Reducing Unit-Acquired Pressure Ulcers with Peer-to-Peer Nursing Rounds:

Purpose:

The purpose of this nurse-driven skin saver quality improvement project is to (1) improve pressure ulcer (PrU) documentation, (2) increase awareness of PrU prevention best practices, and (3) reduce the incidence of unit-acquired PrU’s during quarterly surveys.

Objectives:

After viewing this poster, the learner will be able to:

1. Define what is a skin saver resource leader
2. Verbalize the six steps of Larrabee’s model for evidence-based practice change
3. State why the need for change in practice

Conceptual Model:

Larrabee’s (2007) model for evidence-based practice change.

Subjects and Setting:

A cohort of 34 registered nurses on 33 bed medical-surgical unit in 212 bed community hospital.

Methods:

Biweekly nurse-to-nurse wound and skin rounds conducted by skin saver resource leader with consultation from wound nurse practitioner as needed. Immediate feedback provided to nurse on condition of wound and plan of care adjustments.

Outcomes:

• For 12 consecutive quarterly prevalence surveys from 2012 to 2014 (3 years) there were no unit-acquired pressure ulcers.
• There was 100% increase in pressure ulcer prevention best practice awareness
• Skin tears and moisture associated skin damage (MASD) were not documented in error as PrU’s.