Summary University Hospitals Case Medical Center has demonstrated a consistent decrease in pressure ulcer prevalence since the initiation of NDNQI data collection and reporting. Approximately 18 months ago, our nosocomial pressure ulcer prevalence ranged between 10-30% throughout our medical, surgical, medical/surgical, step-down, and critical care areas. All patient care areas had pressure ulcer prevalence above the national mean. Pressure ulcer prevalence became a key indicator for the nursing department. The first step for improvement was the dissemination of the data to nurse specialists, nurse managers, staff, and key stake holders. A communication web was constructed and the NDNQI data was disseminated at nursing council meetings, quality council meetings, and interdepartmental meetings. Each manager in turn communicated the findings with staff through posters and staff meetings. Senior nursing leaders transformed the NDNQI reports into an action plan that included strategies for improvement in the following areas: nursing orientation, continuing education, and patient care supplies, and equipment.

New nurse orientation was re-structured to include two days of skin care education. The first class focused on using the Braden Score assessment tool (process for completing a risk assessment and Score). The second class focused on staging and pressure ulcer care as well as ostomy and wound care. The action plan also addressed the continuing education needs of the current nursing staff. During the annual competency, each RN participated in a Braden Score competency which simulated a “real-patient” scenario where the RN had to determine the correct Braden Score. Staff that scored low were then followed up with and given additional education related to completing Braden Scores and risk assessments. The multidisciplinary action plan also included new patient care products and equipment including patient beds and therapeutic surfaces. Through interdisciplinary collaboration, administration also budgeted and implemented a bed replacement program. As of this date, 40% of the beds have been replaced with the Versa Care Bed. The result of the multidisciplinary action plan has been a decrease in nosocomial pressure ulcer prevalence throughout the hospital to an average of 0-15% with a majority of the patient care areas under the national mean for their specialty. The poster will include unit based graphical displays of the changes in the NDNQI scores that reflect the results of the different interventions. Clinical Implications for Practice include improved quality of care for patients, decrease cost due to complications of pressure ulcers, and improved patients and staff satisfaction.