Problem: As a result of a sentinel event in which a patient developed a pressure ulcer while hospitalized that resulted in a subsequent amputation, pressure ulcer development was identified as a risk at Gateway Regional Medical Center. This risk was further quantified by Prevalence and Incidence Study that revealed the center's incidence of 57% on the acute care units was higher than the national average. ¹

Plan: The plan included the formation of a skin/wound committee. The committee reviewed and revised current policies and procedures and documentation forms. They also implemented staff education. Additionally, current skin and wound care products were reassessed as well as the availability of appropriate pressure-reducing support surfaces. Although the project had many tasks, the implementation of a comprehensive prevention protocol including skin care products and education were key components. Furthermore protocols and a product formulary were developed for basic skin and wound care.

Results: Following the above measures, chart audits were performed to check compliance with the new policies and to identify any shortcomings. A second Prevalence and Incidence Study was completed and the overall incidence rate decreased to 3%. More patients were noted to be at risk using the Braden scale versus the previous scale. However, there was not a significant change in the documentation of care provided.

Conclusion: A well-developed prevention plan including comprehensive product formulary is invaluable for pressure ulcer prevention. Additionally, on-going education in various formats is needed to reduce the number of hospital-acquired pressure ulcers and to document the care provided.

References 1. Whittington KT, Briones R. National Prevalence and Incidence Study: 6-year sequential acute care data. Adv Skin Wound Care. 2004 Nov-Dec; 17(9):490-4.