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Service Delivery Innovation Profile

Comprehensive, Interdisciplinary Guidelines, Combined With Tools to Promote Adherence, Significantly Reduce Hospital-Acquired Pressure Ulcers


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Snapshot

Summary

St. Vincent’s Medical Center developed a comprehensive, interdisciplinary set of guidelines, known as the SKIN™ bundle, to provide staff with a synergistic group of interventions to implement for the prevention of pressure ulcers in all patients with a Braden score of 18 or less. The bundle focuses on surface selection (e.g., type of mattress), regular turning of patients, incontinence management, and nutrition and hydration interventions. In addition to the bundle, the group developed standards of care, posters, and educational presentations and formed a nursing leadership group that meets weekly to review all incidence of pressure ulcer development in the previous week. The program reduced the incidence of pressure ulcers by more than 90 percent (from 5.7 to less than 0.5 percent), including completely eliminating stage 3 and 4 facility-acquired pressure ulcers for a significant period of time.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the incidence of facility-acquired pressure ulcers.
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Developing Organizations

Saint Vincent's Medical Center
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Use By Other Organizations

The SKIN™ program is being implemented at all 67 Ascension Health system sites. St. Vincent's has shared the pressure ulcer toolkit with IHI and other health care facilities. Kaiser-Permanente, Adventist of Northern California and CMS have all fully or partially adopted the recommended guidelines.

Date First Implemented

2004

Problem Addressed

Facility-acquired pressure ulcers are common and costly, but also preventable. Guidelines exist that lay out specific measures for preventing them, but many facilities fail to consistently apply these steps to all patients.
  • A common, costly problem: Many hospitalized patients get facility-acquired pressure ulcers, with incidence ranging from 0.4 to 38 percent in acute care settings. A 2005 International Pressure Ulcer Prevalence Study reported a 7.3 percent hospital-acquired pressure ulcer prevalence rate.1 Pressure ulcer treatment costs range from $2,000 to $70,000 per wound, with the average hospital’s total costs being between $400,000 and $700,000 annually.2
  • A preventable problem: Pressure ulcers can be prevented through use of relatively simple measures. In fact, national initiatives, such as The Joint Commission's 2009 National Patient Safety Goal #14, focus on preventing health care–associated pressure ulcers through use of established guidelines.3 The Centers for Medicare & Medicaid Services classifies stage 3 or 4 pressure ulcers that occur after hospital admission as a "never event" that will not be reimbursed by Medicare.4
  • Failure to follow established guidelines: Although existing guidelines call for the use of a set of measures designed to prevent the development of pressure ulcers, many hospitals do not consistently use such measures. At St. Vincent's, for example, although the incidence of pressure ulcers was below the national average (at 5.7 percent), the staff was not consistently applying all preventive measures identified in the SKIN™ bundle, suggesting further opportunities for improvement.

What They Did

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Description of the Innovative Activity

