​​​​​​Image of a Toronto Western Hospital team
The 4 Fell team marked a milestone: 30 days without a patient on their unit developing a pressure ulcer.  (Photo: Saverina Sanchez)

To most, it's simply the smell of pizza. But for one UHN team, it's also the scent of success.

At general internal medicine unit 4 Fell at Toronto Western Hospital, the care team recently held a pizza party to celebrate 30 days without any of their patients developing a pressure ulcer.

Pressure ulcers, also known as bedsores, are painful skin wounds that damage skin and muscle, slowing recovery. They are caused by pressure, friction and moisture, and develop when patients have fragile skin, poor circulation and don't move enough. Studies have found between 15 and 30 per cent of patients have pressure ulcers.  There's no data showing how many develop in hospitals, but any clinician will tell you they do.

Saverina Sanchez, clinical manager for 4 Fell, attributes her team's success in limiting the development of pressure ulcers to three factors: measurement, education and daily huddles.


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A look at how employing LEAN quality improvement is helping Toronto Western Hospital staff reduce the incidence of pressure ulcers among its patients

LEAN, a quality improvement methodology that identifies and eliminates waste to improve workflow, reduce costs, and deliver better value to customers, was used in this process. UHN is one of Canada's first health care institutions to apply the principles of LEAN to benefit patient care.

Measurement was the first step. The team had to know how often pressure ulcers were occurring and what was causing them. They put up a calendar and marked days green when new ulcers didn't develop and red when they did. A separate bar graph tracked causes, showing the team where to focus its efforts.

Education sessions, both formal and informal, helped break down professional silos. Patient care assistants are often responsible for bathing patients, so when they received pressure ulcer training they became instrumental in catching skin breakdowns early and alerting nurses.

But the big improvements came from daily huddles.

"We make sure everyone on the team knows which patients have pressure ulcers, and who is at risk during huddles," said Sanchez. "That's incredibly important because patients have different nurses every day — caring for them is a team effort. You won't hear us saying 'your patients' or  'my patients'  because they are all  'our patients.'"

"At first, the huddles seemed onerous but everyone sees the value in them now," said Kanika Russell, a registered nurse at Toronto Western. "It's an opportunity to hold each other accountable for doing our skin exams every day, but also for sharing ideas. One of our patients right now has a cast on his leg that's hard on his skin, so we brainstorm different techniques to try every day and we see what works. It's the best possible environment for learning."

The team's streak was broken by an unlikely culprit. ​​The plastic tubing for oxygen caused a pressure ulcer where it hooked behind a patient's ears.

"We weren't expecting that, but it was a learning opportunity," said Sanchez. "Now we're aware of the risk, and we can watch for it. Knowing those tubes can be a problem will help us get to 40 days."

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