Purpose: Decrease pressure ulcer incidence through development of a comprehensive data base and isolate contributing factors. The WOCN department found that quarterly prevalence information collected was insufficient to affect change. More information was sought regarding patient populations, contributing factors and interventions employed by staff prior to pressure ulcer development.

Objectives: 1. Develop an instrument to track incidence of pressure ulcers and specific data as potential markers for pressure ulcers.

2. Collaborate with Information Technology to establish and maintain a data base.

3. Collaborate with nurse managers in identifying unit specific and house wide opportunities for improvement.

4. Assist nurse managers in developing, implementing, and evaluating action plans to decrease pressure ulcer incidence specific to their patient population .

Outcomes: 1. A comprehensive data base to monitor pressure ulcer incidence was developed with the IT department. The tool has been revised to accommodate additional identified contributing factors.

2. Data is distributed to nurse managers monthly. Nurse managers analyze the data and collaborate with the WOCN department to develop/implement action plans.

3. Through data collection, WOCN staff identified inconsistencies with pressure ulcer documentation. Inservices focusing on pressure ulcer assessment and documentation were offered.

4. Through data analysis, orthopedic and surgical intensive care units were identified as having the highest incidence. Weekly pressure ulcer prevention rounds and unit specific data analysis isolated unit specific issues. Action plans were developed and implemented accordingly.

Conclusions: Medical innovations are advancing exponentially, resulting in lengthier hospital stays. Consequently, patients are at greater risk for the development of pressure ulcers. The assessment of pressure ulcer development requires a multifactorial approach considering all aspects of care that place patients at risk. This innovative approach to monitoring pressure ulcer incidence enables us to provide safe, quality, and individualized patient care, leading to a less than 1% incidence of pressure ulcers.