An Action Plan for Change: Decreasing the Incidence of Hospital Acquired Pressure Ulcers in the Critical Care Unit

Topic: Based on internally derived hospital acquired pressure ulcer incidence reports, our 30 bed Critical Care Unit (CCU) has historically had the highest incidence of pressure ulcers in our 636 bed hospital. Evidence based research suggests several factors increase the risk for development of pressure ulcers in the CCU, including hemodynamic instability, poor perfusion, impaired sensitivity and nutrition and increased issues related to moisture. In evaluating this data, CCU Skin and Wound Resource team members recognized many risk factors are uncontrollable and decided to address the factors that could be changed. As a result, a CCU Action Plan was developed.

Purpose/Objective: The CCU Action Plan outlined three actions to be implemented to decrease the incidence of hospital acquired pressure ulcers in the CCU as calculated by our internal data collection. First, new protocols entitled “Turn-on-hand-off “ and “Turn-on-transfer” were developed to ensure part of RN to RN report included a visual inspection of the patients’ skin, as well as a report of the patient’s specific needs based on the Braden Scale. Second, 1:1 RN education was given on how and when to assess and document pressure ulcers. Third, biweekly skin care rounds on day and night shift were started to educate the bedside nurses on the prevention, assessment and treatment of pressure ulcers.

Outcomes: First quarter 2010, the CCU had 22 reported hospital acquired pressure ulcers. Second quarter 2010, the CCU had 11 hospital acquired pressure ulcers. Finally, the third quarter 2010, the CCU had 7 hospital acquired pressure ulcers. The data shows a greater than 50% reduction in hospital acquired pressure ulcers since the action plan was implemented in December of 2009. With continued education and enforcement of quality outcome measures we anticipate our incidence of hospital acquired pressure ulcers to continue to decrease.