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


Am J Crit Care. 2008;17(4):328-334. 

In This Article


This quasi-experimental practice improvement program was conducted in a 14-bed adult general ICU at the Royal North Shore Hospital, a 600-bed metropolitan teaching hospital in Sydney, Australia. The hospital is a tertiary referral facility for a wide range of speciality services such as spinal, renal, neuroscience, and burns. In this and other Australian ICUs, an accredited ICU staff specialist is ultimately responsible for the admission and management of all patients. The ratio of registered nurses to patients is 1 to 1 for patients receiving mechanical ventilation, and each nurse performs all the care for his or her patient. Additional clinical support is available during the day, Monday to Friday, including clinical nurse educators, a clinical nurse consultant, and nurse unit managers. Assistance is available 24 hours a day from the after-hours nursing unit manager and patient services assistants. The study was done between November 2003 and January 2006. A baseline hospital-wide prevalence survey was conducted in November 2003, and subsequent surveys were conducted in the ICU each month thereafter.

All patients surveyed were at risk, with 50% at high risk for pressure ulcers.

The number of potential opportunities for surveying patients' skin was 601. Skin surveys were performed during 22 audits conducted during the 2-year study period. All patients admitted to the ICU on the day of the audit were included in the surveys. No formal procedure was used to select the day on which the survey was conducted. The availability of the clinical experts to do the surveys was the major factor in the selection of the day; therefore, all surveys were conducted between Monday and Friday. Patients were not included if they had contraindications to movement (eg, severely unstable hemodynamic status), had an unstable spinal injury, were expected to die shortly, had extensive skin grafts, had procedures outside the ICU scheduled during the audit, or refused to participate.

Sixty percent of pressure ulcers occurred on the heels; 30% on the sacrum.

The Waterlow Pressure Ulcer Risk Assessment Scale[16] was used to assess the risk for pressure ulcers. The cumulative score derived by adding scores for each risk factor gives an indication of the risk for a pressure ulcer. A score is assigned for each of the 10 risk factors: body weight, continence, skin condition, nutritional status/appetite, age, sex, mobility, recent surgery, tissue perfusion, and neurological status. The minimum score for adult patients is 2; the maximum possible score is 90. Low scores (<10) indicate low risk. A patient with a score between 10 and 15 is considered at risk, a patient assigned a score between 15 and 19 is at high risk, and a patient assigned a score greater than 20 is at very high risk. The purpose of the tool is to provide a practical method of assessing the level of risk for pressure ulcers and to suggest levels of interventions to reduce risk.[17]

An internationally recognized staging scale[18] was used to describe pressure ulcers. The scale ranges from stage I to stage IV; stage I indicates the least skin damage. Stage I is an observable pressure-related alteration of intact skin. The changes may be one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel), and sensation (pain, itching). The affected area is a defined area of persistent redness in lightly pigmented skin; in darker skin tones, the area may be persistently red, blue, or purple. Stage II is a partial-thickness skin loss involving the epidermis and/or dermis. The affected area is superficial and resembles an abrasion, blister, or shallow crater. Stage III is a full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia. The affected area resembles a deep crater with or without undermining of adjacent tissue. Stage IV is a full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Undermining and sinus tracts may also be associated with stage IV damage.

The baseline prevalence survey was conducted by clinical experts in skin assessment and prevention of pressure ulcers in 4 separate clinical areas of the hospital, including the ICU and the acute aged care unit. The data from this survey and from subsequent monthly ICU prevalence surveys were used to gauge improvements in pressure ulcer rates after the implementation of a hospital-wide strategy for preventing pressure ulcers. The surveys indicated a higher than acceptable rate of pressure ulcers in the ICU and showed that many ICU patients who were at high risk and very high risk for pressure ulcers were not placed on pressure-relieving mattresses.

To engage our ICU bedside nursing colleagues in the project, we provided one-on-one clinical instruction that included training in the use of the Waterlow Pressure Ulcer Risk Assessment Scale,[16] preventive strategies, notification procedures, and skin assessment. During the 26-month study period, the following data were collected each month for each patient assessed: the number, stage, and location of pressure ulcers; the type of strategy used to prevent pressure ulcers; and the most likely location of the patient when the pressure ulcer developed.

The data were entered into an Excel spreadsheet, and the frequency of ulcers was counted. Because prevalence data violate the assumptions of inferential statistical methods, statistical analysis was not performed; data were reported as raw numbers and percentage rates.

The results of the survey, including raw prevalence data and information about particular areas for improvement and focused interventions, were presented in the ICU's monthly newsletter. Reminders about how to obtain pressure-relieving devices were also provided, along with positive feedback and encouragement as rates of occurrence of pressure ulcers plummeted. The results of each monthly survey were reviewed, and any areas of concern were emphasized in the one-on-one clinical instruction provided in subsequent months. For example, focused preventive interventions such as a "pillow campaign" (encouraging colleagues to place a pillow under the lower part of each leg of a patient to keep the heel clear of the bed) were used when the number of heel sores was unusually high.


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