Aiming for the Zero Factor: How one acute care facility decreased the incidence of hospital acquired pressure ulcers by over 75% using evidence based prevention modalities

When a patient enters an acute care facility they expect to be treated competently and safely.  A serious pressure ulcer can affect the patient physically, emotionally, socially and spiritually. The care of that ulcer may overwhelm the care giver at home making living independently difficult.

            The facility too is affected when a pressure ulcer occurs. The care of a stage IV pressure ulcer can cost over $100,000 (Brem, 2010). This large amount of money may not be recouped in today’s changing health care environment.

             In response to this patient safety concern, one hospital system used evidence based methods to decrease the incidence of hospital acquired pressure ulcers by 75% over a 5 year period. Currently the annual incidence of hospital acquired pressure ulcers is 0.30 pressure ulcers per 1000 patient days, with initial rates as high as 2.4 pressure ulcers per 1000 patient days.

            The change occurred over time.  A multidisciplinary team was developed to identify where there was a breakdown in current processes. Research of current evidence based practice was utilized to develop prevention modalities. Staff leaders were identified who then worked with other staff members. Changes eventually became imbedded in the culture of the facility.

            Some prevention modalities included: Accurate and timely assessment, pressure ulcer risk assessment every shift, routine use of barrier creams and moisture wicking pads, consistent repositioning, heel elevation and use of protective boots. The system also completed a comprehensive review of pressure relieving mattresses based on evidence, staff and patient input mattresses were purchased for the entire facility and hospital system.           

            As a result ulcers have significantly decreased and patients are safer. This presentation will discuss what changes were implemented, methods used as well as the current reality for pressure ulcer prevention.