rate was 25%.  Our facility-acquired prevalence was 19%.  We took serious steps towards improving these rates, including mattress replacements, education on nursing assessment - especially the initial assessment - changed the risk assessment scale from Norton to Braden, and had monthly education inservices on all topics of wound and skin care.

 

We have been consistently below the national benchmark of 5% for facility-acquired prevalence since the second quarter of 2005.

 

In 2011, our Pressure Ulcer Prevalence has ranged from 6% - 10%. (This compares to a range of ranged from 9% - 19% in 2010.) The International Benchmark based on HillRom's Annual Pressure Ulcer Prevalence study is 12%. Our facility serves a population which is largely elderly, and this accounts for the higher than average prevalence rate which we see at times.

If pressure ulcer prevalence is diligently followed, the financial impact is from not having to expend more resources in caring for these patients since you are following them from admission on through discharge. Our goal at Hazleton General Hospital is the prevention of pressure ulcers.

Mentor designation - 9/23/08
Information updated - 2/13/12

 

 

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Holy Spirit Hospital — Camp Hill, PA
Availability Status: Available to answer requests
Staffed Beds: 320
Teaching/Non-Teaching Status:  Non-Teaching
Setting:  Urban
Start Date of Intervention Work: August 2007
Mentor Contact Name: Leona S. Mlynek, MSN, RN, Wound Care Coordinator
Mentor Contact Email: lmlynek@hsh.org
Mentor Contact Phone: 717-763-2428

 

Additional Information:

 

Percent of Patients Receiving Pressure Ulcer Admission Assessment:  Data is collected on a quarterly basis. Our goal of 100% has been maintained for this past year.  There had been one unit on which we had seen a pattern in missing a few Braden scores on admission.  When we investigated, we discovered the problem had to do with when the admission was completed (post-op very critical patients).  Staff was educated and the problem has resolved.

 

 

 

 

 

 

 

 

 

 

 

 

Mentor designation - 2/23/09
Information updated - 6/23/11

 

 

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Morristown Memorial Hospital – Morristown, NJ
Availability Status: Available to answer requests
Licensed Beds: 588
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: December 2005
Mentor Contact Name: Janet Munoz
Mentor Contact Email: janet.munoz@atlantichealth.org
Mentor Contact Phone: 973-971-4191

 

Additional Information:

 

Keys to our success:

1. Creation of a Pressure Ulcer Subcommittee consisting of two certified wound, ostomy and continence nurses (WOCN), quality and outcomes manager, risk manager, dietician, physician, and a team of unit-based staff nurses specially educated in wound care management - The committtee has developed specific measureable goals and reports outcomes to the Shared Governance Quality Improvement Council.

2. Development and implementation of wound care guidelines using evidenced-based practices from the National Pressure Ulcer Advisory Panel, the Wound, Ostomy and Continence Nurses Society and the AHCPR guidelines -Guidelines were incorporated into the electronic nursing documentation system. The Wound Care Guidelines were revised in 2009-2010 to incorporate the new NPUAP staging guidelines and make them more user-friendly for the staff.

3. Changing the Braden Scale Risk Assessment from weekly to daily - Definition of "patient at risk" was redefined to a score of 18 or below.

4. Development and implementation of wound care competency for professional and non-professional nursing staff -Wound care competency was posted on web-based training. Wound assessment program with a video demonstrating how to measure wounds was developed for staff to complete. In 2010, SWAT teams will test staff's knowledge about wound measurement and assessment.

5. In 2006 -2007, we purchased pressure redistribution surfaces for all medical surgical inpatient beds. In 2008, we purchased intregrated low air loss surfaces for 85% of critical care beds.

6. Development and implementation of system-wide wound, ostomy, and continence intranet site. Updated in 2010.

7. Collaboration between all disciplines on health care team to protect patient's skin - Information about pressure ulcer program is communicated to senior management on a quarterly basis using NDNQI national benchmarks for comparison.

8. Nursing unit action plans are developed based on NDNQI data and implemented with support of nursing manager, chief nursing officer, and chief medical officer.

