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Use of a total quality management model to reduce pressure ulcer prevalence in the acute care setting
Use of o Total Qua ity M a n a g e m e n t Model to Reduce Pressure U oar Preva enoe in the Acute Care Serf ng Claudia
SacharoK BSN,
RNC, CETN, a n d J a n e t Drew, MSN, CNS, N P
As the population ages and becomes more frail, pressure ulcer prevalence and incidence within specific care settings are being evaluated through outcomes review. This article summarizes the process and outcomes of an ongoing prevalence study at a 300-bed acute care community hospital. All patients on the adult medical, surgical, and critical care units were examined regularly by the "Rear Admirals," a team comprising a skin care resource person and a nursing unit representative. The Total Quality M a n a g e m e n t model, characterized by the phrase "Plan-Do-Check-Act," was used to address barriers to quality care. Findings during that time prompted changes in policies, products, protocols, work assignments, and documentation tools. The outcomes achieved demonstrate the effectiveness of those strategies. After implementation of the Total Quality M a n a g e m e n t model at our institution, the prevalence of patients with nosocomial pressure ulcers was reduced by 83%. (J WOCN 1998;25:88-92)
p
Ms. Sacharok, BSN,RNC, is a Certified Enterostomal Therapy Nurse, Underwood-Memorial Hospital, Woodbury, N.J. Ms. Drew, MSN, NP, is the Clinical Nurse Specialist for the Adult Health Division, Underwood-Memorial Hospital, Woodbury, N.J. Reprint requests: Claudia
Sacharok, BSN,RNC, CETN, Underwood-Mem orial Hospital, 509 N. Broad St., Woodbury, NJ 08096.
Copyright © 1998by the Wound, Ostomy and Continence Nurses Society.
1071-5754/98/$5.00+ 0 21/1/88316
88
ressure ulcer prevention is important to all health care providers. As the population ages and becomes increasingly frail, the incidence and prevalence of pressure ulcers are being monitored by peer review and managed care organizations. Increasingly, hospitals use pressure ulcer prevalence (the presence of pressure ulcers noted in a population at one point in time) to quantify the extent of the pressure ulcer problem at their institutions. 1 Pressure ulcer prevalence in acute care hospitals ranges from 5% to 20%. 2The rate of hospital-acquired pressure ulcers reflects potentially preventableskin impairment occurring within an institution. Therefore, the prevalence of nosocomial pressure ulcers comprises the focus of a prevalence study within our health care facility. In January 1993, a 1-day prevalence study was completed at our institution. All patients on the adult medical, surgical, and critical care units were evaluated. The presence and staging of pressure ulcers was determined using criteria set forth by the Wound, Ostomy and Continence Nurse's Society. 3 Data collected on patients with ulcers included age, site, stage,
laboratory values, Braden Risk Assessment Scale scores, and preventive and therapeutic interventions. Data analysis indicated that the nosocomial prevalence of patients with stage I through IV pressure ulcers in our facility was above the national average (Figure 1). As a result of this information, the adult health and critical care divisions identified improving skin integrity as a continuous quality improvement project. During 1994, nursing representatives from those units met with a nursing administrator, unit manager, the w o u n d care specialist, and the clinical specialist to form a skin care team. With use of the Total Quality Management model's "Plan-Do-Check-Act,"4 this group identified staff, patient, and system factors needing change. An action plan to improve skin integrity was then developed and implemented.
"PLAN" Initially, a literature search was conducted to provide support for our initial observations and ideas for change. Louviere and colleagues 5supported the use of the Total Quality Management model for improving skin integrity. Olson and associates 6 stressed the importance of ongoing risk assessment to promote early intervention. Meehan 7reported that 54% of the patients who acquire a pressure ulcer are between the ages of 70 and 89. Epidemiologic data generated at our institution also indicated that the patients most affected by pressure ulcers were those more than 70 years of age. Nursing-staff knowledge and care-delivery patterns were assessed using a skin care survey and a retrospective chart review tool developed by the team. In addition, a separate retrospective chart review of pressure ulcer incidence was begun in conjunction with the New Jer-
JWOCN Volume 25, Number 2
Sacharok and Drew
70.0% 60.0% 50.0% 40.0%
30.0% 20.0% 10.0%
0,0% %of Patents with
of Patients w/Ulcers, % >70yo
LJlcem
% Sacral Ulcem
ULCER8 Figure I. Comparison of hospital prevalence to national data in 1993.
