Universal Pressure Ulcer Prevention Bundle with Proactive WOC Nurse Support North Memorial Medical Center Robbinsdale, MN

This study was supported by Sage Products, LLC - WOCN® Society CCI Grant for Universal Pressure Ulcer Prevention Bundle with WOC Nurse Support. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Center for Clinical Investigation of the Wound, Ostomy and Continence Nurses Foundation, or the corporate sponsor.

Pressure ulcers in critical care is a significant issue Rates range from 14% to 42% (Brown, Donaldson, Bolton, & Aydin, 2010; Cox, 2011; and Lahmann, Kottner, Dassen, & Tannen, 2012). Critical care units in 196 hospitals reported an average rate of 7.79%-13.89% for stage II or greater (Brown, et.al).

High-risk patients (APACHE II scores greater than 15) admitted to an ICU have a documented incidence of 52 pressure ulcers per 1000 patient–days (Riley, Karakousis, Schrag, & Stawicki, 2007). Minnesota Department of Health reported 68% (n = 33) of stage III and IV pressure ulcers from October 6, 2011-January 6, 2012 in Minnesota occurred while patients were in critical care (MDH, 2012).

North Memorial Estimated an incidence of 9% in critical care units based on historical data from quarterly prevalence and incidence studies. Study Goal: Decrease Pressure Ulcer Rate from 9% to Less than 3%

Current Hospital Standard Pressure Ulcer Prevention of the Critically Ill Patient Protocol 31 Interventions WOC Nurse Consult based on Braden Score of 12 or less

Dependence on Nursing to initiate WOC Nursing consult Cumbersome for staff to sort through lengthy protocol Not visible on unit

The Beginning of a vision: WOC Nursing Leadership Nursing Skin Team Clinicians Center for Clinical Excellence

Current Standard Universal Pressure Ulcer Prevention Bundle (UPUPB) According to Gray-Siracusa and Schrier (2011), a bundle is a standard set of three to five interventions nurses implement collectively in a consistent manner to improve positive outcomes.

S A FER Skin emollients twice daily Assessment head to toe Floating of heels bilaterally Early identification of pressure sources and need for specialty bed Reposition patient and devices

Proactive WOC Nursing Support Twice weekly rounds At the elbow education Provide support for advanced prevention and wound care interventions Reinforce nursing use of bundle elements

Study phases Pre-intervention phase: No change to standard of care, data collected to reflect current standard Intervention phase: introduction of SAFER bundle initiate twice weekly WOC rounds NDNQI pressure ulcer training module Post-intervention phase: Collect data related to bundle adherence and WOC rounds

Study objectives 1.Consistent use of SAFER bundle 2.Focus on sources and duration of pressure 3.Initiate bundle interventions proactively prior to WOC consult 4.100% compliance with NDNQI learning module

Universal Care Bundle Interactive Bi- weekly WOC Nurse Rounding Enhanced Knowledge and Skills All Critical Care Patients Are At Risk Decreased Incidence Decreased Degree of Injury Improved Adherence to Standards.

Pressure ulcer rate for the baseline study was 15%. Eighteen patients had 28 ulcers, with 6 patients having multiple ulcers Preliminary Findings for the Pre-intervention Phase

Introduction of bundle components Introduction of twice weekly WOC nursing rounds NDNQI learning module The Intervention phase

WOC rounding focus 204 rounds over 6 month period Devices targeted due to pre-intervention data Collaboration Culture change and rapport building Assist to remove barriers to assessment/adherence Prevention, prevention, prevention!!!!!!

The post-intervention phase 3 patients developed pressures = 2.3% incidence Stage I sacral Stage I left leg (device related) Stage II buttocks

Adherence to safer skin bundle Composite adherence scores were not significantly different Statistically significant changes occurred in elevation of heels and repositioning Assessment, use of emollients, and identification of pressure were not significantly different

Combination of the universal pressure ulcer prevention bundle and proactive WOC nursing rounds was effective in decreasing pressure ulcers. Presence of the WOC nurse on the unit was a core implementation component. Lack of change in the composite bundle adherence scores may indicate a bundle will not decrease pressure ulcers without the ongoing WOC nurse presence. The result…