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


During this 26-month quality improvement program, the number of pressure ulcers of all stages, particularly stage I, showed a downward trend. The overall prevalence of pressure ulcers decreased from 50% to 8%. In addition, the use of pressure-relieving devices increased for the high-risk patients, and this increase reflects the experience at other facilities.[20] The anatomical site of pressure ulcers and the location of the patient when the pressure ulcer developed remained constant throughout the program. The baseline prevalence of pressure ulcers in the ICU was high by national and international standards; however, the pressure ulcer prevalence trends and final prevalence rate compared favorably with international and national benchmark standards.[9,10,11,12,13,14,15]

With quality improvement, prevalence of pressure ulcers decreased from 50% to 8.3%.

This program had many strengths that warrant consideration. The methods used for the program were highly effective and contributed directly to improving patients' outcomes. The program comprised all aspects of recommended methods of implementing evidence-based health care and sustaining practice over time. A multifaceted approach was used: one-on-one clinical instruction (with the aim of reaching 80% of all nurse clinicians at any time), reminders, and presentation of raw data on the prevalence of pressure ulcers on notice boards and in the ICU newsletter. Providing clinicians with feedback on patients' outcomes is particularly influential because it gives objective data about the effect of the clinicians' performance and provides a powerful reminder of the importance of preventive measures.[21] Therefore, collection of the prevalence data not only was useful in monitoring progress with the education campaign, but also allowed clinicians to see the effect of adopting rigorous strategies for preventing pressure ulcers. The straightforward methods and the prudent use of resources were the most appealing features of this program and are characteristic of other effective programs for preventing pressure ulcers.[15,20,22,23,24]

Busy bedside clinicians are positively influenced by feedback on patients' outcomes.

We collected data on all stages of pressure ulcers, including stage I, which is often excluded from reports in international health care publications. Arguably, this approach allowed us to effectively monitor and manage all levels of skin damage and ensure that the ulcers did not become worse. In one observational study,[25] 13.7% of stage I pressure ulcers deteriorated to a higher stage. We monitored the data constantly for areas of skin at high risk for damage. We quickly identified pressure ulcers on the heel as a priority and continued to target this area with poster campaigns and by providing practical tips in the ICU newsletter on how to relieve pressure on the heels.

Prevalence surveys provide great opportunities for quality improvement.

The program also had several limitations. Prevalence data are a snapshot in time and are therefore considered less reliable than incidence data. Prevalence data are not useful for identifying problem skin areas or the likely location of a patient when skin damage occurred.[26] However, collection of incidence data is more labor intensive and costly than collection of prevalence data.[20] A recent study[20] performed in a comparable ICU in the Netherlands in which the investigators used more rigorous methods and more extensive resources (ie, the employment of a specific wound care nurse specialist) than we used yielded results similar to ours, albeit in a shorter time frame. Prevalence data are less onerous to collect and offer an achievable alternative to collecting data daily from skin assessments of all patients admitted to the unit. Because we collected data repeatedly, we could appraise the general trends in pressure ulcer prevention and focus our efforts on particular areas of concern, as described in the study performed in the Netherlands.[20]

The group of clinical experts who conducted the skin surveys changed slightly during the 26-month program; however, the leader and at least 2 members of the group of experts remained the same. Although all surveyors knew how to use the audit tool and were provided with the same information on skin assessment, assessments by those who were less familiar with pressure ulcer prevention may have been less accurate than assessments by those more familiar with pressure ulcer prevention. This diminished accuracy may have been more likely when the clinicians were differentiating between (1) sluggish capillary return associated with reactive hyperemia and (2) stage I pressure ulcers. Clinicians often have difficulty discerning stage I ulcers from reactive hyperemia, resulting in overdiagnosis of stage I ulcers.[14,25]

Other benefits have emerged from this program. We noted an apparent lack of confidence among some nursing colleagues about removing cervical collars and checking occiput skin areas while caring for areas subject to pressure. The nurses admitted that they lacked the confidence to remove collars in certain circumstances. We were able to address these concerns by offering opportunities to practice collar removal and neck stabilization on healthy volunteers. This training has been incorporated into the regular education service for all nurses working in the ICU. The results and information on the simple design of this program (eg, use of expertise expected of most nurse clinicians and the existing infrastructure within the ICU) have been disseminated locally. Other clinicians in other contexts and organizations have expressed an added confidence in their ability to lead similar programs to prevent pressure ulcers. We plan to use similar methods to improve clinicians' adherence to hospital policy on medication administration in order to reduce medication errors.


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