Preventing Pressure Ulcers in ICU with a "Bundle" Approach

Purpose:
Problem: ICU has seen an increase in pressure ulcers from 2007-2008 (2.58/1000 discharges to 4.27/1000 discharges). Purpose: Decrease pressure ulcer rates in the ICUs at MCR by 50% using a department specific rapid cycle PDCA group comprised of ICU staff nurses and the CNS.

Significance:
In 2008, CMS declared Stage III/IV pressure ulcers a Never Event and non-reimbursable. This change heightened awareness and surveillance of pressure ulcers. Pressure ulcers present a danger to the patient with increased risk of infection, as well as increased length of stay and healthcare cost.

Strategy and Implementation:
Preventing pressure ulcers is clearly a nursing practice issue. A team was formed consisting of ICU staff nurses from each of the ICUs and the CNS. The first step was to identify current practice. An audit tool was developed based on the current standard of care in the ICU and practice was observed. The nurses were following the current standard of care, it was inadequate. The next step was to review the literature, specific to pressure ulcer prevention in ICU patients. Several areas were identified from the literature: repositioning, repositioning equipment, bed surface, skin care products, assessment of risk factors, and general hygiene. The ICUs were very accustomed to using a “bundled” approach, so a bundle was created to address each of the areas of prevention. The staff nurses did education for the ICU nurses and had each nurse be a patient in the bed to “feel” the difference to emphasize correct use of the bed surface and positioning of the patient in the bed.

Evaluation:
The ICUs track pressure ulcer rates (number of pressure ulcers per 1000 discharges/transfers). Combined ICU data: 2008 4.27/1000 discharges, 2009 2.93/1000 discharges, and 2010 1.03/1000 discharges. The bundle was implemented in August 2008. A root cause analysis is done on each event.

Implications for Practice:
The implication in our ICU, a culture change, pressure ulcer prevention is a nursing practice priority. Implications for other ICUs, the bundle is an evidence-based, effective, simple to implement group of interventions that could be used to decrease their pressure ulcer rate.