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Mentor Registry

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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.

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.

 

Key Changes for Improvement

  • Inspect skin daily
  • Manage moisture on skin
  • Conduct a pressure ulcer admission assessment for all patients
  • Minimize pressure
  • Optimize nutrition and hydration
  • Reassess risk for all patients daily

 

The IHI How-to Guide contains detailed information on key changes to prevent pressure ulcers and measures to guide improvement.

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