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Putting a dent in pressure ulcer rates

Dunleavy, Kathleen RN, CNA, CNRN, MA

doi: 10.1097/01.NURSE.0000305900.27041.49
Department: upFront: DOING IT BETTER: Putting research into practice

Kathleen Dunleavy is the patient-care director of the Neuroscience Intensive Care Unit at Columbia University Medical Center, New York-Presbyterian Hospital, in New York, N.Y.

Web site last accessed on November 30, 2007.

IN MY EARLY YEARS as a staff nurse, we religiously turned our patients every 2 hours on the odd hour, and our pressure ulcer rate was extremely low. In 1998, after I mentioned this at an ICU committee meeting during a discussion of pressure ulcer rates, I was asked to chair a skin care task force. Our goal was to reduce the incidence of pressure ulcers, particularly in our ICUs.

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Starting a task force

We formed a skin care task force that included nurse-managers; wound, ostomy, and continence (WOC) nurses; staff nurses; and representatives from physical therapy, nutritional services, and nursing education. We believed that the incidence of pressure ulcers was directly related to higher patient acuity, diminished cardiac output, and heavier workloads for staff nurses.

For 2 years, the committee made recommendations intended to improve nutrition and reduce skin pressure. These recommendations included serum albumin testing upon admission and earlier nutritional support; specialty beds in all ICUs; use of pressure-relieving surfaces; review of do-not-turn policies specific to each critical care area and alternating-pressure surfaces for all do-not-turn patients; and education for staff nurses and nurse-managers.

Unfortunately, our recommendations weren't consistently followed. By 2001, we'd hardly made a dent in pressure ulcer rates, particularly in our ICUs. So we reconvened and set about our mission more aggressively, holding monthly meetings and expanding membership to include nurses from any setting where a patient had to be in one position (usually on her back) for a significant time. These settings included the OR, recovery rooms, the ED, and the dialysis unit.

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Emphasis on skin care

We believed that effective skin care had become a lost art and that the nursing staff urgently needed reeducation because our pressure ulcer rates exceeded the national mean. Around that time, the hospital sent a surgical ICU nurse to a WOC nursing program and we got the expertise we needed. Overall, the WOC nursing staff increased from 2.0 to 3.5 full-time equivalents.

The skin care task force began reviewing and evaluating information about skin and skin care. With the guidance of the director of nursing practice, we educated ourselves about the National Data Base for Nursing Quality Indicators (NDNQI) and the work of the National Pressure Ulcer Advisory Panel (NPUAP). Using the NPUAP guidelines, we collected and studied all skin-related policies, procedures, protocols, and standards at our institution—19 documents—and then developed 3 major documents that we believed covered all aspects of skin care (one each on prevention and management of pressure ulcers, wound care, and incontinence management). We added a fourth document on negative-pressure wound therapy. We presented several all-day workshops on basic and advanced skin care that were “sold out” every time.

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Adding adjunctive therapies

We recruited outside companies to help us identify adjunctive therapies such as specialty beds, mattresses and overlays, and effective skin care products.

The skin care task force forged a relationship with the company that rented us specialty beds, which also provided algorithms showing proper product use. We gave pocket guides to all managers, describing each specialty device and how to use it.

We developed a formulary of 29 products approved for use in our hospital for skin care. We also provided posters and pocket guides showing each pressure ulcer stage and the correct product to use.

To educate the staff about how to select the appropriate specialty bed, mattress, or overlay, we held classes for all nurse-managers, patient-care directors, and evening and night supervisors. Only they can order these products, and then they must confirm their selections with WOC nurses. We've also educated physicians on how to select the correct specialty bed, mattress, and overlay by referring to our algorithm posters in the units.

