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Acute Myocardial Infarction	Medication Reconciliation (ADE)
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Catheter-Associated UTI	Rapid Response Teams
Central Line Infections	Surgical Complications
Congestive Heart Failure	Surgical Safety Checklist
High-Alert Medications	Surgical Site Infections
MRSA	Ventilator-Associated Pneumonia

Use this table to quickly find a mentor for the prevention of Pressure Ulcers with demographics similar to your own, or use 'ctrl+f' in your web browser to search for specific key words on this page.

Baystate Medical Center – Springfield, MA
Availability Status: Available to answer requests
Licensed Beds: 636
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: January 1995
Mentor Contact Name: Jan Fitzgerald, RN
Mentor Contact Email: janice.fitzgerald@bhs.org
Mentor Contact Phone: 413-794-2531

Additional Information:

We developed and implemented reliable processes/systems/interventions to assess skin integrity using an objective standardized tool (Braden Scale) for all patients on admission and regularly after that (every 24 hours and as needed in higher risk patients).  Daily skin observation is done by all clinicians in contact with the patient.  Pressure relief surfaces/mattresses were put in place in 1995 on all nursing units and in the Operating Rooms.  Daily surface use observation/checks by all staff results in 100% of the surfaces in place and on at all times as preventative strategies.  In addition, BMC has had wound care guidelines in place since 1990 for prevention and treatment recommendations based on the evidence and supported by certified wound care clinicians and mid level providers.

Sustained assessment completion on admission rates = 100%

Pressure relief surface use = 100%

Sustained assessment completion on admission rates = 100% as detailed through our EMR which drives the task

Current rate of hospital-acquired wound care rate is zero/1000 patient days (NDNQI benchmark = 9.6%).
Rates over last 3-5 years have been at zero or near zero rates.  We are lowest rate of HAPU in Massachusetts as per Patient Safety Safety Site.

See graphs of their results.

Mentor designation - 3/13/07
Information updated - 2/24/10

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BryanLGH Medical Center – Lincoln, NE
Availability Status: Available to answer requests
Licensed Beds: 378
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: January 1992
Mentor Contact Name: Marilyn Viehl, MHA, BSN, Director for Acute & Post Acute Services
Mentor Contact Email: mviehl@bryanlgh.org
Mentor Contact Phone: 402-481-4914

Additional Information:

Since implementing the AHCPR Pressure Ulcer Prevention Guidelines in 1992, BryanLGH Medical Center has been formally dedicated to preventing this often avoidable harm from happening to any of our patients.  This commitment has come from senior administration in the form of buying pressure redistributing beds throughout the facility; from the medical staff and other advanced practice providers who order necessary prevention items and focus on improving patient health (the skin is a window to our health); from the managers who support use of the Braden Scale and skin standards by staff; the unit secretaries who apply the Braden scoring tool to the chart; physical therapists who help get the patients more mobile; dieticians who focus on protein and other skin health nutrients; and from the nursing staff who diligently apply protective ointment and reposition at-risk persons placing heel lift boots on those whose heels do not stay up on pillows and who consult the Wound Ostomy Continence (WOC) Nurses when the appropriate skin standard is not adequate to protect the patient.

Our nursing techs are key players in the program's success since they see bare skin over bony prominences most often on many units.  We use a computerized Skin Resource that provides guidance in the use of the standards and products frequently used for prevention of skin injury.
 
Over the past 2 years, we have also focused on incontinence-associated skin injury since it is associated with pressure ulcers.  We have upgraded our underpads to the polymer bead-filled type shown to decrease dermatitis.

Responding to feedback from staff has been key to our success.  For example, we have placed our disposable cleanser/moisturizer/protectant cloths at the bedside and changed from a 3-pack to an 8-pack at the request of staff. (We have since seen a decrease in the number of WOC Nurse consults for incontinence-associated dermatitis.)  One type of heel boot was found not be used by staff because patients found it uncomfortable.  Consequently, the team searched and found a comfortable yet very useful protective boot.

When a pressure ulcer occurs in our facility, an Occurrence Report is filed which automatically goes to the WOC Nurses and the unit manager.  All aspects of pressure ulcer prevention are audited on the patient and action is taken to correct any deficits.

Creating and keeping the program scientifically current is a real team effort.  Our Skin Team consists of staff nurses, physical therapists and dieticians with a physician and pharmacist in a consulting role, to assure a practical and comprehesive approach to all Healthy Skin Program upgrades.

Process measure: 100% pressure redistributing beds
Incidence rates (percent of all patients examined):

2007 Incidence - 2.86% (one stage 1 sacral ulcer; one stage 2 sacral ulcer; one stage 2 heel ulcer- all were healed by the following week with no residual effects)

2006 Incidence - <1%

2005 Incidence - 7% (Skin Team examined possible causes for increase.  Incontinence was found to be a common factor in the patients developing pressure ulcers of the sacral area, so incontinence skin care became a focus [see report of research in May/June JWOCN])

2004 Incidence - 4%

2003, 2002, 2001 Incidence - <1%

[4/7/07]

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Children's Healthcare of Atlanta at Egleston – Atlanta, GA
[Pediatric Mentor]

Availability Status: Available to answer requests
Licensed Beds: 216
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: September 2005
Mentor Contact Name: Marie Sosebee, RN, BSN, CWOCN
Mentor Contact Email: marie.sosebee@choa.org
Mentor Contact Phone: 404-785-5251

Additional Information:

The Children's Healthcare of Atlanta Wound Prevention Team was formed in 2005 to reduce the number of hospital-acquired pressure ulcers.  Patients at risk for hospital-acquired pressure ulcers were identified through a system-wide risk assessment.  The team implemented the modified Pediatric Braden Q scale in the Pediatric Intensive Care Units (PICU), the Technology Dependent Intensive Care Units (TDICU), the Cardiac Intensive Care Unit (CICU), and the Comprehensive Rehabilitation Unit (CIRU).  The Neonatal Skin Risk Assessment Scale (NSRAS) was trialed and then implemented in the Neonatal Intensive Care Units (NICU).  After extensive literature review and using evidence-based wound prevention guidelines, the team created interventions for patients who scored as high risk on each scale.  The interventions are specific to either the Pediatric Braden Q scale or the NSRAS.  The staff in each of the units were educated on the specific scale and interventions used in their respective unit.  The team also developed systemwide education on pressure ulcer identification, reporting incidents, and wound prevention.  The education was disseminated through department inservices, ongoing new nurse orientation, and ongoing nurse resident orientation. Other successes include the following:

a.  Through collaboration with the Pharmacy, Equipment & Technology Committee, and Supply Chain, success in standardizing skin and wound care products was achieved at each of our campuses.

b.  Through data collected, the team was able to help support and justify the need for a Wound, Ostomy & Continence (WOC Nurse) at the Egleston Campus, thus allowing both campuses to have equal WOC Nurse representation.

c.  The Scottish Rite campus WOC nurse created a 'Pressure Redistribution Mattress and Bed Selection Guideline' and 'Pressure Ulcer Staging Guideline' for staff reference.

d.  Participation in computerized documentation committees with representation of nursing staff resulted in incorporation of standardized skin & wound assessment criteria in conjunction with the Braden Q and NSRAS scales with General Interventions into our computerized charting.

e.  Skin & wound teaching materials for staff and patient/family education were created.

Initial determination of actual risk statistics was based on 17 WOC Nurse consults for hospital-acquired pressure ulcers in the PICU at one of our hospitals in 2004.  In the beginning of 2005, Children's began measuring our incidence rate of hospital-acquired pressure ulcers system-wide and determined a baseline rate of 4.0%.  As the team worked to implement the risk assessment tools and high risk interventions our incidence rate dropped to 2.87%, a 28% reduction.

Statistical documentation/reporting & tracking of hospital-acquired pressure ulcers were generated through our computerized/online Occurrence Notification System (ONS).  The Wound Prevention Team educated staff on the importance of reporting all hospital-acquired pressure ulcers through this system with the goal of increased reporting.  In 2004, a total of 4 events were reported.  In 2005, 30 events were reported (650% increase).

[7/7/07]

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Children's Healthcare of Atlanta at Scottish Rite – Atlanta, GA
[Pediatric Mentor]

Availability Status: Available to answer requests
Licensed Beds: 234
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: September 2005
Mentor Contact Name: Marie Sosebee, RN, BSN, CWOCN
Mentor Contact Email: marie.sosebee@choa.org
Mentor Contact Phone: 404-785-5251

Additional Information:

The Children's Healthcare of Atlanta Wound Prevention Team was formed in 2005 to reduce the number of hospital-acquired pressure ulcers.  Patients at risk for hospital-acquired pressure ulcers were identified through a system-wide risk assessment.  The team implemented the modified Pediatric Braden Q scale in the Pediatric Intensive Care Units (PICU), the Technology Dependent Intensive Care Units (TDICU), the Cardiac Intensive Care Unit (CICU), and the Comprehensive Rehabilitation Unit (CIRU).  The Neonatal Skin Risk Assessment Scale (NSRAS) was trialed and then implemented in the Neonatal Intensive Care Units (NICU).  After extensive literature review and using evidence-based wound prevention guidelines, the team created interventions for patients who scored as high risk on each scale.  The interventions are specific to either the Pediatric Braden Q scale or the NSRAS.  The staff in each of the units were educated on the specific scale and interventions used in their respective unit.  The team also developed systemwide education on pressure ulcer identification, reporting incidents, and wound prevention.  The education was disseminated through department inservices, ongoing new nurse orientation, and ongoing nurse resident orientation. Other successes include the following:

a.  Through collaboration with the Pharmacy, Equipment & Technology Committee, and Supply Chain, success in standardizing skin and wound care products was achieved at each of our campuses.

b.  Through data collected, the team was able to help support and justify the need for a Wound, Ostomy & Continence (WOC Nurse) at the Egleston Campus, thus allowing both campuses to have equal WOC Nurse representation.

c.  The Scottish Rite campus WOC nurse created a 'Pressure Redistribution Mattress and Bed Selection Guideline' and 'Pressure Ulcer Staging Guideline' for staff reference.

d.  Participation in computerized documentation committees with representation of nursing staff resulted in incorporation of standardized skin & wound assessment criteria in conjunction with the Braden Q and NSRAS scales with General Interventions into our computerized charting.

e.  Skin & wound teaching materials for staff and patient/family education were created.

Initial determination of actual risk statistics was based on 17 WOC Nurse consults for hospital-acquired pressure ulcers in the PICU at one of our hospitals in 2004.  In the beginning of 2005, Children's began measuring our incidence rate of hospital-acquired pressure ulcers system-wide and determined a baseline rate of 4.0%.  As the team worked to implement the risk assessment tools and high risk interventions our incidence rate dropped to 2.87%, a 28% reduction.

Statistical documentation/reporting & tracking of hospital-acquired pressure ulcers were generated through our computerized/online Occurrence Notification System (ONS).  The Wound Prevention Team educated staff on the importance of reporting all hospital-acquired pressure ulcers through this system with the goal of increased reporting.  In 2004, a total of 4 events were reported.  In 2005, 30 events were reported (650% increase).

