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131BEvidence Tables for Chapter 21. Preventing In-Facility Pressure UlcersTable 1, Chapter 21. Multi-component pressure ulcer prevention initiatives conducted in acute care settings in the United States

Author/Year Description of PSP Study Design

Theory or Logic Model

Description of Organization

Contexts Implementation Details Outcomes: Benefits

Influence of Contexts on Outcomes

Lynch and Vickery 20101a

Zero-tolerance philosophyTarget safety problem: PUKey elements:Multidisciplinary team; educate staff/resident/family, streamline documentation, wound-care workshops, case studies, setting goals, identify and address barriers

Pre-post NS 166-bed acute rehabilitation

External:New CMS reimbursementOrganizational Characteristics:NSTeamwork, Leadership, Culture:After reviewing 2007 data on PUs, the team was dismayed at the number of misidentification of PUs at admission; skin assessments incomplete and inconclusive; incorrect staging; incorrect documentation (e.g., document denuded skin as PU); documentation fragmented; definition of thorough skin assessment; inconsistent documentation of interventions; incorrectly transcribing interventions to appropriate documentation.Implementation tools:

Interdisciplinary team Education

at orientation, annually, and one-on-one, via web

Documentation streamlined to 1 form

Wound care workshops for nurses at orientation; after 2 months

Report cards

Length: 1 yearProcess:Multidisciplinary team reviews current processes of care and finds errors with assessment and documentation; education of staff is quickly put in place; staff is encouraged to report HAPUs and view as an opportunity to learn; rate goals are set for hospital and by unit; report cards are posted so units can track their progress.Successes:Due to streamlining documentation, timely and accurate completion of documentation increases from 60% to 90% in 90 days; patients on a neurobehavioral stroke unit did not develop PUBarriers:Patients dissatisfied with off-loading bootsAddressing Barriers:Trial initiated to evaluate use of pillow; leads to improved outcomesSustainability:Quarterly newsletter attached to paychecks

PU Rates:Pre: 2.8%Post: 0.48%(-82.8%)

NS

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Young et al. 20102a

Clinician-led task force leads prevention initiativesTarget safety problem: PUKey elements:Clinician-led task force; skin champions; adoption of Save our Skin logo; education/training; revise policies and procedures based on CPGs; integrate new documentation and assessment tools

Pre-post Shared governance approach (decisions made at point of care)

540-bed acute care facility (3 campuses) in Indiana

External:NSOrganizational Characteristics: NSTeamwork, Leadership, Culture:A clinician-led skin care team replaces administration-ledImplementation tools:

Save our Skin (SOS) logo adopted and appears on educational forms and t-shirts worn during audits and educational in-services

Laminated SOS logo tool placed on doors of patients at-risk

Revise online policies and procedures; 1 new policy remains

Adopt Braden Scale (electronically)

Body map assessment tool

Mandatory training includes presentation of case studies

Educational brochure for residents and families

Feedback on educational presentations

Updating of core orientation, uploaded to hospital Web site

Posters depicting PU rates, examples of new forms, and revised policies/procedures

Length: 2 yearsProcess:Members of clinician-led task force include director of Clinical Care and Oncology Nursing Services, manager of Wound Care Institute, and nursing representatives from 15 hospital units; task force members appoint skin champions from each unit; champions invited to join team; task force members join subcommittees of choice to develop logo, policy and procedures and other program components; after comparing practices to CPGs 7 existing policies are combined into 1; manager of the Wound Care Institute works with the Director of Informatics on revising online policies and procedures; monthly quality auditsSuccesses:Revised policies reduced from 7 to 1; documentation of skin care reduced from 8 to 3Barriers:Time constraints, insufficient computer resources, competing goalsAddressing Barriers:Clinicians were allocated 4 paid hours to carry out responsibilities; web access to library resources were

Incidence:Pre:Campus 1: 12.5%Campus 2: 8.7%Campus 3: NRPost:Campus 1: 9.1%Campus 2: 2.8%Campus 3: NR

NS

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placed on each unit Hospital-wide

standardizing of patient-turning schedules

Flip-chart algorithm placed bedside to differentiate between old and new skin care products