sey Peer Review Organization (PRO).S This group undertook this task to assist acute care facilities with pressure ulcer prevention. The data helped identify the following staff factors as having an impact on skin care: (1) Lack of knowledge regarding conditions that increase patient risk, preventive aids, assistive devices and pressure ulcer treatment products available, (2) Lack of time caused by numerous interruptions while doing assessments and giving care, (3) The need to leave the unit to obtain supplies and equipment, (4) Lack of consistent care between shifts as a result of inadequate documentation, (5) Inadequate intershift communication, and (6) Changing work assignment patterns. Identification of these factors led to the development of a multifaceted action plan for quality i m p r o v e m e n t that included ongoing clinical monitoring and interventions by the "Rear Admirals" (a team comprising a skin care resource person and a nursing unit representative), staff education, protocol and product improvements, and systems adjustments within the institution. iiDOlW
On the first Wednesday of each month in 1994, our Rear Admirals team evaluated the prevalence of pressure ulcers at our institution. The team members saw all adult health and critical care patients hospitalized on those days and examined their skin. When a patient at risk for pressure ulcer development was identified, the team provided either written praise for proper
preventive care or suggestions for improvement when indicated. The kudos provided the staff with prospective consultation and feedback regarding the effectiveness of the skin care they provided. For patients with pressure ulcers, treatment was initiated, continued, or revised as appropriate. Data concerning the patient's age, diagnosis, nutritional status, continence, Braden Scale score, preventive care, and the ulcer site, stage, and treatment were collected. The data were then used for staff education and measurement of quality improvement. The Rear Admirals' evaluations were conducted quarterly from 1995 to 1997. We continue to collect the quantitative data elements recommended by the Agency for Health Care Policy and Research (AHCPR).9 In addition to the direct feedback provided during the Rear Admirals' prevalence rounds, we also initiated an intensive program of staff education. Educational activities are provided by the skin care team in collaboration with product manufacturer's representatives and with the d e p a r t m e n t s of infection control, physical medicine and rehabilitation, and nursing staff development. Posters are displayed on each unit to publicize the hospitalwide and unit-specific results of our prevalence rounds on an ongoing basis. Skin care programs designed to communicate and reinforce changes in available products and protocols are provided at annual m a n d a t o r y staff meetings. The importance of daily skin inspection and prompt intervention as part of the physical assessment is stressed. Annual mandatory equipment fairs are used to reinforce
Uloem
89
90
JWOCN March 1998
Sacharokand Drew
the proper use and maintenance of equipment. A "Skin Care Fair" on ET Day in 1994 emphasized identification, differentiation, and appropriate treatment of stage I pressure ulcers, shearing/friction ulcers, and the impact of incontinence. A luncheon presentation on that day reinforced the causes and risk factors for development of pressure ulcers. Programs provided to all nursing staff at annual upgrades in 1994 by the department of physical medicine and rehabilitation reinforced proper techniques for patient repositioning and transferring. Education highlighting changes in the skin care documentation tool and the Braden Scale was provided to the staff. Pressure ulcer protocols are included in the pocket reference guide developed for the nursing staff. Additional improvements in protocols and products were made based on both the AHCPR guidelines 1and the recommendations of other nationally recognized experts. A pressure ulcer protocol was developed and approved for use throughout our hospital. Pressure-reducing mattresses were tested and purchased. In addition, static air, anti-shear and-friction, low air-toss, and air-fluidized support surfaces have been incorporated into the care plan based on daily patient assessments and consultation with the wound care specialist. Thirty-degree laterally inclined positioning is promoted. The research of Colin and colleagues 1° indicates that these slight position changes prevent the tissue ischemia seen with 90-degree laterally inclined positions. Routine head-of-bed elevations of no more than 30 degrees were implemented as recommended by Alvarez. 