[7/7/07]

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Claxton-Hepburn Medical Center - Ogdensburg, NY
Availability Status: Available to answer requests
Licensed Beds: 129
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: January, 2004
Mentor Contact Name: Jennifer S. Shaver, RN, NM/ICU, Manager, Respiratory Services; Karen Cole, RN, BSN, CDE, WOCN
Mentor Contact Email: shaver@chmed.org; kcole@chmed.org 
Mentor Contact Phone: 315-393-3600 ext. 5337; 315-393-3600 ext. 5181

Additional Information:

Our rural 10-bed ICU was concerned over the prevalence rate for pressure ulcers that, although consistent with national benchmarks for critical care areas, was not acceptable to this ICU!  We implemented processes to accommodate admission and daily skin assessments on all ICU patients, as well as provide documentation and associated interventions.

Everything "came together" for us during the care of a uniquely challenging patient.  A plan of care was developed to ensure that the patient, who was extremely obese, did not experience complications related to prolonged inactivity during her 6-week hospital stay.  Glycemic control was implemented, as were evidence-based strategies for the prevention of Ventilator-Associated Pneumonia and Sepsis.  From the patient care plan, several unit-based initiatives hospital were revisited, and in some instances, redeveloped. 

The use of appropriate equipment, criteria-based care protocols, and education of staff are all necessary for successful results.  We had strong administrative support in ensuring that we had the right number of staff for any patient-centered activity.  It is vital that we care for our caregivers!  As a means of demystifying the various clinical initiatives implemented, each ICU staff member was asked to review and sign a patient care contract that included their commitment to skin health and the prevention of pressure ulcers, along with other initiatives.

 - Implementation of a skin assessment and pressure ulcer prevention process used daily in ICU and Med Surg

 - Implementation of an interdisciplinary team session, held in ICU Mondays - Wednesdays and Friday to address patient and staff needs

Prevalence and incidence studies are completed each October and each March (the March data is included in KCI’s nationwide study).  All patients are assessed for risk on admission and every 24 hours using the Braden Scale in our acute care settings which include CCU.  All patients have daily skin assessments.

ICU Pressure Ulcer Prevalence and Occurrence rates: 

	March	October
2004	12% prevalence/occurrence not available	0% prevalence/occurrence not available
2005	0% prevalence/ 0% occurrence	14 % prevalence/occurrence not available
2006	0% / 20%*	0% / 0%
2007	0% / 0%	43%** / 0%

                                                                                              

*One patient out of 5 developed a stage I.
**3 patients out of 7 had a stage I and stage II’s noted on admission.

[7/7/07]

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Hazleton General Hospital – Hazleton, PA
Availability Status: Available to answer requests
Licensed Beds: 150
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: May 2004
Mentor Contact Name:  Andrea Andrews, RN, Director of Quality/Case Management
Mentor Contact Email: aandrews@ghha.org
Mentor Contact Phone: 570-501-4744

Additional Information:

All patients receive pressure ulcer admission assessment, utilizing the Braden scale.  This is also assessed on every shift.  If a pressure ulcer is present on admission, wound photos are taken with measurements documented.  Wound and skin assessments are done each shift.

If a patient is noted to be at risk for pressure ulcers, skin integrity is addressed on the plan of care.  Interventions for the at-risk patient include the following five components: 1) Daily inspection of skin for pressure ulcers; 2) Proper management of moisture, including both cleaning and moisturizing skin; 3) Optimization of nutrition; 4) Repositioning every two hours; and 5) Use of pressure-relieving surfaces.  However, skin inspection is done on every shift as opposed to daily. 

100% of the patients receive pressure ulcer risk reassessments - this is done on every shift.

First Pressure Ulcer Prevalence study was done in 2004. Our prevalence rate was 25%.  Our facility-acquired prevalence was 19%.  We took serious steps towards improving these rates, including mattress replacements, education on nursing assessment - especially the initial assessment - changed the risk assessment scale from Norton to Braden, and had monthly education inservices on all topics of wound and skin care.

In the third quarter of 2009,  our pressure ulcer prevalence is 12%, and facility-acquired prevalence is 4%.
We have been consistently below the national benchmark of 6% for facility acquired prevalence since the second quarter of 2005.

Keys to success:

Implementation of an Interdisciplinary Skin and Wound Team has been instrumental in helping Hazleton General achieve success.  Members of the team include RNs, LPNs, dieticians, physical therapists, home care RNs, medical staff, and our Wound Ostomy Nurse chairs the meeting.  Each nursing unit has an RN or LPN on the team.  These nurses have been trained by the Wound Ostomy Nurse to act as a resource person on each unit, deal with questions, and offer pressure ulcer prevention strategies and consultation on skin and wound care.  All staff nurses have been educated, but these resource nurses receive additional monthly education and feedback regarding their unit PI measures.  These resource nurses and the Wound Ostomy Nurse also then share information with the staff on the units.

Our certified Wound Ostomy Nurse offers mentoring, guidance, and consultation for staff in addition to direct patient care.  She also circulates a quarterly Wound Ostomy Continence Nurse newsletter that includes important information that needs to be shared and/or reinforced.

Staff buy-in, administrative support, and physician involvement were also keys to our success, as well as collaboration with ancilllary departments.

Key Challenges:

Elderly population - Our wound and ostomy nurse communicates with skilled nursing facilities when patients are admitted to try to maintain similar wound care, unless otherwise indicated.

Have mainly RNs and LPNs do the turning and repositioning of these compromised patients.

If a patient is at risk for pressure ulcers with a Braden scale of 18 or less, the staff addresses skin integrity issues on the plan of care.  Nursing interventions include inspection of skin, every shift, proper management of moisture and cleansing of skin, nutritional iterventions, turning and repositioning every 2 hours, use of support surfaces as indicated, and heels elevated from bed surface while in bed.

