Underappreciated source of pain

Pressure ulcers program solves problem

One in five. That was the incidence and prevalence of pressure ulcers in 2007 at Onslow Memorial Hospital in Jacksonville, NC. Jo Malfitano, RN, MSN, performance improvement director at the facility, says they did not realize how big the problem was until they did a project through the Institute of Healthcare Improvement.

That number was unacceptable, so they took it on as a challenge. And by challenge, they meant “solve the problem” but also “competition.”

After looking at the scope of the problem — which had not been adequately measured before the IHI initiative — Onslow got a certified wound ostomy nurse on board as a skin care champion. They worked on training nurses, and changed documentation to include an assessment on admission and daily as long as the patient remained in the hospital. That “real time” review of skin condition was important, says Malfitano. Each shift gets a documented report on the state each patient’s skin when they come on duty.

Units competed with each other to get their rates up — or down depending on the data point — with the highest compliance rate unit winning a pizza party six months into the project. The unit was recognized in the organizational newsletter, too.

Data were examined regularly, says Malfitano, which helped them determine which units were doing well and which needed more help. Eventually, each unit had stellar performers named skin care champions, who along with nurse managers got further recognition and reward from the administration and board.

Since the project was implemented, nearly every patient has had a daily pressure ulcer risk assessment. There are new patient and family educational materials on pressure ulcers, including a video-on-demand program and reader-friendly handouts.

As of December 2007, there was zero incidence of pressure ulcers, and nursing units were more than 90% compliant with completion of the assessment on admission and daily after that. They were more than 95% compliant with all of IHI’s prevention initiatives related to pressure ulcers, including moisture, optimizing nutrition/hydration, use of pressure relieving surfaces and repositioning.

Three years later, incidence remained zero and compliance neared 100%. Five years later, and they are still going strong with rates at zero or close to it, she says.

Malfitano says that not knowing the scope of the problem was a shock. Having the wound care nurse coach them on the importance of quarterly — not annual — investigation was key to keeping the rates down.

It’s a little easier now, as last fall they started capturing data electronically. That will make knowing how they are doing at a specific point in time or over a span of time equally easy.

Pressure ulcers are the least glamorous of healthcare-acquired conditions. But they are one, just as CLABSI or CAUTI. And you can lose reimbursement for patients who suffer from them. That makes solving the problem more important now than ever, she says. “Infection is important, and it gets higher levels of scrutiny. Pressure ulcers just don’t get the press.”

Still, skin integrity counts, and Malfitano is proud of what her facility accomplished in a relatively short time by increasing awareness and putting an element of competition in her project.

“It all goes back to culture,” she says. “Keep patients at the center of your energy and the focus and the why behind what you do. Do all you can, every day, to provide the highest quality care and safety for every patient every time. It wasn’t a difficult project. It was just a collaborative team of nursing, rehab, physical therapy, and wound care. The front-line team made this happen. They were a team that said we can do this to make it better, using IHI proven practices. We did not have to reinvent anything. We just applied it locally.”

For more information on this topic contact Jo Malfitano, RN, MSN, Performance Improvement Director, Onslow Memorial Hospital, Jacksonville, NC . Telephone: (910) 577-2549.