SummaryOSF Saint Francis Medical Center developed a comprehensive program called "Save Our Skin" designed to reduce the incidence of pressure ulcers. The key elements include upgrading mattresses, clarifying staff roles and protocols, and improving measurement and communication of pressure ulcer performance data. The program reduced the incidence of pressure ulcers from 9.4 percent in 2001 to 1.5 percent in 2006, well below the national average range of 7 to 10 percent, and yielded estimated cost savings of $3 million annually.Moderate: The evidence consists of a comparison of pressure ulcer rates before and after implementation of the program.
Developing OrganizationsOSF Saint Francis Medical Center
Date First Implemented2001
Problem AddressedPressure ulcers are a common, serious, costly, and preventable problem for hospitals. They often cause infections that can lead to longer stays, higher costs, and even death.
- A common condition, especially in high-risk residents: The pressure ulcer prevalence rate (a 1-day snapshot of the percent of patients with pressure ulcers) for the average hospital is more than 15 percent, with incidence rates (the percent of patients who develop a pressure ulcer during their hospital stay) ranging between 7 and 10 percent.1 OSF Saint Francis Medical Center also faced a significant problem, with a prevalence of 13 percent and an incidence of 9.4 percent, with most hospital-acquired pressure ulcers being located on the coccyx, sacrum, and heels.
- Significant human costs: Nearly 60,000 U.S. hospital patients die each year from complications related to hospital-acquired pressure ulcers.1 Without proper treatment, pressure ulcers can lead to severe complications, including blood and bone infections, infectious arthritis, holes below the wound that burrow into bone or deeper tissues, and scar carcinoma, a form of cancer that develops in scar tissue.2
- Significant financial costs: The cost of treating a pressure ulcer ranges from $2,000 to $70,000 per wound, with the total costs for the average hospital being between $400,000 and $700,000 annually.1 The average treatment cost at OSF Saint Francis Medical Center was $3,000 per wound.
- A preventable problem: Most hospital pressure ulcers are preventable with proper clinical care, but staff often fail to follow recommended procedures because skin care is not a high priority.1 When pressure ulcers do occur, nurses may not consider treating them as a high priority, because they are not immediately life threatening, and other issues often take precedence.3 At St. Francis, the existing skin care protocol was not user-friendly and did not emphasize prevention or make it clear which staff members were directly accountable for pressure ulcer prevention.
Description of the Innovative ActivityThe Save Our Skin program makes pressure ulcers a top patient care priority by upgrading mattresses, establishing user-friendly protocols, clarifying staff roles and responsibilities, and improving measurement and communication of pressure ulcer performance data. Key program elements include the following:
- Pressure-relieving mattresses: St. Francis initially used pressure-relieving static air mattresses on six units with above average pressure ulcer rates, with nurses able to order additional mattresses for those on other units thought to be at risk of developing pressure ulcers. These mattresses maximize body weight displacement and minimize pressure on body tissue. A year into the program, the hospital expanded the initiative to provide pressure-relieving mattresses to all adult patients. Nurses can also order special low-air-loss mattresses for patients with or at risk of a severe pressure ulcer.
- Skin breakdown prevention protocols: St. Francis uses an evidence-based skin care protocol that incorporates best practice guidelines from the Agency for Healthcare Research and Quality and the Wound, Ostomy, and Continence Nurses Society, as well as pressure ulcer reduction practices that have worked in other hospitals. Key elements of the protocols include:
- Periodic patient evaluation: All patients are evaluated for pressure ulcers and pressure ulcer risk upon admission and every 24 hours thereafter, using the Braden scale (See the Tools and Other Resources section for more information), with results documented in the patient's chart. Staff pay special attention to bony prominences, especially the coccygeal/sacral skin and heels.
- Moisture management protocol: Staff follow a moisture management protocol for incontinent patients that includes using dry-flow pads to wick the urine or stool away from the skin and premoistened, disposal barrier wipes to help cleanse, moisturize, deodorize, and protect patients from skin problems.
- Staff reminders: Save Our Skin signs are placed outside at-risk patients’ rooms as an ongoing reminder to staff. In addition, a segment of the Olympic theme song plays over the in-house paging system every 2 hours to remind staff to reposition patients. Nurses also receive a reminder page every 2 hours to reposition patients. All staff receive a skin care pocket guide, a condensed version of the skin breakdown prevention protocol with helpful tips outlining pressure ulcer prevention methods.
