Quality Improvement Program to Reduce the Prevalence of Pressure Ulcers in an Intensive Care Unit

Rosalind Elliott, RN, MN; Sharon McKinley, RN, PhD; Vicki Fox, RN, BN, Intensive Care Nursing Cert

Disclosures

Am J Crit Care. 2008;17(4):328-334. 

In This Article

Abstract and Introduction

Background: Critically ill patients are at increased risk for pressure ulcers, which increase patients' morbidity and mortality. Quality improvement projects decrease the frequency of pressure ulcers.
Objectives: To improve patients' outcomes by reducing the prevalence of pressure ulcers, identifying areas for improvement in prevention of pressure ulcers, and increasing the adoption of preventive strategies in an intensive care unit.
Method: Quasi-experimental methods were used for this quality improvement project in which 563 surveys of patients' skin were performed during 22 audits conducted during a 26-month period. One-on-one clinical instruction was provided to bedside nurses during the surveys, and pressure ulcer data were displayed in the clinical area.
Results: The frequency of pressure ulcers of all stages showed an overall downward trend, and the prevalence decreased from 50% to 8%. The appropriate allocation of pressure-relieving devices increased from 75% up to 95% to 100%. The likely origin of the ulcer (ie, whether it was hospital or community acquired) and the anatomical site of the pressure ulcers did not change during the study period.
Conclusions: This program was successful in reducing the prevalence of pressure ulcers among vulnerable intensive care patients and indicates that quality improvement is a highly effective formula for improving patients' outcomes that is easily implemented by using clinical expertise and existing resources.

Pressure ulcers are a complex clinical problem with a multifactorial etiology. They are nationally and internationally recognized as an adverse outcome of admission to a health care facility and as 1 of the 5 most common causes of harm to patients. In addition, pressure ulcers are key clinical indicators of the standard and effectiveness of care.[1] Pressure ulcers are not a new phenomenon; their occurrence was noted as far back as 2050 to 100 BC.[2] Despite recent major technical advances in health care, pressure ulcers still occur at unacceptable rates within health care facilities, even though such ulcers are largely preventable.

Pressure ulcers markedly affect patients' quality of life, morbidity, and mortality. Pressure ulcers also account for considerable direct and indirect costs in the health care economy. International publications provide many illustrations of the financial burden of pressure ulcers. The National Health Service in the United Kingdom estimated that direct costs related to treating pressure ulcers were between £1.4 billion and £2.1 billion (year 2000).[3] Data from the Netherlands reveal that pressure ulcer treatment accounts for 1% of the health care budget.[4] Treatment costs in North America appear to be similar.[5] An estimated 95 695 pressure ulcers occur annually in Australia, requiring a median 398 432 extra bed-days and equating to a median cost of A$285 million,[6] without consideration of the costs of litigation brought by former patients.

The incidence and prevalence of pressure ulcers in acute care facilities and countries vary. International health care publications report incidence rates of 1% to 11% and prevalence rates of 3% to 22% in hospitalized patients.[7] The rates are higher in critical care patients (incidence 5.2%-20% and prevalence 14.4%).[8] These values are reflected in Australian hospital data. Yearly prevalence surveys conducted in Victoria, Australia, between 2003 and 2006 revealed prevalence rates for pressure ulcers of 17.6% to 26.5% overall and 14.9% to 47.7%[9,10,11,12] in critical care patients.

Critically ill patients are at a higher risk for pressure ulcers than are patients in general care areas. Several factors increase the risk: greater severity of illness; increased length of stay; poor tissue perfusion due to hemodynamic instability, use of vasoactive medications, and anemia; sensory impairment resulting in a reduced sensitivity and/or reaction to pressure due to sedation or underlying abnormality; skin maceration due to moisture; immobility; and poor nutritional status.[13,14] These factors all contribute to the mechanical causes of pressure ulcer: pressure, shear, and friction.

Prevention of pressure ulcers is a fundamental aspect of intensive care nursing, and quality improvement methods are arguably the most cost-effective and intuitive approach to addressing this potentially serious problem. Prevalence surveys are often used in quality improvement as a practical means of determining the extent of a problem, identifying at-risk populations and deficits in service provision, measuring clinical and financial outcomes, and monitoring improvement in clinical practice. Such surveys provide a measure of the extent of a disease or health care problem at a particular time and, when performed repeatedly, an indication of trends.[15] The purpose of this practice improvement program was to improve patients' outcomes by reducing the prevalence of pressure ulcers, identifying areas for improvement in prevention of pressure ulcers, and improving the use of prevention strategies in an intensive care unit (ICU).

Pressure ulcers are key clinical indicators of the standard and effectiveness of care.

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