Audit tool

added to intranet;Sustainability:

RNs and LPNs must demonstrate competency annually

Monthly updates provided via intranet to nursing personnel by unit champions/ team members; includes product changes

Bales et al. 20093

Implementation of evidenced-based prevention strategiesTarget safety problem: PUKey elements:Increase hours of certified wound, ostomy and continence nurses (CWOCNs) to full-time to provide 24-hour support to staff, provide mandatory education and resources for staging and treating wounds, increase wound monitoring and reporting efforts, purchase pressure-redistribution beds, add musical alarms to remind nurses to turn patients, and identify at-risk surgical patients.

Time series

NS 300-bed community hospital, USA

External:To comply with principles of the Magnet program, which validates excellence in nursing practicesOrganizational Characteristics:Magnet hospital that serves mostly adult and geriatric patientsTeamwork, Leadership, Culture:Decentralized decision-making in which shared decision-making is encouraged prevails, feedback and participation of all staff is actively encouragedImplementation tools:CWOCNs, computers to aid in staging wounds and treatment information, and external alarms to remind nurses to turn patients

Length: 1 yearProcess:

24-hour support provided by CWOCNs

Mandatory education Strict oversight of

monitoring and reporting

Periodical motivational campaigns that included staff and unit incentives.

Successes: Patients received

optimal care Institution avoided the

cost of treating stage 3 or 4 ulcers

Barriers:Staff motivation and lack of proper reporting and documentation

Addressing Barriers:Monthly to quarterly campaigns are launched to maintain staff motivation. Nursing units that had zero-hospital acquired PUs are recognized and awarded

Hospital acquired prevalence rates:Pre: 4.20%Post: 0%

The hospital’s managerial style encouraged staff involvement in decision-making about the process of developing a program and the leadership team gave strong support to the program and promoted it to both other leaders in the team and hospital staff.

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during campaigns.Sustainability:Success requires awareness of key management skills and priorities, such as strong leadership, involvement of staff in decision-making and a desire to foster interdisciplinary relationships.

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Chicano & Droishagen, 20094

Implement strategies to lower the incidence of hospital-acquired pressure ulcersTarget safety problem: PUKey elements:Developed a protocol for assessment and documentation of wounds, implemented procedures for CWOCN to work with staff and patients to initiate appropriate treatment, implemented the Braden Scale for Pressure Sore Risk, conducted a literature review on the use of thromboembolic device stockings and compression devices and revised practice standards for use of devices based on findings of review

Time series

NS 25-bed intermediate care unit in the United States

External:Quarterly HAPU data indicate increased prevalenceOrganizational Characteristics: NSTeamwork, Leadership, Culture:The care unit supported a self-governing nursing council.Implementation tools:Survey to identify practices regarding skin assessment, documentation, and nursing intervention and opportunities for education, CWOCNs, and Braden Scale

Length: 23 monthsProcess:Phase 1 took 5 months and involved developing protocols and procedures to assess and treat wounds;Phase 2 took 3 months to complete and involved educating staff and implementing the Braden Scale,Phase 3 took 15 months to complete and involved a literature review and revision of practice standards on use of compression devices.Successes:Staff participation in survey, continued adherence to implemented prevention practices, development of educational materials, and staff acceptance of shared governanceBarriers:Engaging staff as council members in the planning and implementation of the project.Addressing Barriers:Updating staff of progress and continual encouragement to participate from other council membersSustainability:Commitment and diligence from the quality improve-ment team and self-governance council.

Hospital acquired incidence rate:Pre:6 occurrences during a 12 month period, 5 during subsequent 5 months

Post:1 occurrence within 12 months following implementa-tion, 0 at latest assessment covering 2 month period.

“Commitment and diligence from the quality improvement team and from the members of the staff’s self-governance councils played a significant factor in achieving our goal of reducing HAPU prevalence in our intermediate care unit.”

