Lean Six Sigma Approach Achieves Breakthrough Reductions in Unit-Acquired Pressure Ulcers for Critical Care Patients

Purpose:
Using Lean Six Sigma principles, an interdisciplinary team designed a unit acquired pressure ulcer (UAPU) prevention program for challenging intensive care units. We aimed to reduce the UAPU rate by 15% and increase staff awareness for patient pressure ulcer risk through targeted interventions.

Relevance/Significance:
Despite broad endorsement, there is little evidence to validate compliance with direct nursing care guidelines alone as sustainable preventatives for UAPUs. Instead of stressing individual nursing tasks, our initiative provides concrete examples of comprehensive team based process improvement approaches. We demonstrate that these approaches successfully reduced persistently high UAPU rates in the most challenging inpatient units over a sustained period of time.

Strategy and Implementation:
We selected three intensive care and stepdown units with UAPU rates persistently above benchmark for like units among Magnet hospitals to implement our initiative. An interdisciplinary team comprising nursing leadership, wound, ostomy and continence (WOC) nursing specialists, nursing support staff, nutritionists, researchers, physical and occupational therapists and physicians employed Lean Six Sigma principles to design and execute the project. We collected and analyzed baseline UAPU rates and contributing factors for UAPUs. The team identified root causes of UAPUs, process insufficiencies and opportunities to maximize intervention impact. Strategies addressing root causes formed the basis of a 10 week pilot program. The pilot program comprised four interventions: standardization of pressure ulcer documentation; tracking vital equipment; monitoring patient out of bed sitting time; and ensuring the inclusion of risk and skin integrity in interdisciplinary rounding.

Evaluation:
During the pilot, the UAPU rate fell from a baseline of 4.4% to 2.8%, surpassing the goal of a 15% reduction (p=0.08). The rate remained below the goal through the control period at 2.9%, showing a statistically significant reduction since the pilot start date (p=0.05). The four process improvement interventions were readily incorporated into daily workflow to maintain staff awareness and buy-in.

Implications for Practice:
System approaches to prevention distribute monitoring responsibilities and increase risk awareness among all clinical stakeholders to facilitate early identification of developing pressure ulcers. Our program can be utilized hospital wide to achieve significant and sustained UAPU rate reductions.