9. Wound Care Coordinators serve as resources to their peers on the units, assist in data collection, and communicate important information to the staff about wound care. Coordinators help to develop goals and action plans for the hospital and their individual units.

10. Intensive education of the staff including nurses, physicians, residents, nursing assistants, dietary, and physical therapists - All members of the staff educated about new CMS regulations to document pressure ulcers "present on admission" (POA) in medical record. Documentation revised to reflect pressure ulcer POA status, and sticker placed on the chart with pertinent information for physician.

 

A single day point prevalence study is conducted quarterly to measure pressure ulcers.  The data was collected by two certified WOCN nurses and a team of registered nurses who were trained in data collection and skin assessment.

 

Following the data collection, HAPU were reassessed by the WOCN nurse to test data reliability.  There was no statistical difference between pre-interventions and post intervention periods in terms of age, gender ot risk assessment score.

 

The number of HAPU, all stages in period one (fourth quarter 2005 and first quarter 2006) was 11% compared to period two (second quarter 2006 and third quarter 2006) which was 4%. An additional third period reveals continued improvement HAPU all stages, ( 3rd and 4th quarter 2009) was 2.5 %, an overall improvement from first period of 77%. An improvement of 64% was seen in stage I HAPU from 6% (1st period), 2% (2nd period), and 0.9% (3rd period). HAPU stage II or higher dropped from 5% (1st period), 3% (2nd period), and 1.6% (3rd period.) From the 4th quarter 2005 to the 4th quarter 2009 there has been continued maintenance of the initial gains and gradual further improvement.

 

The New Jersey Hospital Association pressure ulcer prevention partnership in which we were involved a few years ago has evolved into the North Central New Jersey Partnership for the Prevention of Pressure Ulcers. The partnership's mission is to deliver high quality, innovative care to those patients who are at risk for the development of pressure ulcers through:

• Communication of pertinent information between agencies along the continuum of care;
• Enhancement of interagency networking between wound care professionals;
• Education of health care teams concerning pressure ulcer prevention, early identification, assessment and management;
• Community Education 

Mentor designation - 2/14/07
Information updated - 9/08/10

 

 

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The Nebraska Medical Center – Omaha, NE
Availability Status: Available to answer requests
Licensed Beds: 548
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: January 2004
Mentor Contact Name: Alan Didier, Manager, Burn, HBO & Wound Ostomy Services
Mentor Contact Email: LDidier@NebraskaMed.com
Mentor Contact Phone: 402-552-3442

 

Additional Information:

 

The following results were obtained from 4 skin surveys during calendar year 2010:
 
• Percent of Patients Receiving Pressure Ulcer Admission Assessment = 96.2%

 

 

 

 

Mentor designation - 3/17/07
Information updated - 6/10/11

 

 

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OSF Saint Francis Medical Center—Peoria, IL
Availability Status: Available to answer requests
Licensed Beds:  616
Teaching/Non-Teaching Status:  Teaching
Setting:  Urban
Start Date of Intervention Work: September 2004
Mentor Contact Name: Bevette Griffin
Mentor Contact Email: Bevette.E.Griffin@osfhealthcare.org
Mentor Contact Phone: 309-655-2659

 

Additional Information:

100% of adult patients are assessed upon admission using the Braden skin risk assessment tool and then again every 24 hours thereafter.  A complete skin assessment is performed daily.

Patients that are identified as at risk according to the Braden Assessment score are automatically put on our skin breakdown prevention protocol.

100% of adult patients are assessed daily.

Pressure Ulcer Incidence:
• Our pressure ulcer rate has gone from a baseline of 9.4% in July 2002 to 1.5% in December 2006.
• We met our target of 4% in March 2005 and remained below our target thru December 2008 when our target was changed to 2%. We have been at or below 2.5% since December 2008.

Pressure Ulcer Prevalence:

• We currently conduct our prevalence study quarterly.  All patients are assessed.  Our current prevalence is 4.1%  

 

We know that a single pressure ulcer can cost anywhere from $2,000.00 to $40,000.00.  Therefore, prevention of pressure ulcers can save substantial amounts of money.

