War on Wounds in the Medical Intensive Care Unit

Purpose:
A performance improvement project was developed to increase nursing awareness of risks for pressure ulcer development in the ICU while using continuous lateral rotation therapy(CLRT). This aggressive campaign introduced tools/interventions to reduce pressure ulcer incidence in this high risk group.

Significance:
In 2008 CMS instituted non-payment for nosocomial pressure ulcer treatment. While national standards recommend Q2 hour turning as a prevention strategy, the ICU is using CLRT to prevent/treat pulmonary complications. The challenge is to prevent pressure ulcers while rotating a patient 18 hours/day.

Strategy and Implementation:
An comprehensive pressure ulcer prevention plan was instituted using a modified turning schedule, skin care algorithm, turning wedges, wound care nurse consultation, and extensive staff education. The staff was made aware of the high incidence of pressure ulcers that were developed in the ICU. This occurred through staff meetings, unit-based council, and reports posted on the QI board. Development of a skin care algorithm served as a tool for assessing skin risk and utilizing appropriate skin care products along with other interventions. A specialized turning schedule that incorporated CLRT, manual turns, and skin inspections was posted in each nursing workstation. In addition, overhead announcements were made in 4 hour intervals to remind staff to turn their patients. Special turning wedges were purchased so that patients received optimal manual rotation while maintaining good alignment. Extensive initial and ongoing education was provided that incorporated all elements described.

Evaluation:
WAR on Wounds has resulted in a steady decrease in monthly pressure ulcer development; some months with zero incidence. Heel ulcers have been eliminated. The ICU wound care nurse rounds on all vulnerable patients 2-3x per week and documents any newly developed skin breakdown.

Implications for Practice:
CLRT can be beneficial for ICU patients, but this therapy has been linked to pressure ulcer development. Pressures ulcers are not only costly to the health care facility, they also affect a patients quality of life, morbidity, and mortality. Solutions must be explored eradicate this problem.