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Running head: DECREASING PRESSURE ULCERS IN THE ICU 1
Decreasing Pressure Ulcers in the ICU: A Quality Improvement Initiative
Leadership Strategy Analysis Paper
Kathryn Fox
Ferris State University
NURS 440
DECREASING PRESSURE ULCERS IN THE ICU 2
Abstract
Hospital acquired pressure ulcers have continued to be a clinical issue for decades. Pressure
ulcers cost healthcare facilities millions of dollars, and increase complications and morbidity in
patients. Many successful measures have been implemented to help reduce the formation of
pressure ulcers including frequent repositioning, moisture barrier cream, heel protection, and
keeping the head of the bed lower than thirty degrees. While these measures were successful in
reduction, they have not eliminated the problem. New research supports the implementation of
silicone foam dressings applied to the sacrum and heels in the prevention of pressure ulcers in
acutely ill patients. St. Mary’s hospital treats a large population of acutely ill patients in their
four intensive care units, and because of this, reduction of pressure ulcers is an area of needed
improvement for the facility. A quality control council was formulated to assess the current
situation faced by the level two trauma center. Through literature review and data collection, new
policies and procedures were identified. Changes include the use of silicone foam dressings
applied based on risk assessment, employee education and follow-up on current and new
procedures. Through these changes the quality control council hopes to decrease the incidence of
hospital acquired pressure ulcers in the ICU by 20%.
DECREASING PRESSURE ULCERS IN THE ICU 3
Decreasing Pressure Ulcers: A Quality Improvement Initiative
Preventing pressure ulcer (PU) formation in the hospital setting is an ongoing clinical
problem. The Joint Commission (2008) found that more than 60,000 patients expire annually
related to pressure ulcer complications. Decreasing pressure ulcers acquired in the hospital
setting is especially important due to the economic climate of healthcare cost reduction. This
analysis explores the current literature available on decreasing pressure ulcer prevalence in
intensive care units (ICU), since research has shown that acutely ill patients are at higher risk for
skin breakdown. A quality improvement council was formed at St. Mary’s of Michigan’s, under
the transformational leadership of the ICU clinical manager. The council will review literature,
collect data on current practices, and formulate strategies to decrease PU prevalence. Working
with St. Mary’s employees, this council will collaborate over three months to create and
implement strategies and policies that work to decrease the prevalence of PUs and improve
current practice.
Clinical Relevance
Hospital acquired pressure ulcers (HAPU) have been of clinical concern for decades.
Pressure ulcers cost healthcare facilities millions of dollars annually. Despite many efforts in
prevention, patients still develop PUs. Acutely ill patients are at higher risk of developing a PU,
in fact intensive care unit patients average Braden Scale is 15, compared to a score of 19 for
medical-surgical patients (Chaiken, 2012). Current measures utilized to prevent the formation of
a PU include frequent repositioning, adequate nutrition, heel protection, applying moisture
barrier cream, and keeping the head of the bed less than 30°, and while these are effective
acutely ill patients in the ICU setting are still experiencing skin breakdown and PUs. Research
shows that patients who acquire PUs have increased complications and higher morbidity rates
DECREASING PRESSURE ULCERS IN THE ICU 4
(Santamaria et al., 2012). The increased risk and prevalence of PU formation in acutely ill
patients is of special importance to St. Mary’s of Michigan, since there are four different
intensive care wards. The acutely level of patients treated at St. Mary’s is high due to the facility
being a certified level two trauma center.
Literature Review
The prophylactic use of silicone foam dressings on the coccyx to prevent breakdown
through friction and shearing is a relatively new practice. To explore this measure a search for
scientific articles evaluating the effectiveness of silicone foam dressings in the prevention of PU
and skin breakdown was completed. Online databases Cinahl and PubMed were utilized using
keywords: “foam dressing” “pressure ulcer” and “prophylactic”. Documents published within the
last five years in peer-reviewed nursing journals were utilized.
There is substantial evidence supporting the use of silicone foam dressings for PU
prevention. Walsh et al. (2012) found that after implementing the use of silicone foam dressings
in their intensive care units, the prevalence of HAPUs decreased 5.5% in one year. They
hypothesized that “the dressing prevents sacral PU by absorbing moisture and enhancing tissue
tolerance to pressure, while simultaneously decreasing shear forces on the sacral area” (Walsh et
al., p. 149).