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Preventing skin problems

Probably the most important action the skin care task force took was to conduct intensive mandatory staff education for the entire nursing staff on skin care and the prevention and management of pressure ulcers. Sessions were conducted by WOC nurses, nursing educators, and nurse-managers. Because ICU patients are most susceptible to pressure ulcers, 4-hour sessions were offered for our ICU nurses. Medical/surgical nurses attended 2-hour sessions; ancillary staff, 1-hour sessions. Of our ICU staff, 90% attended the first set of sessions, the highest of all groups.

To spread skin care expertise throughout our facility, we've advocated for one nurse in each patient-care unit to be designated as a skin care resource nurse. These nurses' duties are to attend skin care task force meetings and skin care workshops, ensure that WOC nursing recommendations for individual patients are carried out consistently, focus on preventing pressure ulcers, educate staff, and keep unit statistics.

To help the skin care resource nurses, we hold monthly skin wound action team (SWAT) meetings. Half of the 1-hour class is devoted to skin care and the rest to role implementation, which is how to carry out the skin care resource nurse's duties and responsibilities. We also hold popular monthly classes for unlicensed assistive personnel.

Because the WOC nurses have busy schedules, we're trying to expand skin care expertise to other nurses. We believe that nurse-managers and patient-care directors should be able to manage Stage I and II pressure ulcers without a WOC nurse consult.

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Simple but effective changes

We've made many simple but effective changes at our facility to help prevent pressure ulcers.

  • We've upgraded our standard pillow to a plumper one with a breathable air strip, which allows for a better prop. (The pillow previously used was flat and didn't keep the patient on her side.)
  • We purchased chair cushions for immobile patients to relieve the pressure on their trochanters while they're sitting in chairs.
  • All units have established par levels for skin care products in their units.
  • More heel-flotation devices are in use.
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More changes instituted

In 2005, the skin care task force was reorganized into the pressure ulcer prevention steering committee, chaired by the director of professional nursing practice. The steering committee is responsible for gathering input from all five sites of the New York-Presbyterian Hospital.

Two new initiatives since 2005 are a mandatory e-learning pressure ulcer module for all staff nurses to complete online, and positioning schedules in the critical care units, which are completed by the staff nurse every 2 hours around the clock.

Also in 2005, the vice president for nursing mobilized the critical care nurse-managers into a task force whose sole goal was to reduce the incidence of pressure ulcers in critical care.

In 2006, the pressure ulcer incidence rate in critical care was lower than the national NDNQI benchmark for both the second and the third quarters of the year.

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Taking responsibility

With a growing emphasis on patient safety, hospitals and nursing staff are increasingly held responsible for preventing avoidable complications such as pressure ulcers. In our facility, nurses have risen to the challenge and will continue to do so.

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The skin care task force adopted these goals in 2005:

  • publish our work
  • conduct a turning survey and implement strategies to improve practice based on results
  • promote greater staff nurse attendance at our meetings
  • develop a recognition tool for staff who complete skin care educational programs
  • develop WOC nursing manuals in every unit
  • conduct a 1-day institution-wide prevalence study of pressure ulcer development
  • establish a Web site for skin care
  • approve a specialty bed protocol
  • secure a full-time medical advisor
  • develop a continuing-education skin care program on the Internet
  • present skin care task force work at critical care grand rounds.
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Ayello EA, et al. Nursing2005 wound care survey report. Nursing2005. 35(6):36–47, June 2005.
    Braden BJ, Maklebust J. Preventing pressure ulcers with the Braden scale: An update on this easy-to-use tool that assesses a patient's risk. American Journal of Nursing. 105(6):70–72, June 2005.
    Pressure ulcers in America: Prevalence, incidence, and implications for the future: An executive summary of the National Pressure Ulcer Advisory Panel monograph. Advances in Skin and Wound Care. 14(4):208–215, July-August 2001.
    Price MC, et al. Development of a risk assessment tool for intraoperative pressure ulcers. Journal of Wound, Ostomy and Continence Nursing. 32(1):19–32, January-February 2005.
    .National Pressure Ulcer Advisory Panel.
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