- Well-defined roles and responsibilities: The program assigns clear roles and responsibilities to key staff members, as outlined below:
- Unit managers as "process owners": The program designates nursing unit managers as "process owners" responsible for ensuring their unit’s compliance with the skin care protocol and meeting unit targets for pressure ulcer incidence. These managers work with program champions to develop action plans if quarterly targets are not met. Managers may delegate some of these responsibilities to nursing assistants and other staff.
- Nurses who oversee operating room protocols: Surgery patients are at high risk of pressure ulcers because they may be under anesthesia for long periods of time. SOS gives different nurses key assignments before, during, and after surgery:
- Before surgery: Nurses complete a preoperative assessment to identify at-risk patients and preexisting pressure ulcers. Nurses place a Save Our Skin sticker on at-risk patients' charts to communicate the need for intervention to the intraoperative nurse.
- During surgery: Nurses make sure high-risk patients get appropriate care, such as repositioning during surgery, and communicate the patient's risk and status to the postanesthesia care unit nurse.
- Postanesthesia: Nurses continue to assess at-risk patients and communicate their status to the appropriate floor nurse.
- Save Our Skin "champions": Each hospital unit has a program "champion," typically a registered nurse or patient care technician. The champion coordinates process improvement efforts to reduce pressure ulcers with the unit manager, attends ongoing educational sessions on skin care, and serves on a hospital committee that meets monthly to review new evidence-based practices and products, discuss prevention issues, review quarterly prevalence/incidence results, and attend ongoing educational sessions on skin care.
- Auditing and feedback: The program has a built-in auditing mechanism that promotes continuous improvement. Chart audits are conducted monthly until 90 percent compliance is achieved on four key indicators: initiation of the prevention protocol, provision of patient/family education, repositioning patients every 2 hours, and placing Save Our Skin signage on patients' doors. Audit frequency falls to quarterly once targets are reached. If the performance measure drops below 90 percent, monthly audits return until the target is again achieved. The hospital publishes unit-specific data each quarter, which serves as a means of recognizing successful units and creates an incentive for high-incidence units to improve.
- Training: All staff who interact with patients (including nurses, nursing assistants, and physical therapists) receive a 1-hour training session on procedures to prevent pressure ulcers. Program champions provide the training to all three shifts. An optional online training module is also available to staff.
References/Related ArticlesCourtney B, Ruppman J, Cooper H. Save our skin: initiative cuts pressure ulcer incidence in half. Nurs Manage. 2006;37(4):36-45. [PubMed]
Griffin B, Cooper H, Horack C, et al. Best-practice protocols: reducing harm from pressure ulcers. Nurs Manage. 2007;38(9):29-32. [PubMed]
This profile is adapted from an Improvement Report by the Institute for Healthcare Improvement. Available at: http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventPressureUlcers.aspx
Contact the InnovatorHoa M. Cooper, RN, BSN, MHSA
OSF Saint Francis Medical Center
530 NE Glen Oak Avenue
Peoria, IL 61637
ResultsThe intervention resulted in a substantial decrease in the incidence of hospital-acquired pressure ulcers and significant cost savings:
Moderate: The evidence consists of a comparison of pressure ulcer rates before and after implementation of the program.
- Reduced incidence: The incidence of hospital-acquired pressure ulcers fell from 9.4 percent in the fall of 2001 to 1.5 percent in December 2006, well below the national average range of 7 to 10 percent. Information provided in March 2010 highlights sustained improvement in hospital-acquired pressure ulcer incidence. The incident rate as of last quarter 2009 was 0.6 percent.
- Cost savings: The reduced need to treat pressure ulcers saves the hospital an estimated $3 million annually.
Context of the InnovationOSF Saint Francis Medical Center is a 710-bed, not-for-profit hospital in Peoria, IL, that serves a 37-county area. A magnet-designated, teaching hospital and research institute for the University of Illinois College of Medicine, OSF Saint Francis Medical Center handles 25,000 patient admissions each year and has a level I trauma center and an emergency department.