In the randomized controlled trial questioning the effectiveness of heel and sacral silicone
foam dressings compared to traditional prevention methods, Santamaria et al. (2012), found that
the intervention group had significantly lower PU formation when compared to the control
group. The intervention group utilized dressings applied to the heels and sacrum, and also
continued to use preventative measures per facility protocol. Patients chosen to be in the
intervention group were screened in the emergency department, and based on risk-assessment,
DECREASING PRESSURE ULCERS IN THE ICU 5
had a dressing applied that was changed every three days and as needed.
A 35 month observational study (Chaiken, 2012) monitoring the effectiveness of silicone
bordered foam dressings applied to ICU patients also found a significant reduction when
compared to those who did not have the dressing applied. Chaiken (2012) concluded that
applying the dressings along with other preventative measures helped to reduce the incidence of
PUs, and proved to be financially beneficial especially in a climate of healthcare cost reduction.
The research and studies evaluating the effectiveness of silicone foam dressings in PU
prevention are recent and still requires more analysis. The results of the research completed are
promising and provide evidence that can be incorporated into practice to assist in reducing
HAPUs.
Quality Improvement Team
To evaluate current practice on pressure ulcer prevention a council of employees at St.
Mary’s of Michigan will be created. Employees on this council represent a diverse skill mix in
employees who are all active and involved with pressure ulcer prevention at different levels. This
team of employees will be crucial to success of established goals and outcomes. Members of this
council will include the wound care nurse, ICU clinical nursing supervisor, quality control
manager, Intensivist, assistant director of finance, and two floor ICU nurses.
Each council member’s role and input is diverse, and together will provide a
comprehensive overview of the problem and area for improvement. The wound care nurse is an
expert in wound care, classification, and skin breakdown prevention techniques. His increased
knowledge in this area will be beneficial to determining implementation strategies. The ICU
clinical supervisor will work as council leader since she has management responsibilities over
the units directly involved in the quality improvement initiative. Her transformational leadership
DECREASING PRESSURE ULCERS IN THE ICU 6
characteristics will be necessary to inspire not only council members, but also all direct care
providers to change practices, and work together to reduce PUs in the ICU. As Yoder-Wise
(2011) wrote, Transformational leaders can “bring about changes that are permanent, self-
perpetuating, and momentum building” (p. 40).
The quality control manager will assist the nursing supervisor in working towards
established goals with a focus on positive patient outcomes. Her experience in quality
improvement initiatives will be valuable in assisting the clinical manager in efficiently leading
the group towards a common goal. The role of the Intensivist physician is unique since the
majority of his patients are acutely ill, and at high risk for PU formation. The input from a
physician in regards to changing processes will be vital. The assistant director of finance has a
perspective outside of patient care, and will be able to provide financial information that will be
crucial when the change proposal is presented to the hospital executives and stakeholders. The
two floor nurses provide direct patient care insight for the team, and will be helpful in identifying
possible problems and areas that are unrealistic in the implementation and data collection
process.
Data Collection
The clinical task of identifying problems and areas of improvement in HAPUs is large
and multi-faceted. It’s imperative that as the leader of the QI initiative, the clinical nurse
manager communicates with all team members during the data collection period. Setting mutual
goals will help to keep all council members working in the same direction. To ensure that all
areas can be evaluated, the council will break into small groups for certain areas of the data
collection process.
DECREASING PRESSURE ULCERS IN THE ICU 7
To initially gather data and provide a brainstorming session, together, the entire team will
create a fishbone chart exploring different causes of HAPU on the ICU floors. Once this is
complete the group will work in small groups identifying other possible sources and areas of
needed improvement. To thoroughly evaluate the current protocol utilized to prevent skin
breakdown and PU formation several flow sheets will be created based on hospital policy (see
Appendix A & B). The Braden scale score of the patient prompts nurses to complete
interventions when documenting. St. Mary’s of Michigan has also utilized the S.K.I.N bundle for
PU prevention. The wound nurse and one floor nurse will complete the flow sheets for this area.
The floor nurse and Intensivist will create intricate flow sheets detailing the steps taken
once a HAPU on a patient is identified, and a second flow chart detailing preventative measures
taken in addition to policy protocols. To evaluate the severity of HAPU formation, the quality
control manager and clinical supervisor will retrieve the number of HAPU’s on the intensive care
units in the last six months. Together they will compile a trend chart by month, identifying any
times where occurrence of HAPUs was greater. As a group, the charts of patient’s that acquired
PUs will be evaluated identifying co-morbidities, diagnosis, hospital day of PU finding, and
documented interventions. As a team after compiling data and reviewing the literature and
evidence, the team created a mutual goal to improve patient safety. The goal reads “decrease the
incidence of hospital acquired pressure ulcers by 20% in six months”.
