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It takes a hospital to reduce pressure ulcers

Medicine, radiology departments join forces

From the August ACP Hospitalist, copyright © 2011 by the American College of Physicians

By Stacey Butterfield

Where: Fairview Southdale Hospital, a 352-bed acute care hospital in Edina, Minn.

The issue: Reducing pressure ulcers.

Background

As a wound, ostomy and continence nurse at Fairview Southdale, Vicki Haugen, RN, had been working to prevent pressure ulcers for a long time. “Years ago, we knew enough to turn patients. Even when I started this 20 years ago, there were special beds for pressure ulcer prevention,” she said.

When the Minnesota Hospital Association started a Safe Skin initiative, even more attention was focused on preventing pressure ulcers. Yet Fairview Southdale's reporting—including required reports to the state health department of deeper pressure ulcers—showed that the sores were a continuing issue for the hospital's patients. “If we're doing all this, why are we still getting pressure ulcers on these patients?” said Ms. Haugen. “We started to look in other parts of the hospital.”

Their research revealed that patients' visits to other departments, such as radiology, appeared to be associated with the development of pressure ulcers. Ms. Haugen described one such patient: “He had a bells-and-whistles bed, and all the best care at the bedside, but he was in X-ray all day” which may have contributed to his development of a pressure injury.

Ms. Haugen and her team decided to spearhead an initiative to improve pressure ulcer care in areas of the hospital where it had not traditionally been a focus. They found both willing partners and relatively easy fixes in the radiology department.

How it works

“We got a whole team together for a two-day rapid process improvement to say, ‘What happens to these people when they're off the floor?’ and ‘What can we do about it?’” said Ms. Haugen. Together, the pressure ulcer experts and the radiology department staff came up with a multi-part intervention to reduce ulcer development.

The first step was to identify at-risk patients so that everyone involved in their care would be aware of the issue. “A huge communication gap was between departments. Nursing wasn't letting people know who was at risk,” said Ms. Haugen. “We added that to the handoff communication tool that goes with the patient, and also put a wristband on them if they are a pressure ulcer risk.”

Once they were aware of the risk, radiology staff found simple ways to reduce it. “After a procedure where somebody is laying supine, they'll make sure they lay them on their side for their transport back. It's kind of a no-brainer,” said Ms. Haugen. Other changes included repositioning patients during breaks between tests or scans and keeping their heels elevated away from hard surfaces. “Sometimes they can even call the doctor and do a shorter test,” she added.

Communication was also improved on the other side of the handoff. Before returning a patient, radiology staff now check his or her skin for changes and let the medical floor know of any issues. “They document in the chart, ‘Patient supine three hours, offloaded on their side on the way back,” said Ms. Haugen.

Results

Before the intervention, Fairview Southdale's pressure ulcer rate was 0.35 per 1,000 patient-days. “We were aiming to get our pressure ulcer per 1,000 patient-days down below 0.17 and we ended up at 0.16 within six months of our project,” said Ms. Haugen.

The wristbands have also gotten a favorable response from the nursing staff, even though project leaders had worried that adding another wristband to the rainbow would be unpopular. “Even nursing assistants have said, ‘I don't even need a report and I know who needs to be turned,’” Ms. Haugen said.

Challenges

The project leaders would like to reduce pressure ulcers even more, but their efforts are hampered by the limits of existing technology. “We have actually tried some X-ray table mattresses, but they give really poor X-rays,” said Ms. Haugen.

Operating room technology has also posed challenges. “There aren't as many interventions or mattresses that you can bring in. There's no data, best practices, to say which works though the national operating room and wound, ostomy and continence nursing groups continue to make this a priority,” she said.

Words of wisdom

“I used to feel like nobody cared: ‘Bed sores? Who cares?’ All of a sudden this is a big deal. Everybody cares,” said Ms. Haugen.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated