Pressure Ulcer Reduction Improvement Strategies at a Pediatric Academic Medical Center

Purpose:
Describe how improvement science was used to reduce facility-acquired pressure ulcers including: use of a key driver diagram, tests of change, and a prevention bundle of strategies in a pediatric academic medical center.

Significance:
Impact of pressure ulcers to patient's and family's includes: additional pain and suffering, longer hospital stays, increased cost of treatment, and decreased satisfaction. CMS will not reimburse hospitals for facility-acquired pressure ulcers which can cost up to $70,000 to treat.

Strategy and Implementation:
Improvement science was used to reduce pressure ulcers. Planning was done using a key driver diagram to focus the collaborative work which started on 4 high risk units and then spread across the hospital. The collaborative used evidence-based practice to develop a set of interventions that the bedside nurses could test and implement. The bundle included the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer Prevention Points. The team conducted small tests of change to evaluate the components of the bundle: Modified Braden Q risk assessment, head to toe skin assessment, medical device assessment, nutrition assessment by dietician, moisture checks every 2-4 hours, mechanical loading and support surfaces, repositioning every 2-4 hours, stable air mattress on all beds, educating and engaging patients and families, and education modules for clinicians on pressure ulcer prevention. Additionally the electronic medical record was enhanced to include the bundle strategies.

Evaluation:
Facility-acquired pressure ulcer house wide quarterly prevalence rates have decreased by 63% and the improvement sustained for over a year. We reduced the occurrence of new pressure ulcers in 4 high risk units by greater than 50%. Majority of our pediatric pressure ulcers are medical device related.

Implications for Practice:
Prevention of pressure ulcers is a vital component of nursing practice in order to improve quality of care and patient safety. The bundle of strategies for pressure ulcer prevention was adopted and spread to all inpatient departments. It takes a collaborative effort to reduce pressure ulcers.