PREVENTION for ALL

Although pressure ulcer prevention is viewed as a nurse sensitive quality indicator, the certified wound care specialists at this 5 hospital, 1200+ bed system, recognized that pressure ulcer prevention is multi-dimensional and complex, requiring non-traditional partnerships. In acknowledgment of this, a highly engaged team of 45 stakeholders representing various professions, organizational positions and levels, along with vendor partners met over a 1 year period to review the evidence and identify best practices. The review supported the development of a pressure ulcer prevention bundle.

Goals of the team were: to standardize prevention practices, decrease variation in practice, establish a system wide formulary, and identify each provider groups’ responsibilities in attaining zero hospital acquired pressure ulcers. The team operationally defined the pressure ulcer prevention bundle components and necessary care processes, using standardized products and technology, thus ensuring consistency in bundle implementation.

The initiative included extensive education of all staff, including environmental services, radiology, and transport. Education included a computer based e-learning tool, a video regarding the importance of skin care and repositioning, hands on assessment practice, and problem solving.

The bundle was piloted on 12 units in 4 acute care hospitals and included critical care and medical-surgical areas within the system. Evaluation of the bundle was done, refinement of bundle elements was completed, and a system wide acute care implementation was initiated.      

Next steps included hardwiring practice changes related to pressure ulcer prevention via an innovative consistent auditing process with immediate feedback to staff, re-education related to specific audit findings, deployment of the bundle to the rehab hospital within the system, and tailoring of the bundle to the operating room, emergency department, and procedure areas within the entire hospital system.