If a patient does have a pressure ulcer on admission, correct wound care is ordered as based on wound assessment.
The wound and ostomy nurse is consulted on all patients at risk for pressure ulcers on admission.  The patient is screened to assure correct interventions are in place and ongoing. The wound and ostomy nurse also assesses and recommends wound care on all patients admitted with pressure ulcers.

Mentor designation - 9/23/08
Information updated - 11/17/09

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Holy Spirit Hospital — Camp Hill, PA
Availability Status: Available to answer requests
Staffed Beds: 320
Teaching/Non-Teaching Status:  Non-Teaching
Setting:  Urban
Start Date of Intervention Work: August 2007
Mentor Contact Name: Leona S. Mlynek, MSN, RN, Wound Care Coordinator
Mentor Contact Email: lmlynek@hsh.org
Mentor Contact Phone: 717-763-2428

Additional Information:

Identifying potential areas for improvement by using the Plan Do Study ACT (PDSA) model, we established a multidisciplinary team.  The Pressure Relievers multidisciplinary team developed goals and implemented strategies and evidence-based initiatives to met the goals that were set using PDSA.

A Med/Surg Telemetry unit was used to pilot our program for a two-month period.  Outcomes were monitored and evaluated.  The program was then implemented hospital wide.

Strategies included:

Obtaining approval from the Value Analysis Committee to change to more cost-effective and efficient disposable pads, barrier ointment.  Skin care supplies, chair cushions, and disposable pads were made easily accessible to staff.  After upgrading to a more effective barrier ointment, we made it accessible through each units’ med-select.  Instead of requiring staff to call Central for disposable pads, we now put them in all the units’ clean utility room closets.  Staff also no longer need to call Central for one of the few chair cushions that used to be available.  After the team evaluated different cushions, we decided that each unit should order the number needed for their patient population and keep them in their unit's clean utility room closets.  With the implementation of these strategies, we found that we had a decreased use in products such as attends/depends, barrier ointment and disposable pads.

Nursing-initiated Pressure Ulcer Prevention therapy was computerized as an order set.  This promoted nursing autonomy and empowerment to address patient's needs.

Education of our staff regarding this program was completed through self-learning packets that were given to all members of the nursing staff.

Coinciding with our initiative, our Professional Practice Service Council piloted and then implemented every one hour rounding on patients.  This has helped keep patients safe, turned, hydrated with incontinence checks, and bathroom assistance available.

Nursing Administration implemented a Lift Team.  They provide coverage on all shifts and assist with lifing and repositioning patients.

Data is collected and evaluated on a monthly basis.  Results are shared with the staff and key stakeholders throughout the hospital.  Our team also collects data on a quarterly basis for the National Database of Nursing Quality Indicators (NDNQI) which benchmarks us with other hospitals.

Nosocomial Pressure Ulcers were decreased by 50% or more.

See graphs of their results.

[2/23/09]

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Morristown Memorial Hospital—Morristown, NJ
Availability Status: Unavailable to answer requests
Licensed Beds:  588
Teaching/Non-Teaching Status:  Teaching
Setting:  Urban
Start Date of Intervention Work: December 2005
Mentor Contact Name:
Mentor Contact Email:
Mentor Contact Phone:

Additional Information:

The Pressure Ulcer sub-committee consists of two certified wound, ostomy and continence nurses, performance manager, risk manager, dietician, physician, and a team of unit-based staff nurses specialty educated in wound care management.  The committee has developed specific measurable goals, and reports outcomes to the Quality Improvement Council.  Wound Care Guidelines were created and implemented using evidenced-based practices from the National Pressure Ulcer Advisory Panel, The Wound, Ostomy and Continence Nurses Society and, the AHCPR guidelines.  Guidelines were incorporated into Care Manager Documentation System.

Braden Scale Risk Assessment changed from weekly to daily.  Definition of "Patient at risk" was redefined to a score of 18 or below.  Development and implementation of wound care competency for professional and non-professional nursing staff.  Purchase of pressure redistribution surfaces for all inpatient beds.  Development and implementation of "SAVE OUR SKIN" intranet site.

Collaboration between all disciplines on health care team to protect patient's skin.  Information about pressure ulcer program is communicated to senior management on a quarterly basis using NDNQI national benchmarks as comparisons.  Nursing unit action plans are developed based on NDNQI data and implemented with support of nursing manager, chief nursing officer, and chief medical officer.

Wound Care Coordinators serve as resource to their peers on the units, assist in data collection and, communicate important information to the staff about wound care.  Intensive education of the staff including nurses, physicians, residents, nursing assistants, dietary and physical therapists. Annual education program entitled "SAVE OUR SKIN" held annually (150- 200 participants attend).

Pilot unit was 54-bed medical floor which has a high volume of elderly high risk patients for the development of pressure ulcers.  Evidence-based practices in the prevention of pressures ulcers were used to improve the quality of patient care by reducing the development of hospital-acquired pressure ulcers (HAPU).  Aim statement was to reduce the number of HAPU by 25% by December 2006.  A single day point prevalence study was conducted quarterly in 2005 and 2006.  The data was collected by two certified WOCN nurses, and a team of registered nurses who were trained in data collection and skin assessment.  Following the data collection, HAPU were reassessed by the WOCN nurse to test data reliability.  Data was analyzed and the Plan-Do-Study-Act improvement cycle was utilized to implement improvements and develop prevention strategies.  A total of 1321 patients were surveyed between fourth quarter 2005 and the third quarter 2006.  Interventions were implemented starting in the fourth quarter of 2005.  There was no statistical difference between pre-interventions and post-intervention periods in terms of age, gender or risk assessment score.

