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Service Delivery Innovation Profile

Interdisciplinary, Comprehensive Skin Care Program Significantly Reduces Hospital-Acquired Pressure Ulcers


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Snapshot

Summary

Bay Pines Veterans Affairs Healthcare System developed a comprehensive, interdisciplinary skin care program designed to reduce the incidence and improve the treatment of hospital-acquired pressure ulcers. The program includes the following key elements: standardized protocols and guidelines to encourage proactive assessment and treatment, regular educational rounds for nurses; periodic training for unit nurses and nurse skin care specialists, and ongoing performance monitoring and reporting. The program reduced the incidence of pressure ulcers by 48.7 percent for nine consecutive quarters between 2006 and 2008 and has led to high levels of satisfaction from participating staff and patients.

Evidence Rating (What is this?)

Moderate: The evidence consists of a comparison of pressure ulcer rates before and after implementation, along with post-implementation perspectives on the program from participating nurses.
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Developing Organizations

Bay Pines Veterans Affairs Healthcare System
Bay Pines Veterans Affairs Healthcare System is located in Bay Pines, FL.end do

Use By Other Organizations

  • Staff implementing the successful system-wide program provide resources to health care communities seeking to improve pressure ulcer prevention strategies. The interdisciplinary skin care team was featured in Advance for Nurses in May 2007, and the abstract was presented at the 2007 Summer Institute on Evidence-Based Practice in San Antonio, TX.

Date First Implemented

2005
October

Problem Addressed

Hospital-acquired pressure ulcer is a common, costly, and often preventable health care problem.
  • A common, costly national problem: Pressure ulcers are a significant cause of increased mortality and morbidity, physical disfigurement, and prolonged hospitalizations and are one of the most costly preventable problems for long-term care residents.1,2 Each year, an estimated 1.3 to 3 million adults get hospital-acquired pressure ulcers.3 The average cost of pressure ulcer treatment is $40,381, and chronic wound care costs in the United States is $20 to $25 billion annually.4
  • A significant local problem as well: In 2004, a Process Action Team was formed to investigate reports of an increased number of hospital-acquired pressure ulcers in the acute care units. The facility lacked an organized and accountable skin care program that provided clinicians with the appropriate resources, tools, and guidelines to deliver optimal pressure ulcer care and prevention. The hospital's Chief Nurse of Acute Care collaborated with the Process Action Team to identify and implement necessary practice changes to address the noted incidence in hospital-acquired pressure ulcers on the four acute care units.
  • Available prevention strategies: Practice guidelines, educational resources, and other tools can help to prevent the incidence—and minimize the negative impact—of hospital-acquired pressure ulcers.

What They Did

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Description of the Innovative Activity

