Improving Pressure Ulcer Prevention through Electronic Medical Record (EMR) Redesign

Purpose:
To improve evidence based skin assessment practices by redesigning the electronic medical record (EMR) to positively impact the nurse's work flow by alerting them to complete required skin assessments. Nurses were also prompted to add a skin care plan if patient was at high risk for pressure ulcers.

Significance:
Timely assessment of patient's level of risk for developing a pressure ulcer informs a nurse to implement appropriate prevention strategies on admission. Daily assessment of risk, head to toe skin assessment & medical device assessment supports timely care plan changes to improve patient outcomes.

Strategy and Implementation:
A Patient Safety Task Force developed a bundle of strategies to reduce pressure ulcers at this pediatric academic medical center, including: Pressure Ulcer Risk Assessment & Head to Toe Skin Assessment on admission & daily and Medical Device Assessment every shift. Skin assessment documentation fields were added to the existing EMR in a location that was separate from other body system assessments. To address this problem, two years later a new EMR was redesigned so that skin assessments would appear with other body system assessments. This improved the nurse's work flow & served as a better visual cue that the assessments were required on admission & each shift. Use of a best practice alert (new EMR functionality) prompted nurses to add a pressure ulcer prevention patient plan of care (PPOC) when patient at risk for pressure ulcers. PPOC templates were designed to include the bundle of strategies to reduce pressure ulcers, which increased nurse efficiencies in updating PPOC.

Evaluation:
Implementation of the new EMR functionality improved compliance with admission skin assessments, median compliance ranges: Pre-new EMR 71-80% vs Post-new EMR 86 - 93%. Facility acquired pressure ulcer prevalence rates improved, Pre-new EMR (Apr'09)= 3.2% vs Post-new EMR (Apr'10)= 2.4%.

Implications for Practice:
Since majority of our pressure ulcers are device related, shift skin assessments under devices (eg. trachs & tubes) does help nurses implement protective skin care strategies. Information technologies leveraged appropriately can support nursing staff to optimize care & improve patient outcomes.