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Walsh et al. 20095a

Implementation of evidence-based practicesTarget Safety problem: PUKey elements: revision of skin management program; use of CPGs; educating clinician/nurse; multidisciplinary team; add certified WOCN to management; replace risk assessment tool; replace wound care products

Time series

NS 1 acute care facility in northwest CTBed size: 371

External: CMSOrganizational Characteristics:Regional medical center and community teaching hospital; primary provider for 350,000Teamwork, Leadership, Culture: NSImplementation tools:

Add WOCN nurse to team

Rely on EBPs (AHRQ CPGs, IHI, WOCN Society)

Rely on The National Database of Nursing Quality Indicators’ PU presentation for re-education on wound etiology and staging

Clinician and staff education (computer-based and classroom presentations)

Replace risk assessment tool with Braden Scale

Update skin management policies/ procedures

Assessed wound care products

Multidisciplinary team Alert system (POA

sticker) Visual turning clocks,

laminated pocket cards including CPG information

Bed surface algorithms

Length: 18 monthsProcess:Clinical education relies on 6 essential elements of prevention; in 2007, Braden scale risk assessment tool replaces current un-validated tool form (not research based); each unit assigns an interdisciplinary team; purchases of new beds, stretchers and curtains followed by new skin lotion and incontinence care productsSuccesses:Reduction in prevalence; increased focused communication among patient caregivers; buy-in from clinicians improves behaviorBarriers: NSAddressing Barriers: NSSustainability:“Remains current regarding initiatives for improved patient safety, changes in regulatory mandates, and changes in EBP.”

Prevalence:Baseline: 12.8%Post-implemen - tation:0.6%

NS

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Illustrative wound reference guides with recommended treatment modalities

Standardize wound care products

Dibsie, L. 20086 Implementation of evidence-based protocol and practices for preventing and treating PUsTarget safety problem: PUKey elements:Development of protocol for monitoring, preventing, and treating PUs based on recent evidence, standardization of all products related to prevention and treatment of PUs, and education for nurses on the protocol and use of products.

Time series

NS 4 adult critical care units (54 beds total) at 2 academic medical centers in the United States

External:Two significant events occurred and there was an overall lack of reporting and communication of issues related to skin breakdown (specifics of events not reported)Organizational Characteristics: NSTeamwork, Leadership, Culture: NSImplementation tools:Staff nurse skin committee and skin champions

Length: >1 yearProcess:Change began with becoming educated about current practices and equipment in wound care. Once educated, the nursing skin committee began purchasing equipment, developing procedures for monitoring and documenting skin breakdown, and educating staff on monitoring, reporting, and treating PUs.Successes:Decrease in the rate of hospital-acquired stage 2 or greater pressure ulcers.Barriers:

Coordinating efforts between 2 sites

Coordinating and identifying skin committee members and staff champions

Scheduling staff education

Continuation of efforts Cost of purchasing new

equipmentAddressing Barriers:Communication, active involvement of clinical managerial leaders, and

Surgical ICU acquired:Pre: 6.1%Post: 6.1%Facility-wide overall rate:Pre:4.2%Post: 3.2%

“The changes in the climate and practice related to skin care and prevention of breakdown are the direct result of nursing taking ownership of their practice with the support of nursing leaders at all levels.”

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constant education support.Sustainability:Organization commitment remains strong and next steps for success, such as developing aggressive indicators of success and having staff identify practice issues are in the works.

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McInerney, J. 20087

To implement multiple strategies for decreasing the prevalence of hospital-acquired PUsTarget safety problem: PUKey elements: Electronic medical records, risk assessment measures, pressure relief measures (new equipment and personnel augmentation, and interdisciplinary team to develop protocols.

Time series

NS Two-hospital system with 548 beds in United States; 548 bed; non-profit

External: NSOrganizational Characteristics: NSTeamwork, Leadership, Culture: NSImplementation tools:WOCN oversaw implementation of strategies.

Length:18 months to implement program; follow-up reported for over 5 yearsProcess:

Electronic medical records (EMRs) to assess and document skin care needs.