The number of HAPU, all stages, in Period One (fourth quarter 2005 and first quarter 2006) was 11% compared to Period Two (second quarter 2006 and third quarter 2006), which was 4%. An improvement of 64%.  HAPU, Stage I improved from 6% to 2%.  HAPU Stage II or higher dropped from 5% to 3%.

Morristown Memorial has also participated in the NJHA Collaboration for the Reduction of Pressure Ulcers since 2005.  Monthly prevalence studies were conducted to measure our improvements.  Pre-intervention HAPU prevalence rate was 45%, post intervention HAPU rate was 0%.  The unit was able to maintain 0% for 3 months and has had 0%-5% rate for final quarter of 2006.  When a HAPU was identified the unit conducts a Root Cause Analysis to determine areas for improvement.  It is also an opportunity to re-educate staff about pressure ulcer prevention.

[3/13/07]

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The Nebraska Medical Center – Omaha, NE
Availability Status: Available to answer requests
Licensed Beds: 548
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: January 2004
Mentor Contact Name: Alan Didier, Manager, Burn, HBO & Wound Ostomy Services
Mentor Contact Email: LDidier@NebraskaMed.com
Mentor Contact Phone: 402-552-3442

Additional Information:

The Nebraska Medical Center's Skin and Wound Advisory Team (NMC-SWAT) conducts quarterly pressure ulcer prevalence studies to: (1) monitor pressure ulcer prevalence; (2) monitor rates of hospital-acquired pressure ulcers on a quarterly basis and incidence on an annual basis; (3) identify risk factors for pressure ulcer prevention that are amenable to risk-based prevention protocols; and (4) examine the care processes involved in pressure ulcer prevention to enhance quality improvement efforts.  Results are benchmarked against national rates through quarterly reporting to the NDNQI data base.  The following results were obtained over three skin surveys from April 2009 through October 2009:
 
• Percent of Patients Receiving Pressure Ulcer Admission Assessment = 95.4% 
• Proper pressure ulcer admission assessment includes the following two components = 95.8%
           1) Assessment of pressure ulcer risk using an agreed-upon risk assessment tool = 96.2%
           2) Skin assessment to identify existing pressure ulcers = 95.4%

• Percent of At-Risk Patients Receiving Full Pressure Ulcer Preventative Care Proper pressure ulcer care includes the following five components: See below.
          1) Daily inspection of skin for pressure ulcers = No Data
          2) Proper management of moisture, including both cleaning and moisturizing skin = 85.6%
          3) Optimization of nutrition (MD ordered dietary recommendations) = 85.7%
          4) Repositioning every two hours = 88.2% (April 2009)
          5) Use of pressure-relieving surfaces = 93.1%

• Pressure Ulcer Incidence = 1.7%

• Pressure Ulcer Prevalence = 5.2%

• Patients Receiving Daily Pressure Ulcer Risk Reassessment = 100%

Decreased organizational hospital-acquired pressure ulcer rates from 9.6% in December 2004.  All of our initiatives were rolled out in January 2006.  Since January 2006, our hospital acquired pressure ulcer rate has averaged less than 3%.  This decreased rate of hospital-acquired pressure ulcers has provided an estimated $4,537,000 in avoided costs related to pressure ulcers.

 Decreased overall severity of hospital-acquired pressure ulcers in our organization.
• Improved/sustained results of nursing documentation of nursing care processes related to skin integrity.
• Increased awareness throughout the organization related to pressure ulcer prevention.
• Expanded the role of the wound and ostomy nurse as that of consultant, educator, and mentor.
• Received IRB approval to do a secondary analysis of the data we obtained from our skin surveys which contains 2500 patients.
• Having a strong multi-disciplinary team with staff nurse participation and adminstrative support.

Read the Nebraska Medical Center profile in the 2008 IHI Annual Progress Report

Mentor designation - 3/17/07
Information updated - 2/16/10

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OSF Saint Francis Medical Center—Peoria, IL
Availability Status: Available to answer requests
Licensed Beds:  710
Teaching/Non-Teaching Status:  Teaching
Setting:  Urban
Start Date of Intervention Work: September 2004
Mentor Contact Name: Bevette Griffin
Mentor Contact Email: Bevette.E.Griffin@osfhealthcare.org
Mentor Contact Phone: 309-655-2659

Additional Information:

Pressure Ulcer Incidence: 
• Our pressure ulcer rate has gone from a baseline of 9.4% in July 2002 to 1.5% in December 2006.
• We met our target of 4% in March 2005 and have remained below our target since that time. 

Pressure Ulcer Prevalence:
We currently conduct our prevalence study quarterly.  All patients are assessed.  Our currently prevalence is 2.5%, our lowest rate was 0.6% in September 2008.  We have remained below 3% since March 2007.  Our current target is 2%. 

Keys to our success:

We developed an SOS (Save Our Skin) team for every patient care unit.  Each unit has a SOS champion. 

Process ownership/accountability was assigned to our hospital skin nurse.  This indicator is placed on the hospital and unit-specific scorecard that is reported and monitored by the professional nursing congress. 

Patients are turned every 2 hours when the "Olympic Theme Song" is played over the hospital audio system.  We recently changed our music to "Roll Over Beethoven." 

Documentation issues were addressed and documentation improved.  Pressure ulcers are reported as “Never Events” to high level committees:  Quality Safety Board, Medical Executive Committee, Professional Staff QI, Nursing Educators and Professional Nursing Congress and up to the Corporate Quality Council. 

