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Mentor Registry

Get advice and clinical expertise from hospitals that have volunteered to help others with implementation efforts in this topic area.


Prevent Pressure Ulcers

A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. Because muscle and subcutaneous tissue are more susceptible to pressure-induced injury than skin, pressure ulcers are often worse than their initial appearance. Pressure ulcers cause considerable harm to patients, hindering functional recovery, frequently causing pain and the development of serious infections. Pressure ulcers have also been associated with an extended length of stay, sepsis, and mortality.

 

Although pressure ulcers are preventable in most every case, the prevalence of pressure ulcers in health care facilities is increasing. Preventing pressure ulcers entails to two major steps: first, identifying patients at risk; and second, reliably implementing prevention strategies for all patients who are identified as being at risk.

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  • Braden Scale Risk Assessment and Skin Inspection Flowchart
    A flowchart indicating the steps taken to assess a patient’s risk of developing pressure ulcers and steps to identify and treat pressure ulcers that have formed.
  • Daily Skin Care Flow Sheet
    This tool is used by nurses to help identify the interventions needed for those patients with an identified deficit in any or all of the Braden sub-scales to help reduce the risk for pressure ulcers.
  • How-to Guide: Prevent Pressure Ulcers
    This How-to Guide describes key evidence-based care components for preventing pressure ulcers, describes how to implement these interventions, and recommends measures to gauge improvement.

Getting Started: How to Improve

Learn about the Model for Improvement, forming the improvement team, setting aims, establishing measures, and selecting and testing changes. Go to How to Improve.
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  • Measures: Prevent Pressure Ulcers
    Care teams should measure compliance with each of the key components of evidence-based pressure ulcer care recommended in the How-to Guide: Prevent Pressure Ulcers.
  • Percent of Patients Receiving Daily Pressure Ulcer Risk Reassessment
    The percentage of patients for whom a pressure ulcer risk reassessment (using an agreed-upon risk assessment tool) was documented as performed daily or with greater frequency (or for whom an appropriate contraindication was documented).
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Improvement Map
The IHI Improvement Map is a free web-based tool featuring improvements in key hospital processes that lead to exceptional care.
 
Related Improvement Map processes:
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  • Prevent Pressure Ulcers Brochure
    This brochure provides information for patients and families on what a pressure ulcer is, who is at risk, how to keep skin healthy, what to do at home and in the hospital to prevent pressure ulcers, and what caregivers in the hospital will do to prevent them.
  • Measures: Prevent Pressure Ulcers
    Care teams should measure compliance with each of the key components of evidence-based pressure ulcer care recommended in the How-to Guide: Prevent Pressure Ulcers.
  • How-to Guide: Prevent Pressure Ulcers
    This How-to Guide describes key evidence-based care components for preventing pressure ulcers, describes how to implement these interventions, and recommends measures to gauge improvement.
  • Photographic Wound Documentation Form
    This tool is used to document the presence of a wound and condition of surrounding skin on admission and at regular intervals thereafter to document wound progression.
  • Passport Exclusive: Strategies to Prevent Pressure Ulcers
    In this video IHI Faculty Mamber Kathy Duncan, RN reviews the four recommended components of care and the supporting evidence for improvement outlined in the Prevent Pressure Ulcers How-to Guide.

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