St. Vincent’s Medical Center developed a comprehensive, interdisciplinary set of guidelines, known as the SKIN™ bundle, to provide staff with a synergistic group of interventions to implement for the prevention of pressure ulcers in all patients with a Braden score of 18 or less. The bundle focuses on surface selection (e.g., type of mattress), regular turning of patients, incontinence management, and nutrition and hydration interventions. In addition to the bundle, the group developed standards of care, posters, and educational presentations, and formed a nursing leadership group that meets weekly to review all incidence of pressure ulcer development in the previous week. Key elements of the program include the following:
  • SKIN™ bundle: The SKIN™ bundle includes interventions relating to surface selection (i.e., use of specialty mattresses), regular turning of patients, incontinence management, and nutrition and hydration management, as outlined below:
    • Surface: The guidelines remind staff of the following: (1) Be sure patient is on correct type of mattress; (2) Do not use multiple layers of linens under the patient; (3) Keep linens free of wrinkles; and (4) Be sure patient is not lying on tubing, telephones or call bells.
    • Keep turning: The guidelines remind staff to do the following: (1) Reposition and/or educate the patient of the importance of turning at least every 2 hours when in bed. Documentation of "self-repositioning" is not acceptable; (2) Document the patient's actual position; (3) Reposition at least every hour if in a chair; and (5) Use a chair pad when patient is in a chair.
    • Incontinence management: The guidelines call for caregivers to adhere to the following: (1) To offer toileting assistance every 2 hours; (2) If incontinent, to give perineal care every 2 hours and as needed for stool incontinence; (3) To apply a moisture barrier after incontinence care; (4) If not incontinent, to apply moisture barrier every 8 hours; and (5) To avoid diapers unless needed for containing excessive amounts of stool; patient is not ambulatory, incontinent, or saturates linens with most urinary incontinence episodes; or patient requests diaper.
    • Nutrition and hydration management: The guidelines call for staff to order a nutrition consult for any patient that appears to have a nutrition deficit or is at risk of developing one. Considerations in assessing the patient include a review of albumin levels, recent weight loss, and consumption of food and liquids (i.e., hydration status). The guidelines also call for staff to carry out nutrition orders and record supplement and meal intake.
  • Tools to encourage adherence to the bundle: St. Vincent's has developed a broad array of tools to help staff comply with the bundle, including the following:
    • Regular assessment and documentation on flow sheet: Unit nurses perform skin assessments every shift and consult a wound, ostomy, and continence nurse whenever a patient exhibits skin redness or breakdown. In these cases, the specialist nurse assesses the patient for pressure ulcers. Nurses document the patient's skin status on the daily Skin Flow Sheet.
    • Clinical alerts: Skin risk alert reminders are placed on nursing documentation clipboards at the patient's bedside for all patients with a Braden scale score of 18 or below, indicating increased risk of a pressure ulcer.1
    • Weekly team meetings to review cases: Every Tuesday at noon, a team of 60 staff, including unit skin champions, assistant nurse managers, nurse managers, directors, and educators, meet in the auditorium to review pressure ulcer cases. The multidisciplinary team meetings also include input from a nutritionist and pharmacist. Discussions focus on what has been done well, what could be done better, and what has been learned about preventing future pressure ulcers. Initially, the weekly meetings focused only on pressure ulcers but now the focus has expanded to other quality measures such as fall prevention and use of restraints.
    • Ongoing performance monitoring and reporting: A three-member unit team, composed of the unit expert skin champion, an experienced registered nurse, and a novice nurse, monitors skin care on patients on designated days, collects and analyzes data (using a standardized collection tool), and reports the prevalence and incidence of pressure ulcers each quarter.

Context of the Innovation

St. Vincent’s Medical Center, a faith-based, not-for-profit health system with 528 licensed beds, provides inpatient and outpatient services to residents of northeast Florida. As part of the Ascension Health System, St. Vincent's developed the SKIN™ program in response to Ascension’s strategic plan, which focuses on eight specific health priorities, including patient safety. Ascension's Healthcare That Is Safe initiative established the goal of having no preventable injuries or deaths by July 2008. As part of this initiative, St. Vincent's Medical Center was chosen as the alpha site to develop best practices to eliminate facility-acquired pressure ulcers. St. Vincent's leadership welcomed the opportunity to develop this nursing-driven program as a means of establishing pride in professional nursing practice.1

Did It Work?

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Results

The SKIN™ program reduced the incidence of pressure ulcers by more than 90 percent, including completely eliminating stage 3 and 4 facility-acquired pressure ulcers for a significant period of time.
  • Significantly fewer pressure ulcers: From 2004 to April 2009, the incidence of pressure ulcers fell by more than 90 percent, from 5.7 to less than 0.5 percent (0.448 percent), well below the average rate for the entire Ascension Health System (0.816 percent).
  • No stage 3 or 4 ulcers: No stage 3 or 4 pressure ulcers occurred between August 2004 and February 2006.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the incidence of facility-acquired pressure ulcers.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Forming interdisciplinary pressure ulcer team: The interdisciplinary team included the chief nursing officer; nurse manager; nurse educators; staff nurses; wound, ostomy, and continence nurses; a performance improvement nurse; a dietitian; a pharmacist; and ad hoc members from purchasing and central supply departments.
  • Identifying best practices: The pressure ulcer team reviewed current practices, policies, and procedures, and conducted a literature review of best practices related to pressure ulcer prevention.
  • Forming expert consultant team: Expert consultants included an Institute for Healthcare Improvement (IHI) representative (who participated after St. Vincent's joined IHI's 5 Million Lives Campaign, which includes an initiative focused on preventing pressure ulcers) and wound, ostomy, and continence nurses.5
  • Creating consensus across the teams: The expert consultant team and pressure ulcer team met to review the evidence-based literature and provide implementation guidance.
  • Conducting chart audit: Program developers reviewed 30 charts of patients who had developed a pressure ulcer in the prior 6 months. The audit showed an increased risk of developing a pressure ulcer for patients with one or more comorbidities related to the following diagnoses: cardiovascular disease (including congestive heart failure), sepsis, respiratory failure, and renal failure.1
  • Educating staff: All nursing staff received comprehensive education on the skin care bundle. Education began on the pilot units and then expanded to other nurses over a 5-month period. Education sessions included a 20-minute slide presentation on the skin care bundle that focused on the etiology of and risk factors for pressure ulcers, and on interventions to reduce that risk. Education sessions also reinforced nurses’ knowledge of skin assessment using the Braden scale, pressure ulcer staging using the National Pressure Ulcer Advisory Panel guidelines, and selection of surface devices.1
  • Pilot testing and expansion: The bundle was tested for 3 months on two critical care units and a cardiac care unit that historically had high rates of pressure ulcers. After the successful pilot test, the program expanded to all nursing units throughout the hospital.
  • Developing, disseminating pressure ulcer prevention toolkit: Program leaders developed a toolkit that includes descriptions of best practices and advice and tools to facilitate implementation and practice change. In November 2005, the kit was distributed to all Ascension Health facilities to assist with implementation of the SKIN™ bundle.1