Mentor designation - 3/13/07
Information updated - 11/17/09

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Onslow Memorial Hospital – Jacksonville, NC
Availability Status: Available to answer requests
Licensed Beds: 162
Teaching / Non-Teaching Status: Non-teaching
Setting: Rural
Start Date of Intervention Work: December 2006
Mentor Contact Name: Jo Malfitano MSN, MBA, RN, CPHQ, NE-BC, Performance Improvement & Accreditation Manager
Mentor Contact Email: jo.malfitano@onslow.org
Mentor Contact Phone: 910-577-2549

Additional Information:

Challenges include:

• Frontline buy-in for daily risk assessments
• Compliance with documentation changes
• Accountability for completion of assessment and documentation compliance 
• Sustaining momentum

Keys to success:

Incorporating prevalence and incidence studies to identify the scope of our pressure ulcer issue was crucial in identifying a 20% incidence rate in early 2007.  Utilizing our Certified Wound Ostomy Nurse as our skin care champion, we expanded education and training, reformulated admission assessments and daily nursing forms to incoporate daily risk assessment tool (Braden Scale) and identified interventions. 

Unit-to-unit competition recognition and celebration assisted with addressing above mentioned challenges.  For example, we report our pressure ulcer data on a monthly basis through our 5 Million Lives Committee meeting and that data is broken down by specific units, ie: ICU, MICU, Adult Med-Surg.  Examining data this way enables us to see which units are champions of compliance for completing admission and daily assessments and then instituting the recommended interventions for those found at risk.  After 6 months of data collection, we hosted a pizza party for the unit with the highest compliance rate (they also had the lowest incidence).  We also wrote an article recognizing them for this accomplishment and published it in our organizational newsletter.  In addition, we have skin care champions appointed for each unit that work closely with our Certified Wound Ostomy Nurse.  The champions as well as the nurse manager for those celebrated units were personally recognized in front of our board and received a gift card to a local restaurant.

Percent of Patients Receiving Daily Pressure Ulcer Risk Reassessment: 98%

Pressure Ulcer Incidence: Remains at 0%

Pressure Ulcer Prevalence: 13.5%

Patient- and Family Centered Care initiatives:

• We have included a new "video on demand" series regarding wound care called "You Are Not Alone:  Understanding Pressure Ulcers" for the patients and families.
• A handout for pressure ulcer prevention has been revised to be more reader friendly. 

Zero percent incidence in December 2007.  Prevalance and incidence study was a result of each nursing unit remaining greater than 90% compliant with completion of the admission and daily assessments and greater than 95% compliant with institution of all four IHI prevention initiatives addressing moisture, optimizing nutrition/hydration, use of pressure relieving surfaces and repositioning.  In December 2009, the incidence was at zero percent representing a sustained effective wound care prevention program.  Compliance with the program is greater than 98% with completion of daily assessment.

Mentor designation - 8/15/08
Information updated - 3/12/10

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Owensboro Medical Health System—Owensboro, KY
Availability Status: Available to answer requests
Licensed Beds:  400
Teaching/Non-Teaching Status:  Non-Teaching
Setting:  Rural
Start Date of Intervention Work: March, 2004
Mentor Contact Name: Lisa Thompson
Mentor Contact Email: lthompson@omhs.org
Mentor Contact Phone: 270-688-2868

Additional Information:

• Purchased new pressure relieving mattresses
• Implemented "Turn Every Two" program that includes turn clocks, pagers, and communication sheets
• Adopted and implemented standard assessment method
• Developed a wound care plan and guidelines for prevention
• Developed flow sheet
• Purchased needed equipment and supplies

Owensboro Medical Health System has decreased the incidence of pressure ulcers in the acute care inpatient population from a high of 22% in March 2003 to 1.3% in August 2006.  During this period, the incidence in the extended care population decreased from 40% to 0%, and their rate has been 0% for three of the last seven prevalence studies.  We estimate that more than 390 ulcers have been prevented since the project began. 

[3/13/07]

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Robert Wood Johnson University Hospital at Rahway — Rahway, NJ
Availability Status: Available to answer requests
Licensed Beds:  275
Teaching/Non-Teaching Status:  Non-teaching
Setting:  Urban
Start Date of Intervention Work: 1999
Mentor Contact Name: Denise Gerhab, RN, BSN, NM, WCC
Mentor Contact Email: dgerhab@rwjuhr.com
Mentor Contact Phone: 732-499-7158

Additional Information:

The Skin Care Team, which meets monthly to conduct prevalence/incidence studies hospital-wide, including the 24-bed Sub Acute unit, has worked diligently over the last few years to implement "best practices."  The original Skin Care Team comprised just a handful of nurses. Today, the Skin Care Committee comprises RNs (four of whom are are Wound Care Certified), LPNs, Dietary, Infection Control Nurse and the Quality Director.  There is representation from all acute care areas of the hospital including the Emergency Center, Medical/Surgical Units, CCU, SICU, Telemetry, SDS, OR, PACU, Endoscopy, Radiology, and Post Acute (SNF) unit.  Originally established in 1998, the present committee has RN representation from both 12-hour shifts who act as the "resource" liasons to assist staff/physicians in making appropriate choices in caring for those at risk of breakdown or those who present with pressure ulcers/wounds.  

