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T
tice Spotlight Organization Initiative, please visit www.RNAO.ca. he impact of pressure ulcers (PUs) on patients and
The authors report no conflicts of interest. their caregivers is related to decreased quality of
Correspondence: Monica Frecea, MScN, RN, CETN(C), Mount Sinai Hos- life, increased morbidity and mortality and prolonged
pital, 600 University Avenue, Room 1401C, Toronto, Ontario, Canada length of stay in hospital.1Y4 Pressure ulcers are 1 of the
M5G 1X5 (mfrecea@mtsinai.on.ca).
major drivers of escalating healthcare costs, with millions
Supplemental digital content is available for this article. Direct URL cita-
tions appear in the printed text and are provided in the HTML and PDF of dollars spent annually on treating and managing patients
versions of this article on the journal’s Web site (www.cns-journal.com). with this condition.1 Hospital-acquired PUs (HAPUs) are a
DOI: 10.1097/NUR.0000000000000191 nurse-sensitive indicator that provides data about the
FIGURE. The Best Practice Guidelines Pressure Ulcer working group’s framework demonstrates the alignment of Mount Sinai
Hospital_s core values, Professional Practice Model, and the Donabedian model.
her work on therapeutic support surfaces and PU prevention tice guideline recommends that an individualized approach
and management. All support surfaces from inpatient units needs to be applied and that repositioning of patients should
were assessed and graded according to their condition. occur every 2 to 4 hours.7 To cultivate a standardized ap-
The inventory led to immediate replacement of support proach to the repositioning of patients, a decision tree for
surfaces that were in poor condition and the development positioning patients at risk of developing a PU was devel-
of a protocol for replacing all other support surfaces over a oped. Literature indicates that PU risk is best predicted by
3-year period. A final report by the external consultant pro- total Braden score in conjunction with Braden subscale
vided recommendations that are being used to develop a scores.12,13 Braden subscales provide important informa-
centralized system for procurement, maintenance, and dis- tion about the patients’ positioning profile and guides the
tribution of support surfaces. Through the implementation clinician to specific implementation strategies to address
of this recommendation, MSH ensures that proper pressure each profile. The decision tree guides the nurses to consider
redistribution surfaces are available. not only the total Braden score but also the subscores to help
them implement PU preventative measures that focus on
Recommendation 3.1b identified deficits.
Frequent repositioning of patients to prevent PUs has been The BPGs indicate that risk factors for PU development
standard practice among clinicians at MSH. The best prac- in acute care settings are different on each unit. The working
Skin and wound care policies Updated and revised policies and procedures to reflect best practice, including assessment
and procedures and treatment of pressure ulcers, Braden Scale for predicting pressure ulcer risk with preventative
measures, classification prevention and treatment of skin tears, irrigations wound/sinus, negative
pressure wound therapy, support surfaces active and reactive.
Level I skin and wound care Updated and revised mandatory Level I E-learning modules, including anatomy and physiology,
E-learning modules phases of wound healing, principles of wound management, Braden Scale and pressure
ulcers prevention, skin tears, basic and advance dressings, and wound care documentation.
New Level I skin and wound New E-learning modules created and added to the Skin and Wound Care educational series, including
care E-learning modules moisture-associated skin dermatitis, medical device pressureYrelated injuries, mucous membrane,
and cartilage pressure ulcers.
Level II skin and wound care Title: A Holistic Approach to Skin and Wound Care. Interprofessional education provided by clinical
conference days nursing leadership, a registered dietitian, a certified enterostomal therapy nurse, staff nurses,
plastic surgeons, an occupational therapist, patient, and industry partners. Lecture topics include Best
Practice Spotlight Organization, moisture-associated skin dermatitis, nutrition and wounds, pressure
ulcer prevention and management, debridement and wound care from a patient_s perspective.
Hands-on sessions include assessment and management of skin tears, identification and classification
of wounds, negative pressure wound therapy, therapeutic surfaces, and compression therapy.
Electronic health record Updated and revised the electronic health record to reflect best practice to include revision of
pressure ulcer preventative measures, wound care products and, treatment options.
Skin and wound nurse champions 26 registered nurses completed standardized education in clinical knowledge, skill, and professional
competencies. Working collaboratively with advanced practice nurses, this group serves as a
resource in noncomplicated wound presentations using the opportunity to educate and problem
solve with nursing colleagues. Lecture topics include acute and chronic wound identification,
incontinence-associated dermatitis, Braden subscales, positioning and transferring a patient with
pressure ulcers, skin tears staging, and management.
Hands-on sessions include assessment, classification, and treatment of various wound presentations such
as pressure ulcers, skin tears, and intravenous extravasationYrelated injury wounds.
group reviewed the published risk factors and invited nursing sion making and the development of appropriate PU
staff and advanced practice nurses to select risk factors that prevention plans.
best represent their patient population. Selected unit-specific The BPG PU working group provided educational sessions
risk factors enhance a clinician’s ability to consider and assess to nursing leadership and frontline clinicians to review the
specific risks for PUs in each specialty area such as the inten- educational bundle and discuss strategies for implementa-
sive care unit, medicine, and surgery. tion. All resources were made available electronically for
It is also important for patients and families to under- easy access. For these interventions to be successful and
stand PU risk and what they can do to minimize this risk. for the desired outcomes to be reached, a shared involve-
To involve patients and families in PU prevention, the work- ment from the aforementioned stakeholders was necessary
ing group developed an education pamphlet for patients at to reinforce use of the PU prevention educational bundle
risk of developing a PU. A turning clock tool posted at the hospital-wide.