Bay Pines Veterans Affairs (VA) Healthcare System developed a comprehensive, interdisciplinary skin care program designed to reduce the incidence and improve the treatment of hospital-acquired pressure ulcers. The program includes the following key elements: standardized protocols and guidelines to encourage proactive assessment and treatment, regular educational rounds for nurses, periodic training for unit nurses and nurse skin care specialists, and ongoing performance monitoring and reporting.
  • Standardized protocols and guidelines for assessment and treatment: Bay Pines nurses use standardized protocols, guidelines,3 and VA Nursing Outcomes Database templates to proactively identify at-risk patients, develop a comprehensive plan of care, and treat those who develop pressure ulcers promptly and effectively.
    • Proactive assessments: The Veteran's Health Administration (VHA) handbook provides all-inclusive patient care guidelines. In addition, nurses use the Pressure Ulcer Prevention & General Skin Care Protocol, which calls for all patients to be assessed for risk of pressure ulcers using the Braden Risk Assessment Scale at admission, transfer, and discharge, and when changes in the patient's condition warrant such assessment. Reassessments are conducted at various timeframes (outlined in the protocol) for any patient identified as being at high risk.
    • Proactive treatment: Nurses use the Pressure Ulcer/Wound Treatment Protocol to guide specific treatment for each stage of pressure ulcer formation. The protocol reflects the latest updates from the National Pressure Ulcer Advisory Panel on staging.4 A skin care assessment template integrates assessment of the six domains identified on the Braden scale: activity, dietary intake, friction, mobility, sensory perception, and skin moisture. In addition, the protocol also outlines structured timeframes for reassessment of patients at risk from pressure ulcer formation: every 48 hours for acute care patients, weekly for long-term care patients, and at each consecutive visit for home-based primary care patients. A comprehensive software program provides a standardized format to document pressure ulcer care and includes the VA Nursing Outcomes Database to provide a mechanism to measure compliance and collect data for developing national pressure ulcer prevention strategies. The facility software generates an automatic referral to a nutritionist or wound care specialist when criteria warranting such a referral are met.
    • Ongoing monitoring of individual patients: The hospital's certified nurse wound care specialist oversees care of all patients through direct patient assessment and collaborates with team members to ensure the patient has a comprehensive plan of care that reduces risk of additional skin breakdown.
  • Daily rounds by skin care "champions" with weekly support from wound care specialists: Trained skin care nurses ("skin care champions") conduct daily rounds and assist peers with educational information about pressure ulcer staging, skin care, and documentation. When staff are unable to stage an ulcer on new admissions, the skin care nurses are available as a resource, and the Wound Ostomy Continence Nursing–certified wound nurse is automatically consulted to validate the findings and orchestrate specialized care as needed. Once a week, or more often if needed, the wound care specialist joins the skin care champions on their rounds. In addition, prevalence studies are conducted quarterly by the unit skin care nurses, and results are sent to the National Database of Nursing Quality Indicators for national evaluation and comparison of the program. The Safe Patient Handling Coordinator accompanied the certified wound care nurse and unit skin care champion on rounds once a week to increase interrater reliability and provide educational support as needed for guiding care of complex patients.
  • Ongoing unit nurse and skin care nurse training and staff reinforcement: Unit skin care champions receive periodic training in skin care assessment, documentation, and pressure ulcer prevention. Educational opportunities for improvement are identified from extensive chart reviews, and staff educational reinforcement is conducted on a continuous basis. When care or documentation falls below the committee's care benchmarks, additional staff support is immediately instituted through mandatory nursing education, quality fairs, and hands-on education during the weekly dual skin care rounds. In addition, the unit skin care nurses periodically participate in a train-the-trainer program developed by the hospital's Nursing Professional Development Council Co-Chair who has medical–surgical national certification and the certified wound care specialist. This training focuses on enhancing staff knowledge and skills related to innovations for preventing skin breakdown and pressure ulcer staging. The teaching empowers the "skin care champions" to provide education to peers, while the nursing specialists remain readily available to answer staff concerns.
  • Staff educational resources: Pressure Ulcer Documentation Manuals were developed and distributed system-wide to standardize care and provide staff with an educational guide for pressure ulcer treatment. The manuals contain pressure ulcer tracking forms used to identify existing and nosocomial pressure ulcers for respective units, the Pressure Ulcer Prevention & General Skin Care Protocol, VHA Handbook 1180.2, Pressure Ulcer/Wound Treatment Protocol, Skin Care Committee monthly meeting minutes, a copy of the nursing annual mandatory computerized training module, unit specific historical data, and a copy of the mandatory annual training computer-based training study guide for staff nurses are available on all nursing units and in outpatient clinics (and may be available online in the near future).
  • Ongoing performance monitoring: Unit nurses conduct monthly internal chart reviews to assess compliance with the pressure ulcer prevention and general skin care protocols on every patient with a pressure ulcer to determine whether skin care needs are met and whether interventions are successful. Quarterly reports identify areas of strength and opportunities for improvement through additional staff education. The reports document the percentage of patients with hospital-acquired pressure ulcers and monitors compliance with established protocols. Finally, the Skin Care Committee Chair reports to the hospital's Patient Safety/Risk Management Committee on the regular performance reports, including benchmark comparisons from peer institutions across the nation, which is available as a result of Bay Pine's participation in the National Database of Nursing Quality Indicators. Nationally, the VA Nursing Outcomes Database software is fully implemented to electronically capture facility information on the pressure ulcer incidence, assessment with the Braden scale scores, and timely intervention for all scores less than 18.
  • Interdisciplinary collaboration: Team collaboration is reflected in the following processes:
    • The dietary department introduces new products at the monthly meetings and teaches staff about wound healing requirements as it relates to nutrition and hydration.
    • Central supply keeps the team updated on latest off-loading devices to minimize pressure and products that decrease the effects of incontinence.
    • The certified wound care nurse provides snapshot views of current practice to help identify practice changes.
    • The Safe Patient Handling Coordinator assists staff members to identify high-risk patient care activities and implement safe patient-handling techniques to reduce friction- and shear-related injuries.