Senior leadership support has been essential in order for the Committee to accomplish their goals and reduce HAPUs.  New product lines that assist staff in achieving  their goals include specialty mattresses, skin care creams, heel care boots, VAC systems, fecal management systems, and wound care products.  Yearly competencies and educational sessions for all nursing staff (both RN and LPN, and bi-annual inservices for the Nursing Assistant staff, as they are the "front line in prevention), bi-monthly evidence-based articles supporting best practices on prevention/treatment of wounds are shared with all committee members.  Establishment of Policies and Procedures for Prevention and Treatment of Pressure Ulcers, (including Pre Albumin levels), a Pressure Ulcer Protocol, (presently being revised to include the NPUAP's new 2007 definitions), universal turning and repositioning schedules, creation of a Treatment Administration Record (presently in review by the Nurse Practice Committee) and digital photography/mounting of wounds.  Teaching materials for Patient/Family education flyers are available for the nursing staff to share.  Skin Care carts with guidelines have been provided for each patient care unit, which serves as reference/resource manuel for the nursing staff.  A half hour presentation has been incorporated into the Nursing Orientation program of all new nursing staff hires.  The inclusion of other disciplines has also added to the success of the team, and the dedication of those who serve on the Skin Care Committee has brought our hospital to the forefront of prevention of HAPU's.  Consultation with physicians is imperative in facilitating best practices for prevention and treatment of pressure ulcers.

Robert Wood Johnson University Hospital at Rahway has reduced the prevalence rate of hospital-acquired pressure ulcers (HAPU'S) from 9.52% in 2002, to 4.19% as of June 2007, a reduction of 52%, and falling well below the ANA-NDNQI benchmark of 7.39% as of 2006.  The incidence rate in 2001 was 18.33%, and today stands at 5.07%, a 72.3% decrease of our incidence rate.  Participation in the New Jersey Pressure Ulcer Collaborative to Reduce the Incidence of Pressure Ulcers, further justified the importance of preventing pressure ulcers in the hospital/long term care facilities.  Our hospital received recognition in June 2007 at the final Learning Session where we achieved our goal on "No new incidence for three months or greater and achieved goal of reducing pressure ulcers by 25%."

Our success is due mostly in part to the dedication of those who serve as unit representatives and act as the resource nurse when interventions are needed.  Extensive education for committee members remains a priority with the Chair Person, enhancing their clinical knowledge to identify staging of pressure ulcers appropriately.  Through literature research and evidence-based practices, the Braden Scale has been adopted into our practice and most recently has been incorporated into our 24 hours Nurses Notes, requiring the R.N. to access their patients, thereby determining the best prevention practices.  The Braden Scale- Skin Care Plan serves as a guide for our nurses.  Daily interdisciplinary meetings on all patient care units include discussions on any "skin care issues".  Braden scale scores of 17 or less automatically trigger a dietary and physical therapy consultation.  A proud moment occurred in April 2007, when our Skin Care Committee was selected as one of the Editor's Choice "2007 Best Nursing Team-Among the Best," for the greater New York and New Jersey area. 

[12/6/07]

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Sherman Health – Elgin, IL
Availability Status: Available to answer requests
Staffed Beds: 250
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: February 2007
Mentor Contact Name: Lori Beckwith
Mentor Contact Email: lori.beckwith@shermanhospital.org
Mentor Contact Phone: 847-429-8783

Additional Information:

Top 5 factors that contributed to our success:

1) Made Hospital Acquired Pressure Ulcers (HAPU) and operating plan goal for the organization.  This created urgency and awareness of our HAPU practices.

2) Education to staff and skills competency

3) Tools/resources available:

o Bed Settings
o Float Heels/Boots
o Gel Pads in OR
o Special Beds as Needed

4) Hardwiring of hourly rounding - Nurse asking/doing 3P's (pain, position, potty).

5) Empowering skin champion team : Each unit has designated skin champion that does monthly prevalence study. Skin champs empowered to drill into the "fallout" and analyze what happened if pressure ulcer was found, report out at department meetings, create education tools, and serve as owner and mentor of HAPU practice on unit.

At Sherman Health, we put a focus on reducing pressure ulcers by putting this goal as an operating plan initiative for our quality pillar.

The Hospital-Acquired Pressure Ulcer initiative gained visibility by making it a strategic goal, aligning its performance with individual leader goals, putting resources and a bi-weekly steering team into place, putting intervention as a standing agenda item on all unit meetings, posting results under quality pillar in all department communication boards.

Assessment of pressure ulcer risk using Braden scale - 2nd qtr 2009
Coronary Care Unit: 83.3%
Med-Surg ICU: 100%
Telemetry South: 100%
Oncology: 100%
Adult Medical: 100%
Ortho/Neuro: 100%
General Surgical: 69.23%
Telemetry North: 92.86%

All units at 100% for pressure relieving surfaces.

May-July 2009: 4/3515 = 1.14% incidence of Pressure Ulcers Not Present on Admission/1000

Our baseline was 10.4%.  YTD through January 2008 was 4.0%.
May-July 2009: 6/301 = 2.0% Hospital Acquired Pressure Ulcer Prevalence

Mentor designation - 5/1/08
Information updated - 2/4/10

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Trinitas Regional Medical Center — Elizabeth, NJ
Availability Status: Available to answer requests
Licensed Beds:  341
Teaching/Non-Teaching Status:  Teaching
Setting:  Urban
Start Date of Intervention Work: September 2005
Mentor Contact Name: Deborah Durand, RN, APN
Mentor Contact Email: ddurand@trinitas.org
Mentor Contact Phone: 908-994-5149

Additional Information:

In September 2005, our overall compliance with the best practice "bundle" (see below) components was 70%.  Our rate for implementing "strategies" (standardized skin care products, protein supplements, etc. as detailed below) was 12%.  By July 2007, our overall bundle compliance was 88% and our rate for implementing additional strategies was 74%.  Through September 2009, we have consistently implemented the best practice bundle in all nursing areas.  We monitor compliance by random sampling in each unit and our overall compliance with the best practice "bundle" components is greater than 90%. 

Quarterly prevalence studies are conducted by our PUPI (Pressure Ulcer Prevention Initiative) Team to monitor the success of each unit and provide peer to peer feedback and support at the staff level.  In September 2009, our facility acquired prevalence rate was 2.9%.

