Tools of Change in Critical Care. Impacting Outcomes With A Skin Bundle, An Effective Positioning System and Education

Problem: In 2014, a 19 bed intensive care unit in a 250 bed regional level 2 trauma hospital had higher than acceptable pressure related injuries. We suspected that our rates were even higher than calculated due to lack of staff knowledge and awareness of pressure injuries. Method: Over the next 3 years, successive initiatives were implemented beginning with education of staff through the Wound Treatment Associate ( WTA) certification program. A pressure injury awareness tool based on the Association for the Advancement of Wound Care prevention guidelines was created and posted. The ICU mattresses were upgraded to a gel based surface. Routine risk assessment with the Braden scale on admission was implemented in conjunction with 2 RN skin evaluation to reduce errors. The Skin Bundle checklist was implemented for patients with a Braden score below 14. To address pressure and shear, our every 2 hours repositioning schedule was augmented by use of a turning and positioning system based on a static offloading air mat and fluidized positioners effective at maintaining the therapeutic off-loaded position. The evidence-based, 5 layer, soft silicone prophylactic sacral dressings are applied for high risk patients and prior to prolonged surgical procedures. Additional components of the skin bundle include: an upgraded surface based on Braden score, nutritional interventions and medical device assessment and protection. The bundle is incorporated into the skin integrity plan of care in the EMR. A safety calendar tallying all pressure injuries daily is posted in the ICU to increase staff and leadership awareness. Result: Initially the enhanced knowledge and assessment skill of the nursing staff resulted in an increased pressure injury incidence rate. Since 2015 there has been a 38% reduction in stage 2 and above pressure injury and a 26% reduction in incidence per 1000 bed days in our intensive care unit.