Risk assessment measures (e.g., Braden Scale)

Automated consults and orders through EMRs

Pressure relief measures

Staff education Hiring of second

WOCNSuccesses:Reduction in PUs, cost savings and elimination of pain and suffering for the patientsBarriers: NSAddressing Barriers: NSSustainability: NS

Hospital acquired prevalence rates:Pre:12.8% all PUs;6.7% PUs on heel.Post (4.5 years after implementa - tion):1.9% all PUs;1.1% PUs on heel.

“With the assistance of the automated consults and orders, the addition of another WOC nurse, the appropriate equipment, the inter-disciplinary task force, continuing education, and monitoring, the hospital system was able to reduce the hospital-acquired pressure ulcer prevalence rate by 81%, and the rate for heel ulcers alone was reduced by 90%.”Estimated annual cost savings: $11,466,000

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Ballard et al. 20078

Implementation of multiple strategies in an intensive care unit (ICU) to reduce the rate of PUsTarget safety problem: PUKey elements:Strategies included: restructured risk assessment and documentation, translated numeric data into easy-to-understand graphs of PU rates, increased staff awareness, implemented “turn rounds,” increased prevalence assessments and redesigned “skin team,” used evidence-based practices for monitoring and treating PUs, and created an access database to track weekly prevalence

Time series

NS Two-unit ICU with a total of 44 beds located in two separate geographical locations in the United States.

External:Joining the National Database of Nursing Quality Indicators (NDNQI) and realizing that ICU had high prevalence of PUs.Organizational Characteristics: NSTeamwork, Leadership, Culture:Primary nursing modelImplementation tools:CWOCN conducted a needs assessment, creation of user friendly reports to show rate of PUs, posted data of PU rates for staff to see, skin teams (consisted of nursing staff who performed weekly prevalence assessments and provided education), and Access database

Length: 1 yearProcess:Conducted needs assessment to identify areas of weakness in identifying, monitoring, treating, and reporting PUs; made revisions to protocol based on results of needs assessment; created user friendly reports to display PU rates; increased staff awareness through displaying PU rates and providing education; implemented “turn rounds” every two hours; redesigned skin team, implemented evidence-based practices to assess risk and monitor PUs, and implemented Access database to track PUs.Successes:Reduction in rate of PUs and improved patient outcomes.Barriers: NSAddressing Barriers: NSSustainability:Staff commitment to implementing strategies and maintaining quality care.

Hospital acquired incidence rate: NSHospital acquired prevalence rates:Pre: 34%Post: 8.0%

Utilizing benchmark data helped the ICU focus on pressure ulcer prevention, which led to improved patient outcomes.

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Catania et al. 20079

Design and implementation of the Pressure Ulcer Prevention Protocol Interventions (PUPPI): a nursing initiative to prevent PUsTarget safety problem: PUKey elements:The PUPPI involves assessing risk and nutritional status, providing skin care, documenting, and giving referrals as needed.

Time series

NS All 5 inpatient units in one hospital in the United States. Units included 2 medical units, 2 surgical units, and one critical care unit.

External:2 stage IV ulcer identified; evidence from the NDNQI survey that the prevalence of PUs in the hospital in the study exceeded the national benchmark by close to 50%.Organizational Characteristics:Dedicated cancer hospitalTeamwork, Leadership, Culture: NSImplementation tools:Quality improvement team that consisted of a quality manager, nursing director, certified nurse aids (CNSs), nursing staff developmental specialists, and an enterostomal therapy nurse to develop and implement protocol.

Length:6-months to implement; follow-up data reported for 18 monthsProcess:Initial efforts started in 2003 and involved having clinical nurse specialists assess patient risk using the Braden Scale. These efforts led to the development of a quality-improvement team in 2004 and the development of the PUPPIs. The PUPPI was implemented in September 2004 and included a systematic process for monitoring and educating staff.Successes:Reduction in rates of PUsBarriers: NSAddressing Barriers: NSSustainability:Proactive nursing staff who have adopted initiatives in protocol into their daily routine.

