Prevention Of Hospital-acquired Pressure Ulcers Research Articles

Building information for systematic improvement of the prevention of hospital-acquired pressure ulcers with statistical process control charts and regression

ObjectivesTo demonstrate complementary results of regression and statistical process control (SPC) chart analyses for hospital-acquired pressure ulcers (HAPUs), and identify possible links between changes and opportunities for improvement between hospital...

Peer-to-Peer Nursing Rounds and Hospital-Acquired Pressure Ulcer Prevalence in a Surgical Intensive Care Unit

We conducted a quality improvement project in order to evaluate the effect of nurse-to-nurse bedside "rounding" as a strategy to decrease hospital-acquired pressure ulcers (HAPU) in a surgical intensive care unit. We instituted weekly peer-to-peer bedside skin rounds in a 17-bed surgical intensive care unit. Two nurses were identified as skin champions and trained by the hospital's certified WOC nurse to conduct skin rounds. The skin champion nurses conducted weekly peer-to-peer rounds that included discussions about key elements of our patients' skin status including current Braden Scale for Pressure Sore Risk score, and implementation of specific interventions related to subscale risk assessment. If a pressure ulcer was present, the current action plan was reevaluated for effectiveness. Quarterly HAPU prevalence studies were conducted from January 2008 to December 2010. Nineteen patients experienced a HAPU: 17 were located on the coccyx and 2 on the heel. Ten ulcers were classified as stage II, 3 PU were stage IV, 5 were deemed unstageable, and 1 was classified as a deep tissue injury. The frequency of preventive interventions rose during our quality improvement project. Specifically, the use of prevention surfaces increased 92%, repositioning increased 30%, nutrition interventions increased 77%, and moisture management increased 100%. Prior to focused nursing rounds, the highest HAPU prevalence rate was 27%. After implementing focused nursing rounds, HAPU rates trended down and were 0% for 3 consecutive quarters.

Reduction of Sacral Pressure Ulcers in the Intensive Care Unit Using a Silicone Border Foam Dressing

We sought to determine if a silicone border foam dressing could decrease the incidence of sacral pressure ulcers in an intensive care unit. The study setting was an intensive care unit located in a 303-bed hospital with a designation of level 2 trauma. The unit specializes in the care of critically ill medical and postoperative adults. Two hundred seventy-three patients participated in the study; their mean age was 65 years (range, 18-105 years). Baseline sacral hospital-acquired pressure ulcer (HAPU) incidence was determined during a period of 35 months; skin care representatives examined all patients in our critical care unit for HAPUs on a monthly basis. Based on this baseline incidence, we studied the effect of application of a silicone-bordered foam dressing applied to the sacrum. The observation period for our study intervention was 6 months; the sacral area was examined twice daily during this period. The average baseline sacral HAPU prevalence during the 35-month observation was 13.6% as compared to an incidence of 1.8% during a 6-month prospective study. Three of the 5 patients developed suspected deep tissue injuries and subsequently expired. The remaining 2 subjects developed stage 2 pressure ulcers, one of whom also expired. Following application of a silicone-bordered foam dressing, we were able to achieve a HAPU of 1.8%.

Preventing Device-Related Pressure Ulcers

Data collected through Minnesota's mandatory statewide reporting system indicate that prevention of hospital-acquired pressure ulcers continues to be a challenge, particularly for patients who require the use of stabilization collars or other immobilizers, respiratory equipment, orthotics, and tubing. This article describes the process of identifying a pattern of device-related pressure ulcers through statewide pressure ulcer reports and developing a set of recommendations for prevention.

How to reduce hospital-acquired pressure ulcers on a neuroscience unit with a skin and wound assessment team

Background:In 2008, the incidence of hospital acquired pressure ulcers (HAPUs) continued to increase on a neuroscience unit that included both neurosurgical and neurological patients in a 14-bed intensive care unit, and in a 18-bed floor unit.Methods:To reduce HAPUs, several changes were instituted in 2008; (1) turning patients every 1–2 h/repositioning, (2) specialty beds, and (3) a “skin and wound assessment team (SWAT)” that included one (or two) “expert” nurses/nursing assistants who made rounds on all the patients in the unit at least once a week. They would examine patients from “head to toe”, document/measure all pressure ulcers, and educate primary nurses/nurse assistants on the plan/products needed for the patients wound care based on their assessments. In 2010, further measures included: (1) adding eight Stryker beds, (2) adding pressure relieving heel protector boots, and (3) requiring that all new hospital orientees work one shift (7.5 h) shadowing the SWAT team.Results:The SWAT team initially decreased HAPUs by 48% in 2009; this reduction was further increased in 2010 (57%), and 2011 (61%). Additionally, in 2010, the SWAT team was required to educate nurses in all other units. By 2011, all nurses had to complete the hospital acquired pressure ulcer prevention tutorial.Conclusions:Since instituting a specialized SWAT team for our neuroscience unit, the incidence of HAPUs (cost estimated for grade IV, US $129,248) was decreased by 48% in 2009, by 57% in 2010, and by 61% in 2011. The SWAT program is now hospital-wide.

