Stay Out of the Doghouse: Pressure Ulcer Prevention Strategy (PUPS)

Purpose:
The purpose of this project is to decrease hospital acquired pressure ulcers in high risk cardiovascular patients using DMAIC process. High risk cardiovascular patients include those who have mechanical circulatory devices (MCAD) implanted or Extracorporeal Membrane Oxygenation (ECMO).

Significance:
Literature reveals cardiovascular patients who spend more than 2 hours in surgery are at higher risk for pressure ulcers. Prevalence surveys have supported this. Decreasing hospital acquired pressure ulcers improves the quality of care for patients as well as decreasing costs for the hospital.

Strategy and Implementation:
Critical care and operating room (OR) nurses worked with wound ostomy nurses to develop a workflow for high risk cardiovascular patients. High risk cardiovascular patients included those who had a MCAD implanted and/or were on ECMO. A gel-immersion mattress is used in the OR to provide pressure relief during multiple, very long surgeries. Due to hemodynamic instability, open chests and device cannula insertion sites, these patients frequently cannot be turned or repositioned so a silicone foam dressing is applied to sacrum in the OR. Additionally, in Intensive Care, the patient is placed on a specialty low air loss bed to provide continuous lateral rotation and maximum low air loss to provide pressure relief. Foam heel dressings are applied to provide relief from friction and shear.

Evaluation:
Chart review of patients 6 months prior to workflow change compared with 6 months post workflow. 43% decrease in hospital acquired pressure ulcers in high risk cardiovascular patients. No pressure ulcers on prevalence survey. No sacral/coccyx pressure ulcers. No Stage III, IV or unstageable ulcers.

Implications for Practice:
The interventions were successful in decreasing pressure ulcers in these patients so will continue to implement workflow. Half of pressure ulcers were on heels so ICU is incorporating use of waffle boots with these patients. Physicians in other specialties interested in using these interventions.