Pressure Ulcer Risk Prevention in Procedural Department

          In 1997 Fairview Southdale Hospital began ongoing pressure ulcer surveillance with yearly P and I studies and system quality improvements. Joining The Minnestoa Hospital Association Safe Skin Call to Action brought new initiatives in prevention interventions and has fostered more comprehensive system involvement. After an in depth evaluation of our facility acquired pressure ulcers from 2008 it was determined that 76 % of the patients had multiple (3 or more) procedures prior to their pressure ulcer occurrence. Based on this information a rapid process improvement project was organized by the quality performance improvement department and the wound, ostomy, continence nursing department.  Gaps in pressure ulcer prevention were identified in radiology and imaging related to cumulative pressure from transport to procedures, immobility during procedures and transport back to the nursing unit. New inter departmental guidelines for communication and prevention measures were developed and implemented from the 2 day rapid process improvement project.