| Principal Investigator: | Sarah Herb, RN, BSN, WCC |
| Co-Principal Investigator/Collaborator: | Joyce Reichenbacker |
| Organization: | Schneck Medical Center |
Abstract
Problem
Monthly prevalence and incidence studies revealed a steady increase in the number of hospital acquired pressure ulcers (HAPU).
Evidence
Current evidence indicates a team approach to pressure ulcer prevention decreases rates of HAPU. With support from leadership, creating a culture within a facility that empowers nurses and rewards excellence will help promote staff accountability. AHRQ, Cochrane, Medline and NIH databases were utilized and key words were team and pressure ulcer prevention.
Strategy
Using the PDSA Model of Performance Improvement, bedside nurses took ownership of improving patient outcomes through an aggressive Pressure Ulcer Prevention Initiative. They reviewed the products and interventions that were being used and asked the question: “What is best practice?” They conducted literature reviews and then implemented the changes. The team educated staff, patient and family members and the community. Monthly “Skin Champions” and “Unit Champions” were identified and rewarded.
Practice Change
There were several practice changes that were initiated by the Skin Champions Team. On admission, two nurses began performing skin assessments to correctly identify potential breakdown. Nurse generated nutrition consults were implemented as well as the ability to order pre-albumins. An aggressive turning program was instituted and pressure redistribution surfaces were upgraded.
Evaluation
Monthly prevalence and incidence studies were conducted on all inpatients from the inception of the Skin Champions Team.
Results
The data shows a dramatic decrease in the number of pressure ulcer incidence since the inception of the Skin Champions Team, as evidenced by the monthly Surveillance Rounds completed by the Champions. HAPU rates remained at 0 for 4 consecutive quarters.
Recommendations
- Create a team that is multidisciplinary.
- Establish a physician champion.
- Disseminate information through multiple mediums in a timely manner.
Lessons Learned
A pressure ulcer prevention program driven by bedside nurses and focused on evidence based practices decreased the rate of hospital acquired pressure ulcers, thereby improving patient care and safety.
Bibliography
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