 

Any patient found to be at risk for a pressure ulcer is given a booklet entitled "Prevention of Pressure Ulcers." This not only educates families, but gets them involved in the prevention strategies.  Families are also included in the assessment and teaching when available.

Keys to our success:

• We developed an SOS (Save Our Skin) team for every patient care unit.  Each unit has a SOS champion. 
• Process ownership/accountability was assigned to our hospital skin nurse.  This indicator is placed on the hospital and unit-specific scorecard that is reported and monitored by the professional nursing congress.
• Initially, our patients were turned every 2 hours when the "Olympic Theme Song" was played over the hospital audio system.  We then changed our music to "Roll Over Beethoven." 
• Documentation issues were addressed and documentation improved.  Pressure ulcers are reported as “Never Events” to high level committees:  Quality Safety Board, Medical Executive Committee, Professional Staff QI, Nursing Educators and Professional Nursing Congress and up to the Corporate Quality Council.
• A peer review group reviews all stage III or greater pressure ulcers to determine if the ulcer was avoidable or unavoidable.

 

Mentor designation - 3/13/07
Information updated - 4/18/12

 

 

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Onslow Memorial Hospital – Jacksonville, NC
Availability Status: Available to answer requests
Licensed Beds: 162
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: December 2006
Mentor Contact Name: Jo Malfitano MSN, MBA, RN, CPHQ, NE-BC, Performance Improvement & Accreditation Manager
Mentor Contact Email: jo.malfitano@onslow.org
Mentor Contact Phone: 910-577-2549

 

Additional Information:

 

Challenges include:
• Frontline buy-in for daily risk assessments
• Compliance with documentation changes
• Accountability for completion of assessment and documentation compliance 
• Sustaining momentum

 

Mentor designation - 8/15/08
Information updated - 7/21/11

 

 

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Robert Wood Johnson University Hospital at Rahway — Rahway, NJ
Availability Status: Available to answer requests
Licensed Beds:  275
Teaching/Non-Teaching Status:  Non-Teaching
Setting:  Urban
Start Date of Intervention Work: 1999
Mentor Contact Name: Denise Gerhab, RN, BSN, NM, WCC, Inpatient Wound Care Coordinator
Mentor Contact Email: dgerhab@rwjuhr.com
Mentor Contact Phone: 732-499-7158

 

Additional Information:

 

 

 

In November 2010, Seton Hall University's nursing instructor approached RWJUH about increasing the student nurse's awareness of skin care issues.  Research studies show pressure ulcer education in nursing school is still limited. A group of 10 senior students were part of our monthly November Prevalence study, and the students worked with committee members to assess and identify any potential skin problem that might be occurring or was present on admission to the hospital. (The article was presented/published in Advance for Nurses, in December 2010, "Exposing Pressure Ulcers: RWJUH at Rahway teams up with Seton Hall University to tackle pressure ulcers").   Each week, a student would walk a day in the Inpatient Wound Care Coordinators role to see the importance of early identification of potential skin care problems. This program expanded to 2 student nurses being assigned to the Wound Care Coordinator in the Spring 2011 semester. The goal was to educate the students with hands-on experience, and to increase their awareness of potential breakdown, whether it was from prolonged bedrest or if patient was found on the floor at home.

 

 

 

 

Mentor designation - 12/6/07
Information updated - 8/1/11 

 

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Sherman Health – Elgin, IL
Availability Status: Available to answer requests
Staffed Beds: 255
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: February 2007
Mentor Contact Name: Catherine Munoz
Mentor Contact Email: catherine.munoz@shermanhospital.org
Mentor Contact Phone: 224-783-8180

 

Additional Information:

At Sherman Health, we put a focus on reducing pressure ulcers by setting this goal as an operating plan initiative for our quality pillar. Additionally, once we achieved yearly results at or better than the national benchmark, we set an annual goal of 0%.
The Hospital-Acquired Pressure Ulcer initiative gained visibility by making it a strategic goal, aligning its performance with individual leader goals, putting resources and a bi-weekly steering team into place, making this intervention a standing agenda item on all unit meetings, posting results under quality pillar in all department communication boards. Currently, we continue to do monthly housewide incidence and prevalence surveys, reporting results to nursing leadership. Each unit champion and leader conduct fall out report and share at monthly skin champion meeting.

