Bundled and Evidence-Based: Targeted Interventions to Prevent Pressure Ulcers

Sherry Tennies, MSN, RN, CWOCN, Inpatient Wound Ostomy, St. Joseph's Hospital - Froedtert and the Medical College of Wisconsin, West Bend, WI
Bundled and Evidence-Based:  Targeted Interventions to Prevent Pressure Injuries

Introduction: Skin safety is dependent on early identification of pressure ulcer risk and implementation of targeted, evidence-based interventions to mitigate risk.  Lack of consistent implementation of preventative skin interventions at a Midwestern community hospital was identified as a factor in low, but constant, hospital acquired pressure injury/ulcer (HAPU) rates.  With a goal of zero HAPUs, a preventative program was implemented that included a skin inspection performed by two staff, which was termed “Four Eyes,” and a Pressure Ulcer Prevention (PUP) Best Practice Bundle. The PUP Bundle lists evidence-based, targeted interventions for Braden sub-scores less than or equal to two. The interventions address four risk categories: Sensory, mobility, and activity; moisture; friction and shear, and nutrition.

Methods:  The Plan Do Study Check Framework guided the practice changes.  Skin inspection documentation and a link to the PUP Bundle were incorporated into the electronic medical record (EMR). All nursing staff were educated via a computer based learning module in May 2016. The skin inspection and PUP Bundle went live July 1, 2016.  Lag measures: Pressure injury incidence and completion of skin inspection.  Lead measures: Skin care interventions. 

Results: For third quarter 2016, HAPU rates initially increased on the ICU and Medical-Surgical units by 4.67 and 11.11 HAPUs per 1000 patient days, respectively. Just-in-time education was conducted with staff by the wound, ostomy, continence (WOC) nurse throughout the third quarter emphasizing the PUP Bundle interventions.   By the end of October 2016, all units achieved zero HAPUs. 

Conclusion: Education improves skin assessment skills which and may lead to an initial increase in pressure injury rates due to increased awareness.  A tool with bundled, targeted, evidence-based skin care interventions can effectively prevent HAPUs and improve patient safety.