Resources Used and Skills Needed

  • Staffing: Staff participate in the program as part of their regular duties.
  • Costs: Program costs are minimal, consisting primarily of expenses related to developing the educational materials.
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Funding Sources

The program is funded internally.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Engage leadership: Leadership support and enthusiasm are vital to convincing staff to be active participants in the program, including creating staff accountability and dealing with those who may initially resist the program.
  • Provide "protected" time to work on program: Senior leaders at St. Vincent's allowed two registered nurses to work offsite for 1 week to develop educational resources, including the aforementioned slide presentation.

Sustaining This Innovation

  • Be open to suggestions: Elicit staff input regarding the selection of interventions and products to reduce the risk of pressure ulcers.
  • Continually focus on education: Provide ongoing staff education on pressure ulcer prevention, including an orientation session for new staff and continuing education for all staff that focuses on updates to the SKIN™ bundle and process changes. Incorporate “just-in-time” teaching at the bedside whenever possible.
  • Monitor outcomes: Continually monitor outcomes and address issues as needed. As noted, St. Vincent's uses a three-member unit team to perform this task.
  • Promote free exchange of information: Executive leaders need to create a nonpunitive environment that focuses on the free, regular exchange of information on pressure ulcer reduction initiatives.

Use By Other Organizations

The SKIN™ program is being implemented at all 67 Ascension Health system sites. St. Vincent's has shared the pressure ulcer toolkit with IHI and other health care facilities. Kaiser-Permanente, Adventist of Northern California and CMS have all fully or partially adopted the recommended guidelines.

More Information

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Contact the Innovator

Cissy Shanks, RN, MSN
Director of Nursing Emergence Department and Throughput
St Vincent’s HealthCare Riverside
1 Shircliff Way
Jacksonville, Florida 32204
(904) 308-8294
E-mail: hshan001@jaxhealth.com

Pam Kleinhelter, RN, MSN, CNA-BC
Nurse Manager
St Vincent's Health System
1 Shircliff Way
Jacksonville, Florida 32204
(904) 308-3504
E-mail: pkleinhe@jaxhealth.com

Innovator Disclosures

Ms. Shanks and Ms. Kleinhelter have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Gibbons W, Shanks HT , Kleinhelter P, et al. Eliminating facility-acquired pressure ulcers at Ascension Health. Jt Comm J Qual Saf. 2006;32(9):488-96. [PubMed]

Footnotes

1 Gibbons W, Shanks HT, Kleinhelter P, et al. Eliminating facility-acquired pressure ulcers at ascension health. Jt Comm J Qual Saf. 2006;32(9):488-96. [PubMed]
2 Courtney B, Ruppman J, Cooper H. Save our skin: initiative cuts pressure ulcer incidence in half. Nurs Manage. 2006;37(4):36-45. [PubMed]
3 The Joint Commission Announces 2009 National Patient Safety Goals. Medical News Today. June 19, 2009. Available at: http://www.medicalnewstoday.com/articles/111833.php.
4 U.S. Centers for Medicare & Medicaid Services. CMS Improves Safety for Medicare and Medicaid by Addressing Never Events. August 4, 2008. Available at: http://www.cms.hhs.gov/apps/media/press/factsheet.asp?Counter=3224. Accessed August 25, 2009.
5 Institute for Healthcare Improvement. Prevent Pressure Ulcers. Available at: http://www.ihi.org/explore/pressureulcers/pages/default.aspx.
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Original publication: March 03, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 17, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: June 24, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.