The team from Onslow Memorial Hospital was a participant in the initiative to prevent hospital-acquired pressure ulcers as part of IHI’s 5 Million Lives Campaign.

Crystal Hayden, RN, MSN, Senior Vice President/Chief Nursing Officer, Campaign Leader
Dr. Piper, PhD, Chief Executive Officer, Team Sponsor
Jo Malfitano, RN, MSN, Performance Improvement Director
Bobbi Cole, RN, MSN, Performance Improvement
Jane Both, RN, Performance Improvement
Erin Thomas, Performance Improvement
Vincent Lee, PharmD, Team Member
Jeanette Orr, RN, Team Member
Gloria Horne, RN, Team Member
Sharon McManus, RN, Team Member
Anne Gerichten, RN, Team Member
Nancy Scozzari, RN, CWOCN, Team Member
Sue Sanders, RN, Team Member
Sharon Allen, RN, Team Member
Stacy Jones, Team Secretary

• Increase compliance with the utilization of pressure minimizing interventions such as turning patients and the use of pressure relieving devices to 95 percent by December 31, 2009
• Decrease the organizational pressure ulcer incidence rate of the inpatient population by 50 percent by December 31, 2009

• Percentage compliance with documentation  of pressure ulcers on admission
• Percentage of prevalence of pressure ulcers
• Percentage of incidence of pressure ulcers

In 2006, the Director of Education and CEO at Onslow Memorial Hospital initiated efforts to prevent hospital-acquired pressure ulcers. A multidisciplinary team was formed to oversee improvement efforts. Interventions included the following:

• Implement risk assessment tool in the admission assessment and 24-hour nursing form
• Revise skin care protocol
• Educate staff, including current staff and new hires
• Recruit skin care “champions” from each nursing unit
• Facilitate quarterly Prevalence and Incidence report

In 2006, the hospital joined IHI’s 5 Million Lives Campaign, focusing on the interventions to prevent hospital-acquired pressure ulcers. We implemented a risk assessment tool on admission assessment and 24-hour nurses’ notes to determine at-risk patients. A quarterly Prevalence and Incidence study was implemented to track and trend compliance with documentation and pressure ulcer prevention strategies. A committee of Skin Care Champions was formed to educated staff on policy and procedure for pressure ulcer prevention.

• Beginning March 2007: First Prevalence and Incidence study, risk assessment with interventions placed on admission assessment and 24-hour nursing form, Skin Care policy updated, staffing education on prevention began
  • A collaborative team was developed to revise the admission assessment and 24-hour nursing form to include the risk assessment tool and implementation of interventions based on scores
  • The skin care protocol was revised to reflect evidence-based interventions to prevent pressure ulcers
  • A program was implemented in the new hire nursing orientation to provide information on the risk assessment tool, prevention, and staging of pressure ulcers
• Beginning July 2007: Skin Care Champion Committee formed —Champions from each unit were recruited to participate in the collaborative effort to educate staff and collect data
• Beginning December 2007: A skills fair was organized for staff education and included a station dedicated to providing information on policy and documentation changes, demonstration, and hands-on learning for prevention devices 
• Beginning March 2008: Another skills fair was held and included a pressure ulcer prevention station
• Ongoing: Data from the quarterly Prevalence and Incidence report is now used to identify educational opportunities and process changes

Summary of Results:

As a result of these changes, Onslow Memorial Hospital achieved a significant decrease in the facility-acquired pressure ulcer rate, prevalence rate, and incidence rate between March 2007 and March 2009. Overall , we have achieved 98-100 percent compliance with 24-hour nursing assessment, intervention, and risk assessment scoring ; we also achieved  95-100 percent compliance with skin care admission assessment.

The prevalence rate in March 2009 is half the rate in March 2007. The facility-acquired rate has dropped dramatically, from 43 percent to four percent in the same period. The incidence rate, while based on small numbers of patients, also has declined over the two years.

Lessons Learned:

• Obtain buy-in from front-line providers to ensure success
• Celebrate achievements to motivate front-line providers by providing recognition
• Implement hard-wired tools that are difficult to circumvent
• Set aims that are specific and measureable and do not let “perfection be the enemy of good”

Next Steps:

Education and buy-in from staff was valuable to our success. We continue to re-evaluate our best practice and perform a case-by-case audit when an incidence occurs. Next steps will include revision of policies and procedures for prevention, and beginning root cause analysis when an incidence occurs.

Crystal Hayden, RN, MSN
Senior Vice President/Chief Nursing Officer
Onslow Memorial Hospital
Crystal.hayden@onslow.org