Development of Pressure Ulcer Program Across a University Health System

Pressure ulcers were designated as a priority for quality care initiatives at the University of Pennsylvania Health System. The Penn Medicine Pressure Ulcer Collaborative was developed to address the complex issues of pressure ulcers. The Collaborative used a systematic approach to analyze, plan, and implement a health system-wide pressure ulcer program. As a result, the entire health system had a decrease in hospital-acquired pressure ulcer prevalence rates of 37%. This article describes the Collaborative's innovative approach to quality improvement.

Hospital-acquired pressure ulcers in two Swedish County Councils: cross-sectional data as the foundation for future quality improvement

The objectives of the study were to examine the prevalence of pressure ulcers and hospital-acquired pressure ulcers (HAPU) and identify modifiable factors in patients who develop HAPU as the basis for subsequent quality assurance studies and improvement in hospital care. The study was conducted in five hospitals in two Swedish County Councils. A 1-day prevalence study (n = 1192) using the standards of the European Pressure Ulcer Advisory Panel and Collaborative Alliance for Nursing Outcomes was conducted. The prevalence of ulcers was 14·9% and 11·6% were HAPU. Older age, more days of hospitalisation, less activity, problems with shear and friction and reduced sensory perception contributed significantly to HAPU. Pressure ulcer prevention strategies used more often in those with HAPU were risk assessment at admission, provision of a pressure relief mattress, having a turning schedule and using a heel or chair cushion. The prevalence of pressure ulcers continues to be a significant issue in acute care and the prevalence of HAPU is high. There is significant room for quality improvement in pressure ulcer prevention in Swedish hospitals. Future research needs to address both HAPU and community-acquired pressure ulcers and focus on preventive strategies, including when they are initiated and which are effective in mitigating the high HAPU rate.

Exploring variation in pressure ulcer prevalence in Sweden and the USA: benchmarking in action

To compare overall unit-level pressure ulcer (PU) prevalence, hospital-acquired pressure ulcer (HAPU) prevalence and prevention strategies, as well as nurse staffing and workload in two hospitals in Sweden with data from the USA. Medical and surgical units in a university hospital and a general hospital in Sweden were compared with 207 hospitals in the USA participating in the Collaborative Alliance for Nursing Outcomes (CALNOC) benchmarking registry. All adult inpatients in university hospital (n = 630), general hospital (n = 253) and CALNOC hospitals (n = 3506) were included in the study. Outcome indicators were pressure ulcer prevalence for all types (PU) and HAPU prevalence, specifically. Process indicators were risk assessment and PU prevention strategies. Structure indicators were nurse staffing (hours of care, and skill mix) and workload (admissions, discharges and transfers). The prevalence of PU (categories 1-4) was 17.6% (university hospital) and 9.5% (general hospital) compared with 6.3-6.7% in the CALNOC sample. The prevalence of full thickness HAPU (categories 3 and 4) was 2.7% (university hospital) and 2.0% (general hospital) compared with 0-0.5% in the CALNOC sample. Risk and skin assessment varied between 6% and 60% in the Swedish hospitals compared with 100% in the CALNOC sample. Total hours per patient day were 8.4 in both Swedish hospitals and 9.5 to 9.8 in the CALNOC hospitals The findings suggest a link between processes of care and outcomes that is exciting to observe internationally and suggest the opportunity to expedite performance improvement through global benchmarking. Using HAPU as a complement to point prevalence of PU in Sweden has revealed this indicator as a more valid measure for patient care quality.

