Bundling Up for Pressure Ulcer Prevention

CMS (Centers for Medicare and Medicaid Services) has changed the atmosphere of all acute care hospitals with the new payment scale released October 2008. This agency will no longer pay for hospital acquired pressure ulcers. Along with non-payment, states are beginning to require reporting of nosocomial pressure ulcers as "never events". A multidisciplinary committee was established in the health system, charged with establishing quidelines for patient evaluation, pressure ulcer prevention and treatment. The goal of these guidlines was to increase the consistency of integumentary system evaluation at admission by nursing and medical staff alike; to implement precautions for those at risk for pressure ulcer development; to streamline treatment for wounds.

The team consisted of nurses, physicians, nursing administration, and certified wound, ostomy, and continence nurses. Nursing standards of care were updated, standardization of a product formulary undertaken, and a skin/wound bundle was initiated. The bundle incorporates a skin/wound care kardex, a skin/wound care order set, a sticker to alert the physicians of the presence of a wound on admission. The bundle concept was adapted from success with other bundling nationally: central line bundles, ventilator associated pneumonia bundles,etc.  

Several different learning modules to address the use of the bundle were developed: a full day CME/CEU education program, nursing councils were taught (train the trainer), and walking rounds were implemented.

Challenges faced incorporating the bundle included: differences in the cultures of the institutions within the health system, the process of change itself, consistency of the message delivered to staff, ease of use of the materials involved, and nursing involvement in the development of the tools in the bundle.

The bundle has been in use since May 2009. Incidence rates in the system ranged from 5%-14% prior to implementation of the bundle; post bundle rates are 0%-1%.