Pressure Ulcer Prevention in an Acute Care Setting: A Partnership with the Hospital Quality Patient Safety Department

Hospital Acquired Pressure Ulcers (HAPU) are considered preventable incidents that are part of the National Patient Safety goals for acute care settings across the nation. The WOC nurses at an acute care setting partnered with the Quality Improvement Specialist, nursing director, nursing managers and staff to reduce pressure ulcers. The rate of HAPUs was initially tracked with the quarterly hospital wide prevalence study. The results showed we were not achieving sustainable results. The data from quarterly prevalence surveys was not motivating to staff to demonstrate the need to change nurse behaviors.

The goal was to reduce the rate of hospital acquired pressure ulcers (HAPU) by impressing nursing staff in the importance of their role in prevention. Improved patient and family satisfaction with their hospital stay was a secondary gain. We found many of the nursing staff scored the Braden Risk Assessment Scale “too generously”-giving the patient credit for abilities they had prior to admission but were unable to demonstrate during their hospital stay. We were not capturing our at-risk population and implementing preventative measures.

The methods to create change included in-depth education of Braden Risk assessment to ensure nursing staff identify at-risk patients, weekly unit-based “mini prevalence” surveys conducted by nursing staff and the nurse manager, implementing products used for pressure ulcer prevention based on literature review (such as the silicone foam sacral dressing), development of a bed algorithm to ensure appropriate support surface use.

A HAPU Review tool was developed to “debrief” staff, nurse managers, and other clinicians in the events contributing to the development of a HAPU. This was conducted in a “no blame” environment and looked at patient factors, staffing levels and staff behaviors.

Nursing staff and managers now take ownership of outcome of the mini prevalence survey and celebrate the results!