Predictive Bayesian Network Model Using Electronic Patient Records for Prevention of Hospital-Acquired Pressure Ulcers

The study was designed to determine the discriminating ability of a Bayesian network (BN) for predicting risk for pressure ulcers. Analysis was done using a retrospective cohort, nursing records representing 21,114 hospital days, 3,348 patients at risk for ulcers, admitted to the intensive care unit of a tertiary teaching hospital between January 2004 and January 2007. A BN model and two logistic regression (LR) versions, model-I and -II, were compared, varying the nature, number and quality of input variables. Classification competence and case coverage of the models were tested and compared using a threefold cross validation method. Average incidence of ulcers was 6.12%. Of the two LR models, model-I demonstrated better indexes of statistical model fits. The BN model had a sensitivity of 81.95%, specificity of 75.63%, positive and negative predictive values of 35.62% and 96.22% respectively. The area under the receiver operating characteristic (AUROC) was 85.01% implying moderate to good overall performance, which was similar to LR model-I. However, regarding case coverage, the BN model was 100% compared to 15.88% of LR. Discriminating ability of the BN model was found to be acceptable and case coverage proved to be excellent for clinical use.

Strategies to improve the prevention of pressure ulcers

This article outlines the actions taken by one acute trust to implement evidence-based, best practice recommendations for pressure ulcer prevention. Initially, an exploratory study identified specific areas for practice development, particularly improving early risk assessment, intervention and focus on heel ulcers. Further actions included recruiting tissue viability support workers to promote a pressure ulcer campaign. Prevalence audit results demonstrated improved prevention and reduced prevalence of hospital-acquired pressure ulcers by 6 per cent and heel ulcers by 4.9 per cent. Further work is required to ensure prevention strategies are consistent and documented.

Results of a Clinician-Led Evidence-Based Task Force Initiative Relating to Pressure Ulcer Risk Assessment and Prevention

Integration of research findings into clinical practice is essential for achieving cost-effective, quality patient outcomes. Data confirm that nursing care in most settings is "empiric" and is based largely on untested assumptions, as opposed to being evidence-based. Process improvement efforts must engage clinicians in initiatives that promote the integration of research into clinical practice and acceptance of shared professional accountability for sustaining needed change. A clinician-led task force was assembled to identify and apply current evidence to clinical practice in the areas of risk assessment and prevention of hospital-acquired pressure ulcers in the inpatient setting. Data collected prior to and following our process improvement project demonstrated significant improvement in patient outcomes.

Improving Quality and Patient Safety by Retaining Nursing Expertise

Does nursing experience matter in relation to outcomes and patient safety? Intuitively, most nurses and nurse leaders would say yes. However, data are needed to support this relationship. The author begins this article by reviewing the novice to expert trajectory, describing differences between novice and expert nurses, and reporting the relationship between nurse experience and quality outcomes as measured by nurse-sensitive indicators. Current data already indicate that outcomes, such as the incidence of patient falls and the prevalence of hospital-acquired pressure ulcers (HAPU), are influenced by the experience level of the nurse. The author also discusses the threat of losing experienced nurses in the workforce and presents five strategies (vehicles) to maintain expertise in practice.

Reducing Hospital-Acquired Pressure Ulcer Prevalence Through a Focused Prevention Program

To provide health care organizations with strategies for decreasing the prevalence of hospital-acquired pressure ulcers. Hospital-acquired pressure ulcer prevalence was measured every 6 months for 4.5 years while multiple strategies were implemented. The study took place in a not-for-profit, 548-bed, 2-hospital system in Southwest Florida. All adult patients with the exception of those admitted for obstetric or mental health care. An assortment of interventions were implemented, including electronic medical records, risk assessment tied to automatic consults, pressure relief measures including new equipment and personnel augmentation, and an interdisciplinary team to decide on protocols. Hospital-acquired prevalence rate for all pressure ulcers was reduced by 81%. The rate for heel ulcers alone was reduced by 90%. A pressure ulcer prevention program has been developed, which has shown a trend toward improved patient outcomes with a resultant cost savings.

Reducing Incidence and Prevalence of Hospital-Acquired Pressure Ulcers at Genesis Medical Center

The prevalence of pressure ulcers on both the pulmonary and oncology units decreased to zero in the first quarter after the intervention, results that were largely sustained through the end of 2006.

Leveraging Nurse-related Dashboard Benchmarks to Expedite Performance Improvement and Document Excellence

Using nursing quality benchmarks in operational dashboards and translating those data to drive performance excellence is a strategic imperative. Since access to unit-level, hospital-generated nurse-related benchmarks is an emerging arena, the authors provide an overview of aggregated trends and benchmarks gleaned from the California Nursing Outcome Coalition acute care database for 2 established nurse-related quality indicators-patient falls incidence and hospital-acquired pressure ulcer prevalence. Integrating these acute care benchmarks into clinical dashboards can be invaluable to clinicians, administrators, and policy makers who share a common commitment to expediting evidence-based improvement in patient care safety, outcomes, and excellence.