2New bed frames with elevation scales facilitated implementation of this procedure. Topical skin care products were evaluated and changes were made as indicated. Skincleansing agents that minimize friction, heat, irritation, and dryness were purchased, as were incontinence pads and containment products that wick moisture away from the skin. ~ The use of adult containment briefs was limited to times when the patient is out of bed or in transit to another department. Regular use of lubricants was promoted to reduce the mechanical insult of shearing and friction and return skin to a more normal state) The problems related to staff time and consistency of care were brought to the attention of the unit coordinators as well
as the unit-based, intershift clinical practice committees. The following suggestions were made: (1) Educate the unit secretaries to screen staff calls and take messages to reduce telephone interruptions, (2) Collaborate with the volunteer and nursing education departments to increase the number of functions of the volunteers and nonprofessional staff, optimizing benefits to patients, (3) Review and redesign work assignments within and between shifts, (4) Implement staggered staff mealtimes so that all staff are available for patient feeding, (5) Implement less rigid timing of patient baths, and (6) Modify rotation of staff assignments to promote consistency of care. Many changes were made hospitalwide. Use of the Braden Scale for all adult health and critical care admissions, as recommended by the AHCPR guideline, 1 was implemented. A weekly reassessment was done to promote early identification of risk factors on an ongoing basis. The Braden Scale and the nursing care flow sheet were placed at the patient's bedside for easy accessibility. Multidisciplinary consultations with nutrition services, physical therapy, and ET nursing were promoted through use of Braden Scale information and weekly team conferences. A redesign by the nursing staff of the nursing care flow sheet from one third of a page to a full page allowed for more complete documentation of skin assessment and care. Standardization of the pressure ulcer prevention and treatment products available on each unit saved nursing time and allowed for prompt intervention when a problem was identified.
"CHECK" (RESULTS) We continue to collect pressure ulcer data at our institution through both the Rear Admirals' prospective prevalence study and the PRO retrospective incidence study. Based on the results of data collected at the time of this writing, a reduction in hospitalwide pressure ulcer prevalence was achieved by August 1994 and this trend continued into 1997. The prevalence of patients with nosocomial ulcers was reduced from 19% in 1994 to 3% in 1997 (Figure 2). Improvement also was seen in the implementation of appropriate treatments for those patients with pressure ulcers (Figure 3). Unit-based data analyses (not shown) demonstrate that our gains have been consistent over
JWOCN Volume 25, Number 2
Sacharok and Drew
20% 18% 16% 14%
~
12% 10% 8% 6% 4% 2% 0% Feb '94
Jan'S3
Aug '94
Jan ~J6
Aug '96
Jan 'r/
Figure 2. Prevalence of hospitalized patients with nosocomial ulcers from 1994 to 1997. 90% 80% 70% 60%
~
,50%
40% 30% 20% 10% 0% Jan '93
Feb '94
Aug '94
Jan '96
~
'96
TREATMENT Figure 3. Percentage of ulcers receiving treatment protocol.
time on the individual nursing units, again supporting the benefits of our quality improvement efforts. The results of the retrospective pressure ulcer incidence study that was done in conjunction with the PRO s substantiate our Rear Admirals' prevalence findings. As directed by the PRO, the population chosen for the study were randomly selected patients over the age of 85 admitted during a 3-month time period in 1994, compared with a similarly selected population admitted during a 2-month time period in 1995. Analysis demonstrated that over time more patients were admitted from long-term care facilities, and had risk factors for pressure ulcers. Yet, even in this increasingly frail population, we
reduced our nosocomial pressure ulcer incidence by 43% (Figure 4).