Hospital acquired incidence rate: NSHospital acquired prevalence rates:Pre:11.11% all ulcers;6.67% hospital acquiredPost:4.08% all ulcers;1.36% hospital acquired

“While the unit CNSs have championed this process and continue to monitor the program, it has been the nursing staff who have embraced evidence-based nursing practice and brought it to the bedside by adopting the initiative into daily practice.”

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LeMaster, K. 200710

Pressure Ulcer Prevention Project implemented on targeted units—pulmonary unit and oncology unitTarget safety problem: PUKey elements:Turning at-risk patients every two hours minimally, placing a pressure-reducing overlay on the bed of every patient at risk, and elevating bony prominences at risk

Time series

NS Pulmonary and oncology unit of the largest hospital campus within one healthy system; a 502-bed hospital in the United States.

External:Selection of study units was based on unit having a higher hospital-acquired PU rate than the NDNQI database mean for similar units and having higher hour-of-care ratios than the NDNQI mean for similar units.Organizational Characteristics: NSTeamwork, Leadership, Culture: NSImplementation tools:Manual containing information about wounds and wound care, instructions on the use of the Braden Scale to assess risk for developing PUs, patient turn schedule, and cues to use as reminders to turn patients.

Length:Summer 2004–April 2005Process:The first phase of implementation involved assessing and establishing baseline knowledge of unit staff nurses for assessing risk. Staff then identified resources and studied the manual. Nursing staff began assessing and documenting risk and implementing other aspects of the protocol (placing pressure-reducing overlay on bed). A CNS provided consultation and oversight throughout implementation period.Successes:Reduction of PUs in targeted units and successful duplication of intervention in other medical units.Barriers:Braden scores were not documented at 100% per policy. Patients were missed because of failure in communication between two different electronic documentation systems.Addressing Barriers:Barrier to be eliminated with transition to a single, universal electronic record system within hospital.Sustainability:Manual and cues to help maintain consistent and complete practice patterns.

Hospital acquired incidence rate: NSHospital acquired prevalence rates:Pre Pulmonary Unit: 9.0%Post Pulmonary Unit: 0.0%Pre Oncology Unit: 12.0%Post Oncology Unit: 0.0%

NS

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Courtney et al. 200611

To develop and implement Save Our Skin program to reduce the rate of PUsTarget safety problem: PUKey elements:Updating pressure-relieving mattress, introducing skin breakdown prevention protocols, clarifying staff roles and responsibilities (introduced a skin champion), and improving measurement a communication of PU performance data

Time series

Used procedures of the Six Sigma method, a data-focused, decision-making process that utilizes a five phase process called DMAIC: Defining the problem, Measuring the perform-ance, Analyzing the problem, Improving the situation, and Initiating change.

710-licensed bed, multisite, not-for-profit facility that serves a 37-county area; is Magnet designated

External:Results using the Nursing Care Quality Initiative guidelines that revealed high prevalence of PUs (13%) and lack of documentation and management. Revitalized interest in treatment and prevention shown by American Nurses Association and AHRQ in developing new guidelines.Organizational Characteristics:Magnet designated hospitalTeamwork, Leadership, Culture: NSImplementation tools:Implemented guidelines for the prevention and management of PUs from the Wound, Ostomy, and Continence Nurses Society and assessed risk using the Braden Scale.

Length:Follow-up 3 yearsProcess:Adopted Six Sigma procedures, assessed potential causes of high incidence of PUs and lack of staff coordination and management of PUs, and introduction of solutions: staff training and awareness, development and implementation of Skin Breakdown Prevention protocol, replacement of pressure mattresses, designation of Skin champion, clarification of staff roles, and implementing monitoring proceduresSuccesses:Reduced incidence of PUs and cost savingsBarriers: NSAddressing Barriers: NSSustainability:Defining staff responsibilities, monitoring performance, using data to inform staff performance, and making data public

Hospital acquired incidence rate:Pre: 9.4%Post:1st quarter implementa-tion 3.1%; last follow-up 1.8%Hospital acquired prevalence rates: NS

This project refocused efforts on traditional direct nursing care and problem solving procedures from the Six Sigma method to implement the Save Our Skin program.

