Peer Review: A New Approach to Pressure Ulcer Prevention

Background and significance –Prevention of PU is extremely important to reduce infection potential, and save patient pain, nursing staff time and undue hospital expense.  Our facility continued to experience nosocomial PU in spite of implementing EBP best practices.  Documentation was frequently incomplete leading to a conclusion that best practices were not being followed.

Purpose – A new approach was needed to educate nursing staff, increase accountability and reduce incidence of PU.

Methods – A PU Prevention Peer Review Committee was formed that included Unit Based Skin Experts from five nursing units, two Wound Care nurses, Risk Manager, Clinical Manager of Wound Care(Chair) and Nursing Administrative Assistant. The most serious nosocomial PU occurring each month was selected for review by the Chair. The Unit Manager and Unit Based Skin Expert (UBSE) from the treating unit were invited to the meeting. 

The Unit Manager and UBSE participated in the discussion of documentation, interventions and ideas for improvement.  An action plan was created with input from the committee.

Results/Outcomes – All guests to the Peer Review Meeting reported this was a positive educational experience resulting in many good practice recommendations from the review team.  An action plan follow up is required from the guests two and nine months after the original meeting.  Pressure Ulcers continue to decrease.

Discussion/Implications for Practice –Staff education was provided about when to call a wound care nurse, describing wounds, and skin and PUP assessment documentation. When pressure ulcers were reported on a patient treated on more than one unit/area, all units involved are invited. The Peer Review process plays an essential role in assuring quality outcomes and maintaining professional autonomy. The creative synergy between guest unit staff and committee members resulted in positive relations, increased communication and workable methods to help prevent PU.