Planning and Development ProcessKey steps in the planning and development process include the following:
- Adoption of Six-Sigma procedures: OSF Saint Francis Medical Center used Six Sigma, a process that focuses on developing and delivering near-perfect processes, to develop the SOS program.
- Initial data assessment and root-cause analysis: The hospital conducted an internal analysis to determine the magnitude of the problem with pressure ulcers. A preliminary review concluded that the high incidence rate was due to several factors, including incomplete initial and ongoing skin assessments, underuse of the existing skin care protocol, failure to follow activity orders, and failure to regularly reposition patients.
- Research into best practices, pocket guide development: Hospital officials performed a literature review, visited several nearby hospitals, and conducted phone interviews with pressure ulcer experts at other hospitals. Based on this research, staff created and distributed the pocket guide on pressure ulcer prevention to staff.
- Setting project scope and goals: The hospital determined that the project would cover all inpatient adults over age 17 years old, with monitoring to begin at admission and end at discharge. The hospital set an initial goal of reducing hospital-acquired pressure ulcers by 50 percent within the first year.
- Purchase of static air mattresses: At the program's outset, the hospital bought 140 pressure-relieving static air mattresses to cover six units with above-average pressure ulcer rates. (As noted, nurses could special order a rental mattress for at-risk patients on other units.) A year later, the hospital bought several hundred more mattresses so that all adult patients could use them, thus eliminating the need for special orders and reducing rental costs significantly.
Resources Used and Skills Needed
- Staffing: OSF Saint Francis Medical Center hired an RN with substantial experience in Six Sigma to implement the program.
Funding SourcesOSF Saint Francis Medical Center
Program funds came out of the OSF Saint Francis Medical Center operating budget.
Tools and Other ResourcesThe guideline for the prevention and management of pressure ulcers from the Wound, Ostomy, and Continence Nurses Society was current at the time the project was developed.
The Braden Scale for Predicting Pressure Sore Risk© is a clinically validated tool that allows nurses and other health care providers to reliably score a patient/client's level of risk for developing pressure ulcers. Available at: http://www.bradenscale.com/images/bradenscale.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .)
Getting Started with This Innovation
- Get leadership buy-in: Gain the support of the hospital leadership. In this case, 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.
- Gather baseline data: Collect as much data as possible before implementing the program, including the incidence and prevalence of pressure ulcers as compared with benchmark hospitals.
- Contact other organizations: Contact other facilities to identify programs and tactics that work. For example, OSF Saint Francis Medical Center got the idea to play music on the public address system as a reminder to reposition patients from another hospital.
- Set goals and identify quick wins: Establish concrete, aggressive, and achievable goals, such as a 50 percent reduction within 1 year. Also identify "quick wins" that can jump-start the program. For example, OSF Saint Francis Medical Center project leaders concluded that replacing existing mattresses with pressure-relieving mattresses in six units would lead to a rapid decrease in pressure ulcers. This quick win—incidence quickly fell from 9.4 to 7.3 percent—helped create momentum for the program.
- Provide training: Provide across-the-board training at the program's outset. In addition to increasing clinical knowledge, this step raises awareness and generates enthusiasm for the program.
Sustaining This Innovation
- Define responsibilities: Delineate responsibilities clearly and emphasize accountability at all levels, from frontline staff to management and high level administrators.
- Monitor performance: Monitor performance closely through built-in mechanisms such as monthly audits.
- Make data useful: Convert pressure ulcer incidence and prevalence rates (percentages) into the number of patients affected by pressure ulcers; this step helps convey the issue's significance in more human terms to nursing staff.
- Make data public: Publish performance data on a periodic basis, thus providing motivation for staff to improve.
Courtney B, Ruppman J, Cooper H. Save our skin: initiative cuts pressure ulcer incidence in half. Nurs Manage. 2006;37(4):36-45. [PubMed]
Grey JE, Harding KG, Enoch S. Pressure ulcers. BMJ. 2006;332:472-5. [PubMed]
Griffin B, Cooper H, Horack C, et al. Best-practice protocols: reducing harm from pressure ulcers. Nurs Manage. 2007;38(9):29-32. [PubMed]
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Service Delivery Innovation Profile
Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: June 13, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: March 20, 2011.
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.