To decrease the number of hospital acquired pressure ulcers by 50 percent in the first six months.

Pressure ulcer prevalence and incidence study

OSF St. Francis Medical Center (Peoria, Illinois, USA) has decreased the number of hospital acquired pressure ulcers by 55 percent, primarily by using the Six Sigma methodology to:

• Define the opportunity to decrease hospital acquired pressure ulcers
• Measure the process performance and the rates of pressure ulcers using a prevalence and incidence study
• Analyze the information obtained from data collection, benchmarking and from literature searches
• Improve our processes by implementing changes
• Control (sustain) the gain made over the course of the project and into the future

[Six Sigma is a methodology for improving the quality of organizational processes, originally developed at Motorola and most successfully applied at General Electric.]

Changes we made to decrease pressure ulcers include the following:

• Implemented pre-operative skin risk assessment to identify at-risk patients and completed skin assessment to identify pre-existing pressure ulcers on admission
• Placed an S.O.S. (Save Our Skin) sticker on the charts of at-risk patients to communicate to intra-operative and PACU nurses
• Implemented intra-operative nursing intervention appropriate for the patient, such as “Position Aids” the RIK mattress, and communicatedGett to the PACU nurse the risk and status of the patient
• Implemented a process for the PACU nurse to continue to assess the patient at risk and communicate it to the floor nurse during report
• Implemented skin risk assessment to identify at-risk patient in the emergency department
• Developed skin breakdown prevention protocol with pocket guide for the nurses 
• Placed 140 AtmosAir mattresses on six units (Neuro ICU and general, Ortho, IMSU, Rehab, Urology) in March 2001, and in a five month period we saved $100,000 in rental costs and reduced pressure ulcer incidences by more than two percent 
• Conducted skin assessment daily and upon admission to the unit by nursing 
• Conducted skin risk assessment and additional risk assessment daily 
• Standardized intervention for the at-risk patient (i.e., patient with Braden score of 16 or less, or patient who is not able to turn self) to include:
  • Initiate skin breakdown prevention protocol
  • Place S.O.S. sign outside the patient room
  • Provide patient/family education booklet
  • Turn/tilt/reposition every 2 hours on the even hours (nurse page and overhead music every 2 hours as the reminder)
  • If the patient is not on AtmosAir mattress, need to place patient on special overlay mattress (i.e., Waffle mattress or First Step) 
• Clearly defined the role and responsibility of Charge Nurse, Team RN, and Patient Care Tech
• Initiated weekly process performance data collection (turning every two hours, appropriate mattresses, protocol, S.O.S. sign outside the door) until meeting greater than 75 percent compliance, then transitioned to monthly data collection
• Created a unit S.O.S. champion with the responsibilities of data collection, resource for skin, encourage unit compliance, ensure S.O.S. materials available on the unit, attend house-wide S.O.S. team meeting, review data with the Unit Nursing Care Manager, make recommendation for improvement, and help prevalence and incidence study quarterly
• Developed a process of accountability and responsibility for the Unit Manger as the process owner with the responsibilities of:
  • Accepting the implementation by signing the turnover agreement
  • Implementing the solutions
  • Overseeing the process data collection and entry
  • Taking corrective action to keep the process performance (>75 percent compliance) and outcome (<5 percent incidence) in control
  • Adding process and outcome metrics from the Process Management Plan into regular management reporting including the 90-Day Action Plan 
• Incorporated the changes into the nursing and Patient Care Tech orientation 
• Conducted quarterly prevalence and incidence study starting in June 2003; reported results to the National Center for Nursing Quality, process owner, Nursing Director, and Chief Nursing Officer

Lessons Learned:

• Identify and involve the process owner (Unit Manager) and S.O.S. unit champion early in the project 
• Develop detailed training plan to include delegation and team work 
• Communicate the changes to everyone 
• Streamline the process to make it as easy as possible
• Celebrate success, give recognition (e.g., administration sending cookies to the unit), spread the success 
• Define roles and responsibilities
• Realize that you can not fix everything at one time
• Support and commitment from senior leadership is critical to the success and helped to sustain the gains

Hoa Cooper, RN, MS
hoa.m.cooper@osfhealthcare.org

[Storyboard presentation at IHI's National Forum, December 2003]