Trinitas Hospital’s participation in the New Jersey Hospital Association Pressure Ulcer Collaborative focused our efforts to minimize pressure ulcers in our patients.  Our interdisciplinary team collaborated to implement "strategies" that included supply chain improvements to standardize skin care products, a standardized method of providing protein supplements to at-risk patients, and purchasing and using equipment (turning wedges, new beds with specially designed surfaces) to aid pressure re-distribution.

In addition to this, we monitored our compliance with the "bundle" of best practices identified by the NJHA Pressure Ulcer Collaborative, and made these practices our standard of care.  The bundle includes a skin assessment within 8 hours of admission, a risk assessment (Braden Score) within 8 hours of admission, a daily skin re-assessment, a nutritional assessment for at-risk patients within 48 hours, implementation of appropriate pressure ulcer prevention strategies in at-risk patients within 24 hours and evidence of repositioning every 2 hours for at-risk patients.  Monitoring these elements focused our improvement efforts and showed gaps in equipment, supplies and documentation that needed attention.
 
Ongoing efforts include the development of a Pressure Ulcer Prevention Initiative (PUPI) Team of staff nurses from each unit who participate in learning sessions and work with our Advance Practice and Wound Care Nurse Specialists to conduct quarterly prevalence studies and to monitor compliance with the bundle of best practices on their own units.  We have also incorporated a daily risk assessment by adding the Braden Score to the computerized nursing charting system.  Qualitative advances included a standardized method of providing protein supplements to at-risk patients, supply chain improvements to standardize skin care supplies and continuous staff education in a "bundle" of best practices known to have an impact on pressure ulcer prevention.  Documentation of risk assessments and interventions as well as detailed wound assessment is now incorporated into our computer documentation system.  We've developed a "Pressure Ulcer Prevention Nursing Order Set" to standardize our interventions to meet individual patient needs.

Implementation of interventions for at-risk patients has been the cornerstone of our improvement efforts.  We used grant funds to purchase turning wedges which have been a great success and our bed replacement project provides every patient with pressure-redistribution.

Mentor designation - 1/18/08
Information updated - 1/15/10

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Yuma Regional Medical Center – Yuma, AZ
Availability Status: Available to answer requests
Licensed Beds: 333
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: April 2003
Mentor Contact Name: Mary Jo Beneke, RN, CWOCN; Marla Moore, BSN, MA, Director of 2 West Medical; Sarah Medrano, RN, BSN, WOCN
Mentor Contact Email: mbeneke@yumaregional.org; mmoore@yumaregional.org; smedrano@yumaregional.org
Mentor Contact Phone: 928-336-3334 (Beneke); 928-336-7425 (Moore); 928-271-3094 (Medrano)

Additional Information:

Yuma Regional Medical Center has been successful in decreasing the hospital-associated pressure ulcer prevalence by implementing a formal pressure ulcer prevention (PUP) program.  Initially, a multidisciplinary Wound Care Advisory Council, including a physician champion, was formed to evaluate existing problems, set goals, and develop plans for hospital-wide process improvement.  Subcommittees were formed for staff education, patient education, Braden scale risk assessment, competencies, and documentation to address identified problems and propose solutions.  The outcome of recommendations made by the subcommittees included revision of wound-related policies and guidelines to reflect best practice, purchase of digital cameras for wound documentation, standardized and improved nursing documentation forms, and patient education pressure ulcer prevention brochures in English and Spanish.

A new tool, the Daily Skin Care Flowsheet, was created to use for patients at risk for pressure ulcers and document interventions to reduce risk.  It is on the reverse side of the Braden Scale Assessment Form.  Photographic Wound Documentation Form was implemented to document pressure ulcers and wounds on discovery and at regular intervals thereafter to document wound progression and facilitate communication among interdisciplinary team.  An initial Pressure Ulcer Prevalence and Incidence study was completed for all acute care units for baseline data, and have since conducted quarterly prevalence studies to measure improvement.  New pressure redistribution beds were purchased for ICU and high-risk medical unit, and mattresses in other units are being replaced as needed with upgraded support surfaces.  Each patient is given four pillows to provide adequate protection and support for positioning.

Comprehensive pressure ulcer prevention education was provided to all clinical staff for the PUP kick-off.  YRMC provides continuous education on wound care and pressure ulcer prevention to staff and patients and their families as well as mandatory pressure ulcer competencies required annually.  As a result of product trials conducted by selected nursing units, our skin care product line and several dressings have been replaced by newer evidence-based products to improve patient outcomes. The PUP program, documentation requirements and associated forms, digital cameral, PUP brochures, and skin care products, are included in all new hire clinical orientation classes.  In the past 3 years, a Skin & Wound Care team was established to provide additional education to interested individuals (RNs and nursing assistants) and to provide additional wound care resources on the nursing units.  The Skin & Wound Care team meets monthly for “lunch and learn” sessions where wound and skin care related education is presented, often with hands-on training.

The Braden scale risk assessment is used at Yuma Regional Medical Center (YRMC).  Braden Scores are calculated for all patients on admission and daily to determine risk and initiate appropriate interventions to reduce risk.

98.8% of patients at YRMC had a Pressure Ulcer Risk Assessment performed within the last 24 hours on our February 2010 Pressure Ulcer Prevalence Study.

Incidence of hospital-acquired pressure ulcers in August of 2009 was 0.0%.

Hospital-acquired pressure ulcers in June 2003 (baseline data) was 13.0%.

In February 2010, YRMC's hospital-acquired pressure ulcers was 2.4%.

Mentor designation - 2/8/08
Information updated - 3/16/10