Caring - It's Skin Deep - Using NDNQI Data and Evidence Based Practice Interventions for Pressure Ulcer Prevention

Purpose:
NDNQI Pressure ulcer prevalence data revealed an opportunity to change the culture and prevent skin compromising incidents. A Pressure Ulcer Prevention Team was formed to develop innovative improvement strategies to prevent hospital acquired pressure ulcers

Significance:
Pressure ulcer prevalence rates in the Adult Medical Units were significantly higher than the comparative mean. Because this rate serves as a snapshot of overall performance we considered that our problem involved daily operational compromise of skin care.

Strategy and Implementation:
A multidisciplinary team consisting of a surgeon, nurses and other professionals was formed. Strategies and tools used to identify patients with pressure ulcers and recommended treatment plans included use of Failure Modes and Effects Analysis (FMEA) to proactively identify breakdowns in the skin care process. The team reviewed processes and identified patients at risk for developing pressure ulcers and recommended prevention plans. The team explored innovative ideas for improving relationships between nursing assessments performed, interventions used and the prevention of pressure ulcers critical to early detection, intervention and treatment. They implemented several evidence based practice interventions including innovative strategies to educate patients and their families about skin care, training and empowering clinicians in preventing pressure ulcers, developing strategies for communication and working out specific protocols that could be easily implemented hospital-wide.

Evaluation:
After implementation our goal of detecting and preventing pressure ulcers was achieved. We reduced risks to our patients, reduced liability and improved patient safety. Pressure ulcers are preventable; having knowledge of evidence based practice is not enough; knowledge must be combined with action.

Implications for Practice:
Standardized pressure ulcer care enabled us to reach prevention goals. Prevalence data revealed five quarters out of eight quarters below the comparative mean. Our skin care plan bridges disciplines, reduces patient risk, reduces liability, improves patient safety and meets patient care needs.