"ACT" (CONCLUSION) The improvement process is ongoing. In 1996, the importance of involving the emergency department (ED) was recognized. Consequently, ED educators and staff leaders now discuss skin care issues at ED staff and clinical practice meetings. In addition, we have added ED patients to our quarterly rounds. Patients who are immobile, more than 65 years of age, and experience an extended length of stay (defined as > 2 hours) in the ED are assessed, and implementation of appropriate preventive measures are instituted. Pro-
Jan '97
91
92
JWOCN March 1998
S a c h a r o k and Drew
Retrospective Pressure Ulcer Incidence Study (PRO) 100%
8o% 70% [Z Jan-A,0r94
mSep-Oct9S 4o% 30% 20% 10%
0% Admission from Nursing Home
Pressure Ulcerson admission
Braden donem admission
RiskFactor present
~ a l Ulcer presentQ discharge
Demographlcs Figure 4. C o m p a r i s o n of d e m o g r a p h i c s a n d ulcer i n c i d e n c e in patients a g e d 85 a n d o l d e r in the PRO study.
spective r e v i e w a n d direct f e e d b a c k n o w occur in this clinical area as well. Recently, o u r efforts h a v e e x t e n d e d into l o n g - t e r m care facilities. We n o w collaborate monthly to a d d r e s s issues related to continuity a n d q u a l i t y of care. N u t r i t i o n , skin care, res t r a i n t r e d u c t i o n , a n d i m p r o v e m e n t in the transfer of i n f o r m a t i o n are evaluated. O u r ET n u r s e c o n t i n u e s to e v a l u a t e p r o d u c t s a n d p r a c t i c e s b a s e d on c u r r e n t i n f o r m a t i o n p r e s e n t e d m o n t h l y at Delaw a r e V a l l e y ET m e e t i n g s , n a t i o n a l conferences, j o u r n a l s , a n d on the internet. W e also continue o u r p a r t i c i p a t i o n in the P R O ' s r e t r o s p e c t i v e p r e s s u r e ulcer incidence s t u d y . In 1996, Bankert a n d associates 11r e p o r t e d on the v a l u e of collaborative b e n c h m a r k i n g as a m e t h o d of press u r e ulcer r e d u c t i o n . The o p p o r t u n i t y to n e t w o r k w i t h o u r p e e r s has b e e n h e l p ful. P e r h a p s the single g r e a t e s t factor in r e d u c i n g p r e v a l e n c e at our institution b y 83% c o n t i n u e s to b e o u r p r o s p e c t i v e monitoring and feedback on all of the adult units t h r o u g h our Rear A d m i r a l s ' q u a r terly surveys. REFERENCES I. Panel for the Prediction and Prevention of Pressure Ulcers in Adults.Pressure ulcers in adults: prediction and prevention; clinical practice guideline No. 3. Rockville(MD): US Department of Health and H u m a n Services, Agency for Healthcare Policy and Research M a y 1992; AHCPR Pub No. 92-0047. 2. Alvarez OM. Pressure ulcers: criticalconsider-
ations in prevention and management. Cli0 Mat 1991 ;8:209-22. 3. W o u n d Ostomy and Continence Nurses Society. Standards of care--patients with dermal wounds, pressure ulcers. Costa Mesa (CA): W O C N ; 1992. 4. Scholtes P. T e a m handbook. Madison (WI): James Association Inc',1988. p. 5-31. 5. Louviere M, Leuszler L, Helmick C. T Q M saves money, patient's skin. Mat M a n a g e 1992;March:48-50. 6. Olson B, L a n g e m o D, Burd C, Hanson D, Hunter S,Cathcart-Silberberg T.Pressure ulcer incidence in an acute care sefling.J W O C N 1996;23:15-22. 7. M e e h a n M. National pressure ulcer prevalence survey. Adv W o u n d Care 1994;7:27-38. 8. Drew J,Sacharok C. Pressureulcerprevention at Underwood-Memorial Hospital.In:Conte M (Chair). The power of partnerships: quality improvement projects with the Peer Review Organization of N e w Jersey. Princeton (N J): N e w Jersey Hospital Association; 1997. 9. Panel for the Treatment of Pressure Ulcers. Treatment of pressure ulcers: clinical practice guidelines No. 15. Washington (DC): US Department of Health and H u m a n Services, Agency for Healthcare Policy and Research 1994; AHCPRPub No. 95-0652. 10. Colin D, Abraham P, Preault L, Pregeon C, Saumet JL Comparison of 90° and 30 ° laterally inclined positions in the prevention of pressure ulcers using transcutaneous oxygen and carbon dioxide pressures. Adv Wound Care 1996;9:35-8. 11. Bankert K, Daughtridge S, Meehan M, Colburn L The application of collaborative benchmarking to the prevention and treatment of pressure ulcers. Adv Wound Care 1996;9:21-9.
