Pressure ulcers are a problem in hospitalized adults, with incidence of 10-17% in acute care (Ayello, El, Predicting Pressure Ulcers, AJN, November 2007).  Research supports that pressure ulcers and treatment negatively affect not only the physical, emotional and spiritual health of the patient, but also increase length of inpatient stay and costs. 
In compliance with the IHI Protecting 5 Million Lives campaign and the emphasis on wound care in 2008, BWMC tasked the Skin Care Committee to further improve prevention of pressure ulcers.  The challenge was to decrease hospital acquired pressure ulcer development and to create user friendly screens and menus in the electronic record.  
Initially we explored ways to reduce the number of Stage I heel pressure ulcers by implementing a "Heels Up" Campaign.  The next hurdle was to streamline the documentation.  We explored a way to capture and take action in preventing ulcer development in patients at risk.  Using a trigger Braden score of 18 or less, the CNS team developed an "APPLE" model that prompts the nursing team to implement preventative measures proactively.  A red apple appears on the nursing task list when a Braden score of 18 or less is documented.  This apple is a visual reminder to implement the nursing protocol for alteration in skin integrity.  The campaign included a red apple pin to place on each name badge to further reinforce the reminder.
Initial results and compliance with the improvements was demonstrated. The challenge is to assure that this improvement is sustained over time with the electronic screen changes and the visual prompts.  By increasing the sensitivity of the Braden score from 16 to 18 as a trigger for action, we predict that the rate of hospital acquired pressure ulcers will decrease and remain low as we continue into our prevention efforts.