bedside alerts members of the healthcare team that the
patient has been identified as being at risk for PUs. The Recommendation 3.3
positioning clock also serves as a reminder to staff, patients, The rehabilitation members of the BPG PU working group
and family members that the patient should be repositioned were instrumental in providing strategies to reduce pressure,
at each 2-hour interval. The patient and family education friction, and shearing forces in patient positioning and han-
pamphlet and the positioning clock are tools for patients, dling. To assess current practice regarding positioning and
family, and clinicians to use as they partner in education transferring techniques and the use of equipment, a needs
and PU prevention strategies. assessment survey was distributed to all inpatient reha-
The decision tree for positioning patients at risk of de- bilitation and nursing staff. Results identified that the
veloping a PU, the unit-specific risk factors for developing gaps between current practice and best practice were
PU, the educational pamphlet for patient and family, and largely attributed to lack of available pressure redistribu-
the positioning clock are incorporated into the Pressure tion equipment. Having the necessary equipment, such
Ulcer Prevention Education Bundle. The education bundle as seating cushions, positioning wedges, and transfer
(Table 2) promotes awareness and supports clinical deci- sheets, is fundamental in pursuing decreased HAPU
Positioning Decision Tree for Patients at Risk Uses Braden Scale subscores (sensory, perception, nutrition, mobility, activity,
friction and shear, and moisture) to predict patients_ level of risk and provides
preventative positioning interventions
Unit-Specific Risk Factors for Pressure Ulcer Provides unit-specific risk factors based on the Registered Nurses_ Association of
Development Ontario Best Practice Guidelines for Risk Assessment and Prevention of Pressure
Ulcers (Supplement 2011)
Are You at Risk for Getting Pressure Ulcers? Pamphlet for patients and families
Topics include the following: Facts About Pressure Ulcers, How I Can Prevent
Pressure Ulcers, Tips for Good Skin Care, Take the Pressure Off, I Am Caring for a
Family Member, Am I at Risk of Getting a Pressure Ulcer?, Nutrition and
Hydration, Resources for Patients and Families
Repositioning clocks Visual tool to prompt care providers to reposition patient every 2Y4 h and to
serve as communication tool to facilitate continuity of care between staff,
patients, and families
rates. The procurement of new equipment was achieved Synthesizing, critiquing, and applying research are cen-
through the successful application to the Hospital’s Pa- tral to the CNS role and contributed to the success of this
tient Safety Fund. project. In an effort to promote best practice, the PU BPG
A review of the PU P&I results over the previous 3 quar- was reviewed and applicable recommendations were chosen
ters and taking into consideration unit-specific risk factors for implementation across the organization. Leadership, con-
for PU development, pressure redistribution equipment sultation, and education were also demonstrated by the
was strategically allocated to the various patient care units working group. Practice changes in PU prevention were
to benefit vulnerable populations. Education on the proper identified and addressed, such as standardizing the fre-
use of the new equipment through hands-on training and quency that nurses would complete a PU risk assessment.
in-services was organized for rehabilitation and nursing Collaborative partnerships were developed, and commitment
staff. To encourage the incorporation of the equipment into from key stakeholders was obtained to facilitate and manage
daily practice, the rehabilitation staff provides ongoing change. The working group assumed the role of change
support and training. A supplemental chart was also pro- agents and educators by planning, initiating, and coordi-
vided to all patient care units, including a list of allocated nating educational sessions across all clinical units to
equipment, infection control procedures, and indications promote evidenced-based strategies for PU prevention.
for use to provide staff with a clinical decision making tool. The use of these domains facilitated the successful im-
In addition, this education has been incorporated into plementation and outcomes of this project. There has
new hire orientation and training with the supplemental been an 80% reduction in HAPUs since the implementa-
goal of reducing workplace injuries incurred from patient tion of best practices by the BPG PU working group. The
handling. immediate replacement of unsatisfactory support sur-
faces occurred in the first quarter of fiscal year 2013Y2014.
Outcomes The replacement of support surfaces contributed to the re-
The 5 domains of practice associated with the role of the CNS duction in HAPU rate from 0.24% in the first quarter to
were evident within this interprofessional QI project. 0.08% in the second quarter. This outperformed the Canadian
These domains include clinical practice, consultation, educa- Institute for Health Information benchmark of 0.15% for
tion, research, and leadership.14 The CNS-led interprofessional Canadian acute care hospitals (see Graph, Supplemental
team integrated clinical experience with theory, research, Digital Content 2, http://links.lww.com/NUR/A9). The rate
and expert opinion in the development of assessment was measured calculating the total number of nosocomial
and intervention strategies for the prevention of PUs at PU divided by the total number of patient discharges.
MSH. Clinical practice competencies were evidenced by To measure the uptake of change in clinical practice
leading an initial environmental scan including an assess- related to the implementation of the Pressure Ulcer Preven-
ment of current nursing documentation, surface review, tion Education Bundle, audits were conducted concurrently
and equipment needs assessment. Intervention strategies with the quarterly PU P&I study. Sixty-three percent of all
included equipment and mattress replacement program, patients at risk of developing a PU, as determined by their
changes to nursing documentation standards, and the de- Braden scores, had a turning clock posted at the bedside.
velopment of a PU prevention education bundle. Furthermore, all clinical inpatient units had the Positioning
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