SacharoK BSN,
RNC, CETN, a n d J a n e t Drew, MSN, CNS, N P
As the population ages and becomes more frail, pressure ulcer prevalence and incidence within specific care settings are being evaluated through outcomes review. This article summarizes the process and outcomes of an ongoing prevalence study at a 300-bed acute care community hospital. All patients on the adult medical, surgical, and critical care units were examined regularly by the "Rear Admirals," a team comprising a skin care resource person and a nursing unit representative. The Total Quality M a n a g e m e n t model, characterized by the phrase "Plan-Do-Check-Act," was used to address barriers to quality care. Findings during that time prompted changes in policies, products, protocols, work assignments, and documentation tools. The outcomes achieved demonstrate the effectiveness of those strategies. After implementation of the Total Quality M a n a g e m e n t model at our institution, the prevalence of patients with nosocomial pressure ulcers was reduced by 83%. (J WOCN 1998;25:88-92)
p
Ms. Sacharok, BSN,RNC, is a Certified Enterostomal Therapy Nurse, Underwood-Memorial Hospital, Woodbury, N.J. Ms. Drew, MSN, NP, is the Clinical Nurse Specialist for the Adult Health Division, Underwood-Memorial Hospital, Woodbury, N.J. Reprint requests: Claudia
Sacharok, BSN,RNC, CETN, Underwood-Mem orial Hospital, 509 N. Broad St., Woodbury, NJ 08096.
Copyright © 1998by the Wound, Ostomy and Continence Nurses Society.
1071-5754/98/$5.00+ 0 21/1/88316
88
ressure ulcer prevention is important to all health care providers. As the population ages and becomes increasingly frail, the incidence and prevalence of pressure ulcers are being monitored by peer review and managed care organizations. Increasingly, hospitals use pressure ulcer prevalence (the presence of pressure ulcers noted in a population at one point in time) to quantify the extent of the pressure ulcer problem at their institutions. 1 Pressure ulcer prevalence in acute care hospitals ranges from 5% to 20%. 2The rate of hospital-acquired pressure ulcers reflects potentially preventableskin impairment occurring within an institution. Therefore, the prevalence of nosocomial pressure ulcers comprises the focus of a prevalence study within our health care facility. In January 1993, a 1-day prevalence study was completed at our institution. All patients on the adult medical, surgical, and critical care units were evaluated. The presence and staging of pressure ulcers was determined using criteria set forth by the Wound, Ostomy and Continence Nurse's Society. 3 Data collected on patients with ulcers included age, site, stage,
laboratory values, Braden Risk Assessment Scale scores, and preventive and therapeutic interventions. Data analysis indicated that the nosocomial prevalence of patients with stage I through IV pressure ulcers in our facility was above the national average (Figure 1). As a result of this information, the adult health and critical care divisions identified improving skin integrity as a continuous quality improvement project. During 1994, nursing representatives from those units met with a nursing administrator, unit manager, the w o u n d care specialist, and the clinical specialist to form a skin care team. With use of the Total Quality Management model's "Plan-Do-Check-Act,"4 this group identified staff, patient, and system factors needing change. An action plan to improve skin integrity was then developed and implemented.
"PLAN" Initially, a literature search was conducted to provide support for our initial observations and ideas for change. Louviere and colleagues 5supported the use of the Total Quality Management model for improving skin integrity. Olson and associates 6 stressed the importance of ongoing risk assessment to promote early intervention. Meehan 7reported that 54% of the patients who acquire a pressure ulcer are between the ages of 70 and 89. Epidemiologic data generated at our institution also indicated that the patients most affected by pressure ulcers were those more than 70 years of age. Nursing-staff knowledge and care-delivery patterns were assessed using a skin care survey and a retrospective chart review tool developed by the team. In addition, a separate retrospective chart review of pressure ulcer incidence was begun in conjunction with the New Jer-
JWOCN Volume 25, Number 2
Sacharok and Drew
70.0% 60.0% 50.0% 40.0%
30.0% 20.0% 10.0%
0,0% %of Patents with
of Patients w/Ulcers, % >70yo
LJlcem
% Sacral Ulcem
ULCER8 Figure I. Comparison of hospital prevalence to national data in 1993.
