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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: 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


(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,


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


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.


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.


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


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


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.


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


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.


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


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


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)


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:


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


Appendix D


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