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4529 Addressing Perioperative and Medical Device Related Pressure Ulcer Events: A Minnesota SAFE SKIN* Update

Denise Nix, MS, RN, CWOCN , Park Nicollet Methodist Hospital, Clinical Practice Specialist, Minneapolis, MN
Julie Apold, MA , Minnesota Hospital Association, Director of Patient Safety
Vicki Haugen, RN, MPH, CWOCN, OCN , Fairview Southdale Hospital, WOC Nurse
Kathy Borchert, MS, RN, CWOCN, ACNS-BC , HealthEast Care System, WOC Nurse
Anita Carteaux, RN, BS, CWON, COCN , United Hospital, Wound and Ostomy Nurse, St. Paul, MN
Anne Hanzel, RN, MSN, MA , UMMC-Fairview, Director, Perioperative Services
Kim Kleinschmidt, RN, BSN, CWOCN , Hennepin County Medical Center, WOC Nurse
Julie Kula, RN, BSN, CWOCN , Park Nicollet Methodist Hospital, WOC Nurse
Wendy Kraft, RN, BSN, CWOCN , North Memorial Medical Center, WOC Nurse
Theresa Meister, RN, C, BSN , Regions Hospital, Wound Clinic Manager
Mary Murphy, RN, MA, CWOCN , VA Medical Center, WOC Nurse
Mary Zink, RN, BSN, CWOCN , Unity Hospital, WOC Nurse
Background:  A law created in 2003 mandated Minnesota Hospitals to report stage 3 and 4 pressure ulcers (PU) along with other significant Adverse Health Events (AHE).  Despite creation and dissemination of a statewide protocol after the first public report in 2005, by 2006 PU became the most frequently reported AHE (1, 2). The Minnesota Hospital Association (MHA) responded by initiating the SAFE SKIN Call to Action for PU prevention.

Today, Minnesota Hospitals have increased implementation of SAFE SKIN components from 56% to 93%.  Stage 3 and 4 PU has decreased by 25%. Following the addition of unstageable PU to the reportable definition, additional queries added to the AHE report system (interim analysis) data showed that 27% of reported PU were associated with medical devices and 33% developed after multiple or long surgeries. Objective/purpose: Decrease perioperative and device related pressure ulcers.
Outcomes: The MHA SAFE SKIN*initiative was expanded through the following actions:

  1. Surveyed MN Hospital regarding operating room (OR) support surfaces and criteria for use
  2. Convened MHA pressure ulcer advisory group with OR nurse expert to analyze AHE data, relevant literature, care standards and an MHA hospital survey (3, 4)
  3. Developed an OR  guidance document for pressure ulcer prevention
  4. Disseminated and discussed the guidance document via statewide conference and AORN meeting with subsequent postings on a list serve and website (including a recording of the conference call).
  5. Convened MHA pressure ulcer advisory group to analyze AHE device related data and relevant literature.
  6. Disseminated and discussed AHE findings and strategies used to address device related pressure ulcers via conference call with subsequent postings (including a recording of the conference call) on the SAFE SKIN website.
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