sey Peer Review Organization (PRO).S This group undertook this task to assist acute care facilities with pressure ulcer prevention. The data helped identify the following staff factors as having an impact on skin care: (1) Lack of knowledge regarding conditions that increase patient risk, preventive aids, assistive devices and pressure ulcer treatment products available, (2) Lack of time caused by numerous interruptions while doing assessments and giving care, (3) The need to leave the unit to obtain supplies and equipment, (4) Lack of consistent care between shifts as a result of inadequate documentation, (5) Inadequate intershift communication, and (6) Changing work assignment patterns. Identification of these factors led to the development of a multifaceted action plan for quality i m p r o v e m e n t that included ongoing clinical monitoring and interventions by the "Rear Admirals" (a team comprising a skin care resource person and a nursing unit representative), staff education, protocol and product improvements, and systems adjustments within the institution. iiDOlW
On the first Wednesday of each month in 1994, our Rear Admirals team evaluated the prevalence of pressure ulcers at our institution. The team members saw all adult health and critical care patients hospitalized on those days and examined their skin. When a patient at risk for pressure ulcer development was identified, the team provided either written praise for proper
preventive care or suggestions for improvement when indicated. The kudos provided the staff with prospective consultation and feedback regarding the effectiveness of the skin care they provided. For patients with pressure ulcers, treatment was initiated, continued, or revised as appropriate. Data concerning the patient's age, diagnosis, nutritional status, continence, Braden Scale score, preventive care, and the ulcer site, stage, and treatment were collected. The data were then used for staff education and measurement of quality improvement. The Rear Admirals' evaluations were conducted quarterly from 1995 to 1997. We continue to collect the quantitative data elements recommended by the Agency for Health Care Policy and Research (AHCPR).9 In addition to the direct feedback provided during the Rear Admirals' prevalence rounds, we also initiated an intensive program of staff education. Educational activities are provided by the skin care team in collaboration with product manufacturer's representatives and with the d e p a r t m e n t s of infection control, physical medicine and rehabilitation, and nursing staff development. Posters are displayed on each unit to publicize the hospitalwide and unit-specific results of our prevalence rounds on an ongoing basis. Skin care programs designed to communicate and reinforce changes in available products and protocols are provided at annual m a n d a t o r y staff meetings. The importance of daily skin inspection and prompt intervention as part of the physical assessment is stressed. Annual mandatory equipment fairs are used to reinforce
Uloem
89
90
JWOCN March 1998
Sacharokand Drew
the proper use and maintenance of equipment. A "Skin Care Fair" on ET Day in 1994 emphasized identification, differentiation, and appropriate treatment of stage I pressure ulcers, shearing/friction ulcers, and the impact of incontinence. A luncheon presentation on that day reinforced the causes and risk factors for development of pressure ulcers. Programs provided to all nursing staff at annual upgrades in 1994 by the department of physical medicine and rehabilitation reinforced proper techniques for patient repositioning and transferring. Education highlighting changes in the skin care documentation tool and the Braden Scale was provided to the staff. Pressure ulcer protocols are included in the pocket reference guide developed for the nursing staff. Additional improvements in protocols and products were made based on both the AHCPR guidelines 1and the recommendations of other nationally recognized experts. A pressure ulcer protocol was developed and approved for use throughout our hospital. Pressure-reducing mattresses were tested and purchased. In addition, static air, anti-shear and-friction, low air-toss, and air-fluidized support surfaces have been incorporated into the care plan based on daily patient assessments and consultation with the wound care specialist. Thirty-degree laterally inclined positioning is promoted. The research of Colin and colleagues 1° indicates that these slight position changes prevent the tissue ischemia seen with 90-degree laterally inclined positions. Routine head-of-bed elevations of no more than 30 degrees were implemented as recommended by Alvarez. 2New bed frames with elevation scales facilitated implementation of this procedure. Topical skin care products were evaluated and changes were made as indicated. Skincleansing agents that minimize friction, heat, irritation, and dryness were purchased, as were incontinence pads and containment products that wick moisture away from the skin. ~ The use of adult containment briefs was limited to times when the patient is out of bed or in transit to another department. Regular use of lubricants was promoted to reduce the mechanical insult of shearing and friction and return skin to a more normal state) The problems related to staff time and consistency of care were brought to the attention of the unit coordinators as well
