Impact of a Pressure Ulcer Prevention Competency Model to Reduce Hospital Acquired Pressure Ulcers

Objectives:   

•   Decrease incidents of hospital acquired pressure ulcers in a 100 bed acute care rural hospital
•   Increase nurses implementation of skin care and pressure ulcer prevention measures at the bedside  

Purpose:    Hospital acquired pressure ulcers are devastating never events that should be prevented on hospitalized patients.  The purpose of this innovation was to decrease the incidents of hospital acquired pressure ulcers by requiring nursing staff to complete a competency and computer based learning module (CBL).  

Method:     A root cause analysis of 5 incidents of hospital acquired pressure ulcers occurring in 1 month at a 100 bed rural acute care hospital was performed.  The analysis identified nursing staff had a lack of knowledge regarding skin care and were not performing basic skin care, assessments, and documentation of skin to prevent pressure ulcers. An action plan was initiated to decrease pressure ulcers.  All nurses and nursing care partners were required to complete a computer based learning module (CBL) with post test and a competency of an evidence of daily work or return demonstration in front of an educator prior to a deadline. This competency model also included staff education of a skin assessment form to be completed hospital wide on every admitted patient.  This form was initiated to identify skin condition on admission. 

Outcomes:    This hospital had 15 hospital acquired pressure ulcers in the 7 months prior to initiation of this action plan. 

 After the action plan this hospital:

-         With “0” hospital acquired pressure ulcers for 3  months    

-         Skin is being assessed on admission evidenced by completed skin admission forms 

-         Pressure ulcers are being addressed and prevention measures implemented prior to development of Stage 3 or 4 ulcers.