From 'worst' to 'first' in pressure ulcer incidents

Teamwork, consistent monitoring, audits key

About six years ago, Cooley Dickinson Hospital in Northampton, MA, had the highest rate of pressure ulcers in the state; including Stage I patients, it was in the 20%-30% range. Today, the facility can boast 10 quarters of 0%, beginning in December 2005.

"When I came, it was at 8.9% for Stage 2 and greater," recalls Michele Craig, RN, CWS, COCN, RN, wound and ostomy nurse. "We started doing quarterly surveys, and every quarter we'd check every patient's skin. If I found an ulcer, I'd do a chart audit, find out what happened, and present a case study at staff meetings."

Why were rates so high? "Often, things had not been charted — such as a patient refusing to be turned," Craig recalls. "I talked about what to chart, and how to do things differently."

Her goal, she continues, is to take care of the problem, not to point a finger at anybody. "It's always a systemic problem," she insists.

Craig conducted education sessions, going to the quarterly hospital staff education fair and teaching about pressure ulcers. "The NDNQI [National Database of Nursing Quality Indicators] pressure ulcer inservice on competence is very good," she notes. "I made it like a game show; I'd have people say what they thought the answer was after they brainstormed together." She also created a "Jeopardy" game using a template she found online about wound care.

Creating a team

When Craig put together a new protocol, it led to a team atmosphere around pressure ulcers. "I built a protocol that called for the addition of physical therapy for people who have problems with mobility, and a dietitian for people with lower Braden Scores [a scale for predicting pressure ulcer risk] or low albumin; so I spent a lot of time talking to those departments," she explains. "They were initially very frustrated and felt this was a nursing problem, so I had to talk a lot with them about why it was everybody's problem. They always thought it to be an indicator of nursing quality, but it's really an indicator of hospital quality; for example, how well are nutritional and mobility issues being met?"

Pressure Ulcer Precautions

When should a patient be on Pressure Ulcer Precautions?

  • Total Braden Score of 18 or less OR
  • A 2 or less in any category OR
  • Any patient with a lower extremity orthopedic problem OR
  • Existing or recent history of pressure ulcers

What do I need to do?

  • Post sign over bed and stickers on chart
  • Apply an air pump to the bed (except CC)
  • Referrals to nutrition and P.T.
  • Turn every 2 hours
  • Aloe Vesta to the bony prominences twice a day
  • Heel boots for red heels, patients with lower extremity orthopedic issues, and diabetics
  • Keep knee gatch in the flat position, elevate legs with pillows if needed
  • Waffle chair cushions for all patients with red or broken skin on bottoms
  • Keep the HOB at 30 degrees or less if possible
  • Address moisture with toileting programs, condom catheters, barrier creams
  • Address incontinence of diarrhea with a rectal pouch or Flexiseal tube
  • Foam ear pieces on O2 tubing or alternate cannula

Source: Cooley Dickinson Hospital.

She made a number of other early changes, such as removing the bath blanket from beds so that there were fewer layers between the patient and the mattress. "I also worked with the respiratory department to get foam earpieces and an oxygen cannula (tube) that actually goes underneath the ears because I had noticed an increase in ear pressure ulcers," Craig says.

How does Craig handle things if she notices something is not right? "I go to the staff meeting and talk about it, or to the department head, and we talk it over," she says. "They often have excellent ideas of how to make something work."

Craig says consistency is one of the keys to her success. "We do a daily Braden Score, and we have a check-off for pressure ulcer precautions so there is documentation to support what we've done," she notes. "For example, I found a lot of times pumps would be on the bed but not necessarily turned on. I track that quarterly to look at the percentage of precautions that are documented. We're 100% a lot of time on most floors now."

It's important, she adds, to let staff know how they are performing. "I put signs up on each floor, like the documentation percentage is such and such," Craig explains. "It helps people to know you are watching, but I also write some positive notes to let them know I appreciate what they're doing."

[For more information contact:

Michele Craig, RN, CWS, COCN, RN, Wound and Ostomy Nurse, Cooley Dickinson Hospital. Phone: (413) 582-2866.]