Pressure Ulcer Reduction: It Takes More Than a Skin Care Team

Reducing the prevalence of hospital-acquired pressure ulcers (PUs) continues to challenge Certified Wound Ostomy Nurses (CWON). Nurse-run Skin Care Teams (SCT) have had mixed results. At our academic hospital, more than a SCT was needed to lower our pressure ulcer rate: we needed a multidisciplinary approach plus further empowerment of nurses.

To reduce PUs, a DMAIC (Define, Measure, Analyze, Improve and Control) process was utilized. The team included directors/managers of nursing, physicians, process improvement leaders and CWONs.

Prevalence was defined by assessing intensive care unit (ICU) patients. In July 2013, prevalence of PUs was 45% in the medical ICU. Patient charts revealed inconsistent documentation between doctors, nurses, incident reports and prevalence day data.

Upon further patient analysis, more than 20 risk factors were identified: ventilation>48 hours, history of PUs, Braden scale score<15, sepsis and malnourishment. 

The Improvement Phase included: 1) "Skin Time Out" - upon patient admission/transfer, the nurse and physician perform a skin assessment, stage PUs and develop a prevention/treatment plan. 2) Computer charting updates to reflect “always” practices based on Braden subscales (e.g. applying a multi-layered foam sacral dressing). 3) Education for unit-based SCT members: 8 hour seminar, distribution of a reference card, and ongoing mentorship by CWONs. 4) Change prevalence day from quarterly to monthly.

The Control Phase is in development. 

This project has brought PUs to the forefront: doctors are including “skin” during review of systems; nurses are taking more responsibility in developing a plan of skin care; and nursing assistants are given clearer expectations for prevention interventions. PU prevalence in the medical ICU has dropped from 45% to 14%. Although reducing pressure ulcers is an ongoing challenge, making it a priority for the entire organization is helping to achieve the goal of safe patient care.