Context of the Innovation

The Bay Pines VA Healthcare System provides comprehensive health care services, including medical, surgical, rehabilitative, and psychiatric inpatient services (provided in a 181-bed hospital); long-term medical and psychiatric care; and outpatient services in a wide variety of specialties. The skin care program was developed in response to the findings of a Process Action Team that was formed in 2005 to investigate reports of an increased incidence of hospital-acquired pressure ulcers in the facility's four acute care units. The team confirmed that the hospital identified a need for developing a comprehensive skin care program with the guidelines, educational resources, and other tools needed to support the provision of appropriate pressure ulcer prevention and care. The VHA provided an additional impetus for the program because improved assessment of pressure ulcer risks has been made a national VHA goal. In addition, pressure ulcer reduction remains a Joint Commission national patient safety goal. Also, in August 2007, the Centers for Medicare & Medicaid determined nosocomial pressure ulcers are preventable and will no longer pay for pressure ulcers resulting from a patient's hospitalization.

Did It Work?

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Results

Pre- and post-implementation results show that the program significantly reduced the incidence of pressure ulcers; in addition, nurses expressed increased job satisfaction and ownership for improved patient outcomes.
  • Fewer pressure ulcers: Over nine consecutive quarters (during fiscal years 2006 to 2008), the incidence of pressure ulcers fell by 48.7 percent on the four units in which the program was implemented. Information provided in October 2011 indicates that patient obesity and acuity continue to rise, contributing to a higher pressure ulcer risk among veterans; nevertheless, the institution's acquired pressure ulcer rate fell from 1.76 percent in fiscal year 2006 to 0.92 percent in fiscal year 2011, well below the national rate goal of less than 3 percent.
  • High satisfaction among nurses: Nurses have expressed high levels of satisfaction with the program, notably the assistance it provides in updating their skills as skin care experts and participation in Train-the-Trainer.
  • Improved patient outcomes: Decreased pain, increased satisfaction, and increased self-esteem in issues related to distorted body image were areas of improved patient outcomes.

Evidence Rating (What is this?)

Moderate: The evidence consists of a comparison of pressure ulcer rates before and after implementation, along with post-implementation perspectives on the program from participating nurses.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Forming an interdisciplinary process action team: An interdisciplinary team that included representatives from various nursing units, dietary services, quality systems, central supply, social work, physical therapy, and medicine reviewed evidence-based literature and guidelines related to pressure ulcers to create a successful skin care strategy.
  • Updating protocols and guidelines: A Skin Care Committee, led by a nurse manager, used the VHA 2006 handbook, Assessment and Prevention of Pressure Ulcers, to revise and update protocols and guidelines related to skin care assessments and pressure ulcer prevention and treatment. The committee meets monthly to review the effectiveness of skin care initiatives, with a focus on the prevention of pressure ulcers.
  • Performing research: Information provided in October 2011 indicates that staff members are awaiting institutional approval for a research project that would evaluate whether friction-reducing devices decrease pressure ulcers in intensive care unit patients.

Resources Used and Skills Needed

  • Staffing: Information provided in October 2011 indicates that the wound care specialist position has increased from 0.5 to 1.0 full-time equivalent.
  • Costs: Program costs are minimal, consisting primarily of expenses related to the written educational materials and offsite training. Staff members serve on the skin care committee as a collateral duty and professional responsibility. Educational material produced on the main campus is supported by the VHA guideline publications, and the Train-the-Trainer education to skin care nurses to share with peers on their respective units was provided by the Safe Patient Handling Coordinator. The Safe Patient Handling Coordinator, with assistance from a skin care nurse, developed a Skin Care Documentation manual that provided system-wide education to the main campus and satellite clinics.
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Funding Sources

The program is funded internally.end fs

Tools and Other Resources

VHA's handbook, Assessment and Prevention of Pressure Ulcers, provides updated skin care protocols related to pressure ulcer prevention and treatment. The handbook can be accessed with the following link: http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2422.

