Problem: 30 bed Med-Surg unit with one RN trained to conduct the quarterly Pressure Ulcer Prevalence Incidence Survey (PIS). The RN frequently carries a normal patient assignment while performing the PIS. The 2006 1st quarter PIS was not completed. The 2005 data indicated a higher than benchmark incidence of nosocomial pressure ulcers in 2 out of 4 quarters surveyed.

Hypothesis: Perceived lack of support signals to staff that pressure ulcers are not a high priority. The RN, related to time constraints, does not mentor staff in the area of identifing patients at risk, prevention, staging, and the treatment of pressure ulcers.

Method: The TCAB (Transforming Care at Bedside) interdisplinary team developed a pilot program implemented on the Med-Surg Unit. Identify Specific Staff: 2 RNs, 1 Care partner Take Out of Staffing Mix Day of Survey. Focus Education with WOCN. Ongoing Monthly Education with WOCN Group. Monthly Survey. Report Results at Monthly Med-Surg-Meeting.

Purpose: Provide trained staff that can mentor their peers in the identification of patients at risk and in the use of pressure ulcer prevention bundling (moisture barrier, moisturizing lotion, nutrition consult, support surfaces, and every 2 hour turn and repositioning) and standing orders to treat existing skin breakdown.

Goal: Staff 1. Focused Education. 2. Decreased Frustration. 3. Sense of Accomplishment. 4. Effective Communication. 5. Better Time Managment.

Goal: Patient 1. Recognize Patient at Risk. 2. Immediate Implementation of Prevention, Treatment. 3. Effective Communication of Risk, Interventions, Treatment. 4. Continuity of Care.

Outcome: The monthly PIS and reportable quarterly PIS indciated a decline in pressure ulcers. 1st quarter, prior to implementation of the pilot, had no data. The 2nd quarter had I patient out of 25 with a nosocomial pressure ulcer and the 3rd quarter had 0. Positive staff feedback.