as the unit-based, intershift clinical practice committees. The following suggestions were made: (1) Educate the unit secretaries to screen staff calls and take messages to reduce telephone interruptions, (2) Collaborate with the volunteer and nursing education departments to increase the number of functions of the volunteers and nonprofessional staff, optimizing benefits to patients, (3) Review and redesign work assignments within and between shifts, (4) Implement staggered staff mealtimes so that all staff are available for patient feeding, (5) Implement less rigid timing of patient baths, and (6) Modify rotation of staff assignments to promote consistency of care. Many changes were made hospitalwide. Use of the Braden Scale for all adult health and critical care admissions, as recommended by the AHCPR guideline, 1 was implemented. A weekly reassessment was done to promote early identification of risk factors on an ongoing basis. The Braden Scale and the nursing care flow sheet were placed at the patient's bedside for easy accessibility. Multidisciplinary consultations with nutrition services, physical therapy, and ET nursing were promoted through use of Braden Scale information and weekly team conferences. A redesign by the nursing staff of the nursing care flow sheet from one third of a page to a full page allowed for more complete documentation of skin assessment and care. Standardization of the pressure ulcer prevention and treatment products available on each unit saved nursing time and allowed for prompt intervention when a problem was identified.
"CHECK" (RESULTS) We continue to collect pressure ulcer data at our institution through both the Rear Admirals' prospective prevalence study and the PRO retrospective incidence study. Based on the results of data collected at the time of this writing, a reduction in hospitalwide pressure ulcer prevalence was achieved by August 1994 and this trend continued into 1997. The prevalence of patients with nosocomial ulcers was reduced from 19% in 1994 to 3% in 1997 (Figure 2). Improvement also was seen in the implementation of appropriate treatments for those patients with pressure ulcers (Figure 3). Unit-based data analyses (not shown) demonstrate that our gains have been consistent over
JWOCN Volume 25, Number 2
Sacharok and Drew
20% 18% 16% 14%
~
12% 10% 8% 6% 4% 2% 0% Feb '94
Jan'S3
Aug '94
Jan ~J6
Aug '96
Jan 'r/
Figure 2. Prevalence of hospitalized patients with nosocomial ulcers from 1994 to 1997. 90% 80% 70% 60%
~
,50%
40% 30% 20% 10% 0% Jan '93
Feb '94
Aug '94
Jan '96
~
'96
TREATMENT Figure 3. Percentage of ulcers receiving treatment protocol.
time on the individual nursing units, again supporting the benefits of our quality improvement efforts. The results of the retrospective pressure ulcer incidence study that was done in conjunction with the PRO s substantiate our Rear Admirals' prevalence findings. As directed by the PRO, the population chosen for the study were randomly selected patients over the age of 85 admitted during a 3-month time period in 1994, compared with a similarly selected population admitted during a 2-month time period in 1995. Analysis demonstrated that over time more patients were admitted from long-term care facilities, and had risk factors for pressure ulcers. Yet, even in this increasingly frail population, we
reduced our nosocomial pressure ulcer incidence by 43% (Figure 4).
"ACT" (CONCLUSION) The improvement process is ongoing. In 1996, the importance of involving the emergency department (ED) was recognized. Consequently, ED educators and staff leaders now discuss skin care issues at ED staff and clinical practice meetings. In addition, we have added ED patients to our quarterly rounds. Patients who are immobile, more than 65 years of age, and experience an extended length of stay (defined as > 2 hours) in the ED are assessed, and implementation of appropriate preventive measures are instituted. Pro-
Jan '97
91
92
JWOCN March 1998
S a c h a r o k and Drew
Retrospective Pressure Ulcer Incidence Study (PRO) 100%
8o% 70% [Z Jan-A,0r94
mSep-Oct9S 4o% 30% 20% 10%
0% Admission from Nursing Home
Pressure Ulcerson admission
Braden donem admission
RiskFactor present
~ a l Ulcer presentQ discharge
Demographlcs Figure 4. C o m p a r i s o n of d e m o g r a p h i c s a n d ulcer i n c i d e n c e in patients a g e d 85 a n d o l d e r in the PRO study.