Adoption Considerations

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Getting Started with This Innovation

  • Obtain leadership support: Leadership support and commitment is critical to encourage staff to take ownership and accountability over the provision of high-quality skin care, including the proactive prevention and treatment of pressure ulcers.
  • Use certified nurse specialists: Identify role-model nurse leaders able to develop a cost-effective program that is driven on improving patient care. Nurses who are certified in their area of expertise elevate standards of care among colleagues, improve retention, and develop legally defensible practice standards.

Sustaining This Innovation

  • Provide ongoing education: Provide periodic education to all direct care staff and interdisciplinary partners accountable for skin care prevention and reinforce ongoing rounds.
  • Monitor performance improvement measures: At Bay Pines, the Nursing Shared Governance Practice Council and Quality Council work closely with the Skin Care Committee to monitor skin care and pressure ulcer incidence on an ongoing basis.
  • Promote interdisciplinary collaboration: Interdisciplinary cooperation, professional collegiality, and skillful negotiation play key roles in the program's success.
  • Encourage nursing certification in clinical area of expertise: Key players on the skin team are certified in their area of specialty. Nursing certification in a specialty field has a dramatic impact on improving practice outcomes. All VA nurses receive guidance and resources to facilitate certification in specialty areas of practice to improve patient care. The impact of nursing specialty certifications is federal recognition, and financial support is available through the Federal campaign "Let's Get Certified!"

Use By Other Organizations

  • Staff implementing the successful system-wide program provide resources to health care communities seeking to improve pressure ulcer prevention strategies. The interdisciplinary skin care team was featured in Advance for Nurses in May 2007, and the abstract was presented at the 2007 Summer Institute on Evidence-Based Practice in San Antonio, TX.

Additional Considerations

  • The innovations of the skin care program were recognized as best practice interventions by the VHA System-wide Ongoing Assessment and Review Strategy (SOARS) survey in August 2008 and again in 2009.

More Information

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Contact the Innovator

Judee Gozzard, RN, MSN, BC
Safe Patient Handling Coordinator
Bay Pines VA Healthcare System
10,000 Bay Pines Blvd.
Bay Pines, FL 33744
(727) 398-6661 Ext. 7726
E-mail: judee.gozzard@va.gov

Innovator Disclosures

Ms. Gozzard has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Wound Ostomy Continence Nursing–certified nurse wound care specialist [Web site]. Accessed September 30, 2008. Available at: http://www.wocncb.org

Howard CA, Gozzard JL. Patient safety: decreasing pressure ulcers in acute care. Poster presented at Seventh Summer Institute for Evidence-Based Practice, San Antonio, TX, 2008. Abstract available at: http://www.acestar.uthscsa.edu/institute/su08/documents/25Gozzard.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)

Footnotes

1 Institute for Healthcare Improvement (IHI). Prevent Pressure Ulcers [Web site]. Accessed September 22, 2008. Available at: http://www.ihi.org/explore/pressureulcers/pages/default.aspx
2 Gozzard, J. Raising the stakes on pressure ulcers. Adv Nurs. April 22, 2009 Online Extra. Accessed June 22, 2009. Available at: http://nursing.advanceweb.com/Article/Raising-the-Stakes-on-Pressure-Ulcers-3.aspx?prg=26
3 Lorenz JM. Geriatric skin care. VA healthcare system nurses assess, treat, and prevent pressure ulcers using a systematic, interdisciplinary approach. Adv Nurse. 2007;9(11):39. Accessed June 22, 2009. Available at: http://nursing.advanceweb.com/Article/Geriatric-Skin-Care-5.aspx
4 National Pressure Ulcer Advisory Panel. Updated Staging System [Web site]. Accessed September 22, 2008. Available at: http://www.npuap.org/
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: October 14, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: November 20, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: October 27, 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.