Current data on Percent of Patients Receiving Pressure Ulcer Admission Assessment:
4th Quarter 2011
1) % with risk assessment on admission = 99.42%
2) % with skin assessment on admission = 98.7%

Current data on Percent of At-Risk Patients Receiving Full Pressure Ulcer Preventative Care Proper pressure ulcer care:
4th Quarter 2011
1) % receiving daily skin inspection = 98.3%
2) % receiving proper moisture management = 86.5%
3) % receiving nutrition optimization = 86.8%
4) % receiving repositioning every 2 hours = 81.6%
5) % on pressure relieving surfaces = 98.3%

Current data on Percent of Patients Receiving Daily Pressure Ulcer Risk Reassessment: (risk assessmentdone in past 24 hours)
4th Quarter 2011 = 90.5%

Current data on Pressure Ulcer Prevalence:
FY 2007 (May 2006 - April 2007) HAPU Rate = 12.0%
FY 2008 (May 2007 - April 2008) HAPU Rate = 4.5%
FY 2009 (May 2008 - April 2009) HAPU Rate = 5.3%
FY 2010 (May 2009 - April 2010) HAPU Rate = 2.0%
FY 2011 (May 2010 - April 2011) HAPU Rate = 1.8%
FY 2012 (May 2011 - April 2012) HAPU Rate = 0.6%

 

Top 5 factors that contributed to our success:

1) Made Hospital-Acquired Pressure Ulcers (HAPU) and operating plan goal for the organization.  This created urgency and awareness of our HAPU practices initially
 
2) Educated staff and strengthened skills competency initially and annually
 
3) Tools/resources available:

o Bed settings
o Float heels/boots
o Gel pads in OR
o Special beds as needed
o EZ Wrap for nasal cannulas
o EMR task reminders

4) Hardwiring of hourly rounding - Nurse asking/doing 3P's (pain, position, potty). In addition, the inpatient nursing units use a number of different strategies to "hardwire" hourly rounding, including initial training, creating hourly rounding champions, validation by managers of hourly rounding logs being completed (determining hourly rounding percentages daily), observation, making hourly rounding a permanent section on patient’s white board, and otherwise continuing to reinforce its importance.
 
5) Empowering skin champion team: Each unit has a designated skin champion who does monthly prevalence study. Each unit was asked to select an RN who has a passion for skin integrity who will dedicate one day a month to doing pressure ulcer surveillance. The champions have a brief meeting before and after to go over the data and trends they are seeing. They became so passionate that they naturally wanted to talk to their other peers from their units about the data, what they are seeing, etc. They serve as a natural mentor for their units.

Skin champs empowered to drill into the "fallout" and analyze what happened if pressure ulcer was found, report out at department meetings, create education tools, and serve as owner and mentor of HAPU practice on unit.

Mentor designation - 5/1/08
Information updated - 4/25/12

 

 

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Trinitas Regional Medical Center — Elizabeth, NJ
Availability Status: Available to answer requests
Licensed Beds:  341
Teaching/Non-Teaching Status:  Teaching
Setting:  Urban
Start Date of Intervention Work: September 2005
Mentor Contact Name: Caterina Tenore, RN, MSN, CWOCN
Mentor Contact Email: ctenore@trinitas.org
Mentor Contact Phone: (908) 994-5149

 

Additional Information:

 

In September 2005, our overall compliance with the best practice "bundle" components was 70%.  Our rate for implementing "strategies" (standardized skin care products, protein supplements, etc. as detailed below) was 12%.  By July 2007, our overall bundle compliance was 88% and our rate for implementing additional strategies was 74%.  Through September 2009, we have consistently implemented the best practice bundle in all nursing areas.  We monitor compliance by random sampling in each unit and our overall compliance with the best practice bundle components is presently 95%. 

Mentor designation - 1/18/08
Information updated - 7/15/11