Gibbons et al. 200612

To develop and implement best practice guidelines, known as the SKIN bundle (Surfaces, Keep the patient turning, Incontinence management,

Time series

NS Large 528-bed hospital, part of nation’s largest Catholic and non-profit health system

External:Development of the SKIN bundle is part of the Ascension Health Care system’s initiative to reduce/eliminate preventable hospital-related injuries and deaths.Organizational

Length:10 months to implement; follow-up 2 years

Process:Began with engaging leadership, forming an interdisciplinary team, and providing “protected” time to

Hospital acquired incidence rate:Pre: 5.7%Post: 0.448No new Stage III or IV HAPU

Of eight priorities identified for action by Ascension Health; St. Vincent’s Medical Center was

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Nutrition) to prevent PUsTarget safety problem: PUKey elements:Developed a synergistic group of interventions that includes appropriate surface selection (e.g., pressure mattress), regular turning of patients, incontinence management, nutrition and hydration, ongoing monitoring and staff training.

Characteristics:Faith-based, non-profit hospitalTeamwork, Leadership, Culture: NSImplementation tools:Regular assessment and documentation on flow sheets, skin risk alert reminders, weekly team meetings, and ongoing performance monitoring and reporting.

work on project. The project moved toward identifying best practices, assessing current practices, and developing the SKIN bundle. Lastly, the project involved educating staff and piloting the SKIN bundle.Successes:90% reduction in incidence of PUs.Barriers:Educating staff, communication, motivation, and hard- to-treat patients (patients whose treatment involves hours of sitting or lying down, such as radiology or dialysis)Addressing Barriers:Keep educational offerings basic, short and focused, and available at multiple times; make sure key staff organizing initiative have good communication skills and plan for times and methods of communication, celebrate successes and provide tangible incentives, make a plan for hard-to-treat patients.Sustainability:Being open to suggestions from staff, continually focusing on education, monitoring outcomes, and promoting free exchange of information.

occurred between August 2004 and February 2006

selected to develop the PU process.The hospital leadership “welcomed the opportunity to develop this nursing-driven program as a means of establishing pride in professional nursing practice.”67 acute care facilities in the Ascension health system agreed to implement the SKIN bundle plus “common measures of quality and performance.”

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Hiser, et al. 200613

To implement a team approach to performance improvement and develop an education plan for clinical staff to better prevent and treat PUsTarget safety problem:PUKey elements:Education, policy changes, development of evidence-based protocols, cost improvement strategies, implementing new support surfaces, and improved reporting and monitoring through quarterly prevalence studies and improved risk assessment using the Braden scale.

Time series

NS 580-bed regional medical facility in the U.S.

External: NSOrganizational Characteristics: NSTeamwork, Leadership, Culture: NSImplementation tools:Created a Wound Care Team that consisted of CWOCNs and an advanced registered nurse practitioner to implement changes and educate staff; replaced the Norton Scale with the Braden scale to assess risk.

Length:2 years follow-up.Process:Implementation started with a review of the literature of best practices for prevention and treatment of PUs.Successes:Reduced prevalence of PUs and annual cost savings.Barriers: NSAddressing Barriers: NSSustainability:Ongoing education and newsletters reporting progress and positive feedback to staff.

Hospital acquired prevalence rates:Pre: 9.2%Post: 6.6% (measured at 2 years follow-up)

NS

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Lyder et al. 200414

To implement a multihospital collaboration to increase the identification of patients at high risk of PUs and to promote the use of preventive measures among hospitalized Medicare patientsTarget safety problem: PUKey elements:Increase in the following: tracking of PUs, performance and documentation of risk assessment, use of prevention protocol (includes education and oversight of staff), scheduled repositioning, use of pressure-reducing devices, nutritional consults, and accuracy of staging.

Pre-post Plan-Do-Study-Act (PDSA)

17 hospitals ranging from 200 to 800 beds with 9 located in urban and 8 in rural settings in the U.S.

External:In response to Centers for Medicare & Medicaid Services charge to improve quality of care to Medicare patients.Organizational Characteristics: NSTeamwork, Leadership, Culture:Hospitals needed to develop a team approach to implementing changes.Implementation tools:Qualidigm, the Connecticut QIO,Computerized charting system for tracking PUs, creation of skin care task force, and pocket-sized wound staging card.