Implementation
The implementation process involves several strategies, and will be based on evidence
based research and data findings. The implementation process will take place over six weeks,
and involve all members of the interdisciplinary team. Motivation and employee participation is
crucial during implementation, and without active involvement the measures will be ineffective.
DECREASING PRESSURE ULCERS IN THE ICU 8
The first step in improving the practice of PU prevention in the ICU’s will be inspiring
and gaining the support of hospital leadership staff. In the successful PU prevention program
implemented by Saint Francis Medical Center, they noted that “top hospital officials made it
clear that reducing pressure ulcers was a priority, and that they were willing to provide the
resources necessary to address the issue” ("Service delivery innovation," para. 8, 2012).
To gain support, the council will create a presentation outlining the financial benefits and
increased patient satisfaction, safety and outcomes of PU reduction in the ICUs. The presentation
will be presented to hospital stakeholders and executives. With approval from stakeholders and
executives, nursing and educational staff will be presented with the information and asked to act
as leaders in the implementation of PU reduction strategies.
Education to direct care employees will be the next step towards decreasing pressure
ulcers. While many of the studies reviewed utilized silicone foam dressings as the main
intervention, the importance of continuing current prophylactic measures was noted (Santamaria
et al, 2012, Chaiken, 2012). Staff will need increased education on the importance of following
current PU prevention measures including frequent repositioning, heel protection, keeping HOB
<30 degrees when applicable, moisture barrier cream, and incontinence management. This
education will be in the form of computer learning modules and staff meetings held by the
wound nurse and clinical supervisor. The S.K.I.N bundle will be reinforced in the learning
modules, and posters with interventions will be placed throughout the units. Increased education
to direct care employees proved effective along with the addition of silicone foam dressings in
the Walsh et al. study (2012).
The addition of a risk-assessment for application of silicone foam dressings to coccyx
and heels in nursing documentation is an imperative step in the implementation process. The risk
DECREASING PRESSURE ULCERS IN THE ICU 9
assessment (appendix C) was modified from the Danbury Hospital selection criteria in the Walsh
et al. study (2012). The risk assessment will be added to nurse’s documentation completed every
shift and as needed. Nurses will complete the assessment, and be prompted to apply a silicone
foam dressing to coccyx and heels if not already applied. If the dressing is already in place, they
document the day and assessment of skin below the dressing. Appendix D outlines the process
for nursing risk assessment shift documentation. Nursing staff will need thorough education on
how to apply and maintain silicone foam dressings properly. The quality control manager will
provide 15-minute in-services on the ICU floors educating nurses on proper application and
maintenance of silicone foam dressings. The policy on skin breakdown and pressure ulcers will
also be updated and include the risk assessment for placing silicone foam dressings.
Evaluation
Evaluation of the practices and changes implemented will be valuable in measuring
success. Monthly council meetings will be held to monitor progress in implementation. Staff
feedback will be encouraged, and beneficial in the continuation and improvement of the
implemented changes. After six months of implementation the council will perform chart audits
to record the number of HAPUs acquired after implementation, and compare it to data obtained
prior to implementation of improvement strategies. Going forward the number of HAPUs will be
acquired semi-annually to continue to track progress, and implement current evidence based
practice when appropriate.
Conclusion
In conclusion, reducing HAPUs is a large, but important task to undertake. Implementing
current evidence based practice along with reinforcing current policies can potentially help to
decrease the rate of pressure ulcers acquired in the ICU by 20% or more. The active teamwork
DECREASING PRESSURE ULCERS IN THE ICU 10
put forth by the quality improvement council will be pivotal in creating this change. Through
precise research, data collection, and implementation the quality improvement council, together
with St. Mary’s employees can work to become a role model for reducing HAPUs in the ICU
setting.
DECREASING PRESSURE ULCERS IN THE ICU 11
References
Chaiken, N. (2012). Reduction of sacral pressure ulcers in the intensive care unit using a silicone
border foam dressing. Journal of Wound, Ostomy, & Continence Nursing, 39(2), 143-
145. Retrieved from
http://stoppressureulcersnow.com/wp-content/uploads/2012/10/Chaiken-
ePrint_041612.pdf
Santamaria, N., Gerdtz, M., Sage, S., McCann, J., Freeman, A., Vassiliou, T., … Knott, J.