spective r e v i e w a n d direct f e e d b a c k n o w occur in this clinical area as well. Recently, o u r efforts h a v e e x t e n d e d into l o n g - t e r m care facilities. We n o w collaborate monthly to a d d r e s s issues related to continuity a n d q u a l i t y of care. N u t r i t i o n , skin care, res t r a i n t r e d u c t i o n , a n d i m p r o v e m e n t in the transfer of i n f o r m a t i o n are evaluated. O u r ET n u r s e c o n t i n u e s to e v a l u a t e p r o d u c t s a n d p r a c t i c e s b a s e d on c u r r e n t i n f o r m a t i o n p r e s e n t e d m o n t h l y at Delaw a r e V a l l e y ET m e e t i n g s , n a t i o n a l conferences, j o u r n a l s , a n d on the internet. W e also continue o u r p a r t i c i p a t i o n in the P R O ' s r e t r o s p e c t i v e p r e s s u r e ulcer incidence s t u d y . In 1996, Bankert a n d associates 11r e p o r t e d on the v a l u e of collaborative b e n c h m a r k i n g as a m e t h o d of press u r e ulcer r e d u c t i o n . The o p p o r t u n i t y to n e t w o r k w i t h o u r p e e r s has b e e n h e l p ful. P e r h a p s the single g r e a t e s t factor in r e d u c i n g p r e v a l e n c e at our institution b y 83% c o n t i n u e s to b e o u r p r o s p e c t i v e monitoring and feedback on all of the adult units t h r o u g h our Rear A d m i r a l s ' q u a r terly surveys. REFERENCES I. Panel for the Prediction and Prevention of Pressure Ulcers in Adults.Pressure ulcers in adults: prediction and prevention; clinical practice guideline No. 3. Rockville(MD): US Department of Health and H u m a n Services, Agency for Healthcare Policy and Research M a y 1992; AHCPR Pub No. 92-0047. 2. Alvarez OM. Pressure ulcers: criticalconsider-
ations in prevention and management. Cli0 Mat 1991 ;8:209-22. 3. W o u n d Ostomy and Continence Nurses Society. Standards of care--patients with dermal wounds, pressure ulcers. Costa Mesa (CA): W O C N ; 1992. 4. Scholtes P. T e a m handbook. Madison (WI): James Association Inc',1988. p. 5-31. 5. Louviere M, Leuszler L, Helmick C. T Q M saves money, patient's skin. Mat M a n a g e 1992;March:48-50. 6. Olson B, L a n g e m o D, Burd C, Hanson D, Hunter S,Cathcart-Silberberg T.Pressure ulcer incidence in an acute care sefling.J W O C N 1996;23:15-22. 7. M e e h a n M. National pressure ulcer prevalence survey. Adv W o u n d Care 1994;7:27-38. 8. Drew J,Sacharok C. Pressureulcerprevention at Underwood-Memorial Hospital.In:Conte M (Chair). The power of partnerships: quality improvement projects with the Peer Review Organization of N e w Jersey. Princeton (N J): N e w Jersey Hospital Association; 1997. 9. Panel for the Treatment of Pressure Ulcers. Treatment of pressure ulcers: clinical practice guidelines No. 15. Washington (DC): US Department of Health and H u m a n Services, Agency for Healthcare Policy and Research 1994; AHCPRPub No. 95-0652. 10. Colin D, Abraham P, Preault L, Pregeon C, Saumet JL Comparison of 90° and 30 ° laterally inclined positions in the prevention of pressure ulcers using transcutaneous oxygen and carbon dioxide pressures. Adv Wound Care 1996;9:35-8. 11. Bankert K, Daughtridge S, Meehan M, Colburn L The application of collaborative benchmarking to the prevention and treatment of pressure ulcers. Adv Wound Care 1996;9:21-9.