Length:9 months implementation, 2 years follow-up.Process:The PDSA framework involved 1) identifying problem to be changed and designing an intervention; 2) implementing this intervention; 3) evaluating the impact of the intervention, and implementing what was learned from evaluation.Successes:Significant increases in identifying high-risk patients, repositioning bed and chair bound patients, use of nutritional consults, and staging of acquired Stage II or greater PUs.Barriers:View that PU prevention was a nursing issue.Addressing Barriers:Re-educating various disciplines about their role in PU preventionSustainability:Hospitals found that the most sustainable interventions were institutionalized, such as change in pressure-relieving mattress. Interventions that depended more on sufficient staff such as turn schedules were less sustainable.

Hospital acquired incidence rate:No statistically significant change from baseline to follow-up (20.6 to 20.8, p = 0.90)Hospital acquired prevalence rates: NSDecrease in median length of hospital stay (8.0 days to 7.0 days, p = 0.05)

“Focusing pressure ulcer prediction and prevention programs on the nursing staff is limited insofar as effective pressure ulcer prevention requires a multidisciplinary effort. The PDSA model assists hospitals in working in multidisciplinary teams and places the onus for improvement on the team rather than on a particular discipline.”

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Stier et al. 200415

To implement a system wide multidisciplinary skin care initiative to standardize care to reduce the incidence and severity of PUsTarget safety problem: PUKey elements:The project involved standardization of risk assessment methods, delineating timeframes for patient assessment, and reassessment, developing a uniform skin care formulary, negotiating a system-wide contract for therapeutic support surfaces, and providing staff education.

Time series

NS A large not-for-profit health care system in the U.S. with over 5,600 beds and more than 33,000 employees. The system is composed of 18 hospitals, 4 skilled nursing facilities, 1 certified home health agency, and 2 hospice agencies. The focus of current study is on implementing skin care initiatives in acute care hospitals.

External: NSOrganizational Characteristics: NSTeamwork, Leadership, Culture: NSImplementation tools: Implemented Braden scale to standardize risk assessment

Length: 2 years follow-upProcess:Convened a multidisciplinary team of experts to develop an implementation plan. The first initiative implemented was the Braden scale of risk assessment. The second was working closely with Materials Support Services to develop a formulary for skin care products. The final steps involved staff education and implementing quality control measures.Successes:Reduction in the inpatient incidence of PUs.Barriers: NSAddressing Barriers: NSSustainability:Valid and reliable measurement system that allows for ongoing assessment and evaluation of performance and ongoing education.

Hospital acquired incidence rate:Pre: 2.2%Post: 1.3%

“A standardized approach to patient assessment/ re-assessment through the use of evidence-based guidelines and educational programs led to a common understanding of pressure ulcer management, improved communication among care providers, and sustained improvement in patient outcomes.”

a Not included in the Soban 2009 review16

CMS: Centers for Medicare and Medicaid ServicesCNS: Clinical nurse specialistCPG: Clinical practice guidelinesCWOCN: Certified Wound, Ostomy, and Continence NurseDMAIC: Defining, measuring, analyzing, improving, initiating changeEBP: Evidence-based practiceEMR: Electronic medical recordHAPU: Hospital-acquired pressure ulcerICU: Intensive care unitIHI: Institute for Healthcare ImprovementLPN: Licensed practical nurse

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MICU: Medical intensive care unitNDNQI: National Database of Nursing Quality IndicatorsNR: Not reportedNS: Not statedPDSA: Plan-Do-Study-ActPOA: Present on admissionPSP: Patient safety practicesPU: Pressure ulcerPUPPI: Pressure Ulcer Prevention Protocol InterventionQIO: Quality Improvement OrganizationRN: Registered nurseSKIN: Surfaces, Keep the patient turning, Incontinence management, NutritionSOS: Save our skinWOC: Wound, ostomy and continenceWOCN: Wound, Ostomy and Continence Nurses Society

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