(2013). A randomised controlled trial of the effectiveness of soft silicone multi-layered
foam dressings in the prevention of sacral and heel pressure ulcers in trauma and
critically ill patients: the border trial. International Wound Journal, 1-7. doi:
1.1111/iwj.12101
St. Mary’s of Michigan. (2011, August 01). Skin and pressure ulcer risk assessment, prevention
and management policy. Available from St. Mary’s of Michigan
The Joint Commission. (2008). Strategies for preventing pressure ulcers. Joint Commission
Perspectives on Patient Safety, 8(1), 5-7. doi: http://www.jcrinc.com/Pressure-Ulcers-
stage-III-IV-decubitis-ulcers/
United States Department of Health and Human Services, (2012). Service delivery innovation
profile: Comprehensive, hospital-based program significantly reduces pressure ulcer
incidence and associated costs. Retrieved from Agency for Healthcare Research and
Quality website: http://www.innovations.ahrq.gov/content.aspx?id=1851
Walsh, N. S., Blanck, A. W., Smith, L., Cross, M., Andersson, L., & Polito, C. (2012). Use of a
sacral silicone border foam dressing as one component of a pressure ulcer prevention
DECREASING PRESSURE ULCERS IN THE ICU 12
program in an intensive care unit setting. Journal of Wound, Ostomy, & Continence
Nursing, 39(2), 146-149.
Yoder-Wise, P. S. (2011). Leading and managing in nursing (5th ed.). St. Louis, MO: Mosby.
DECREASING PRESSURE ULCERS IN THE ICU 13
Appendix A
Low RiskIf Braden Scale Score is 15-18,
pressure ulcer prevention precautions will be
implemented:
Frequent turning
Maximal remobilization
Protect heels
Manage moisture, nutrition, shear and friction
Pressure reduction support surface if patient is
bedbound or chairbound
Moderate Risk If Braden Score is 13-14, pressure ulcer prevention
precautions will be implemented:
Turning schedule
Use pillows for 30 degree lateral positioning
Pressure-reduction support surface
Maximal remobilization
Protect heels
Manage moisture, nutrition, shear and
friction
High Risk If Braden Scale Score is 10-
12 strict pressure ulcer prevention precautions will be
implemented.
Increase frequency of turning, supplement with
small shifts
Use pillows for 30 degree lateral positioning
Pressure reduction support surface
Maximal remobilization
Protect heels
Manage moisture, nutrition, shear and friction
Very High Risk If Braden Scale Score is 9 or
below, very strict pressure ulcer prevention precautions
will be implemented
All high risk interventions
Use pressure-relieving surface if patient has
intractable or severe pain exacerbated by turning or
additional risk factors
(St. Mary’s of Michigan, 2011)
DECREASING PRESSURE ULCERS IN THE ICU 14
Appendix B
N
I
K
S
(St. Mary’s of Michigan, 2011)
Vasopressor use (norepinephrine bitartrate [Levophed], dopamine, vasopressin, etc)Cardiac arrest at the time of admissionShock (septic, hypovolemic, cardiogenic), SIRS, MODSMechanical ventilation > 24 hUse of paralytics/continuous sedation > 24 hGeneralized edema/anasarcaFecal incontinence not controlled by fecal management systemSpinal cord injuryDrive lines (LVAD, RVAD, IAPB)
Automatically apply
silicone foam dressing if:
DiabetesTractionMorbid obesityAge > 65 yHistory of pressure ulcersLiver failureRestraint useMalnutritionETOH/drug use active withdrawal
Apply if the patient has 4
or more of the following:
DECREASING PRESSURE ULCERS IN THE ICU 15
Appendix C
(Walsh et al., p.148, 2012)
RN completes Risk assessment
Criteria met for silicone foam dressing
Skin assessment completed and Silicone Foam dressing applied to coccyx and heels
Document dressing application
Patient already has dressing that is intact
Assess skin below dessing and document
Does not meet criteria for foam silicone dressing
Skin assessment documented and Standard
preventative measures (per policy) utilized
DECREASING PRESSURE ULCERS IN THE ICU 16
Appendix D
DECREASING PRESSURE ULCERS IN THE ICU 17
Instructor FeedbackGrade : 100.00 out of 100Comments :Kathryn:
Excellent job on the assignment. I enjoyed reading your assignment; quite intrigued by the content and subject matter. Thank you for the extensive supportive research; it clearly supported your work. I believe one thing that we can take from this particular assignment is that regardless of the topic we choose, there is always opportunity in quality improvement including process improvements (if you will). Again, excellent job!
Thanks,
Eppie