Using Tools and Guidelines to Significantly Reduce Hospital-Acquired Pressure Ulcers

Agency for Healthcare Quality and Research (AHRQ)


May 25, 2010

In This Article

How They Did It

Context of the Innovation

St. Vincent's Medical Center is a faith-based, not-for-profit health system with 528 licensed beds, and provides inpatient and outpatient services to residents of northeast Florida. As part of the Ascension Health System, St. Vincent's developed the SKIN™ program in response to Ascension's strategic plan, which focuses on 8 specific health priorities, including patient safety. Ascension's "Healthcare That Is Safe" initiative established the goal of having no preventable injuries or deaths by July 2008. As part of this initiative, St. Vincent's Medical Center was chosen as the alpha site to develop best practices to eliminate facility-acquired pressure ulcers. St. Vincent's leadership welcomed the opportunity to develop this nursing-driven program as a means of establishing pride in professional nursing practice.[1]

Planning and Development Process

Key steps in the planning and development process included the following:

  • Forming an interdisciplinary pressure ulcer team: the interdisciplinary team included the chief nursing officer; nurse manager; nurse educators; staff nurses; wound, ostomy, and continence nurses; a performance improvement nurse; a dietitian; a pharmacist; and ad hoc members from purchasing and central supply departments;

  • Identifying best practices: the pressure ulcer team reviewed current practices, policies, and procedures, and conducted a literature review of best practices related to pressure ulcer prevention;

  • Forming an expert consultant team: expert consultants included an Institute for Heathcare Improvement (IHI) representative (who participated after St. Vincent's joined IHI's "5 Million Lives Campaign," which includes an initiative focused on preventing pressure ulcers) and wound, ostomy, and continence nurses[5];

  • Creating consensus across the teams: the expert consultant team and pressure ulcer team met to review the evidence-based literature and provide implementation guidance;

  • Conducting chart audit: program developers reviewed 30 charts of patients who had developed a pressure ulcer in the prior 6 months. The audit showed an increased risk of developing a pressure ulcer for patients with one or more comorbidities related to the following diagnoses: cardiovascular disease (including congestive heart failure), sepsis, respiratory failure, and renal failure[1];

  • Educating staff: all nursing staff received comprehensive education on the skin care bundle. Education began on the pilot units and then expanded to other nurses over a 5-month period. Education sessions included a 20-minute slide presentation on the skin care bundle that focused on the etiology of and risk factors for pressure ulcers, and on interventions to reduce that risk. Education sessions also reinforced nurses' knowledge of skin assessment using the Braden scale, pressure ulcer staging using the National Pressure Ulcer Advisory Panel guidelines, and selection of surface devices[1];

  • Pilot testing and expansion: the bundle was tested for 3 months on 2 critical care units and a cardiac care unit that historically had high rates of pressure ulcers. After the successful pilot test, the program expanded to all nursing units throughout the hospital; and

  • Developing, disseminating pressure ulcer prevention toolkit: program leaders developed a toolkit that includes descriptions of best practices and advice and tools to facilitate implementation and practice change. In November 2005, the kit was distributed to all Ascension Health facilities to assist with implementation of the SKIN™ bundle.[1]

Resources Used and Skills Needed

  • Staffing: staff participate in the program as part of their regular duties; and

  • Costs:program costs are minimal, consisting primarily of expenses related to developing the educational materials. The program is funded internally.

Getting Started With This Innovation

  • Engage leadership: leadership support and enthusiasm are vital to convincing staff to be active participants in the program, including creating staff accountability and dealing with those who may initially resist the program; and

  • Provide "protected" time to work on program: senior leaders at St. Vincent's allowed two registered nurses to work offsite for 1 week to develop educational resources, including the aforementioned slide presentation.

Sustaining This Innovation

  • Be open to suggestions: elicit staff input regarding the selection of interventions and products to reduce the risk for pressure ulcers;

  • Continually focus on education: provide ongoing staff education on pressure ulcer prevention, including an orientation session for new staff and continuing education for all staff that focuses on updates to the SKIN™ bundle and process changes. Incorporate "just-in-time" teaching at the bedside whenever possible;

  • Monitor outcomes: continually monitor outcomes and address issues as needed. As noted, St. Vincent's uses a 3-member unit team to perform this task; and

  • Promote free exchange of information: executive leaders need to create a nonpunitive environment that focuses on the free, regular exchange of information on pressure ulcer reduction initiatives.

Use by Other Organizations

The SKIN™ program is being implemented at all 67 Ascension Health system sites. St. Vincent's has shared the pressure ulcer toolkit with IHI and other healthcare facilities.

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation.

Innovation Profile Classification

Disease/Clinical Category: Decubitus ulcer; Nosocomial infection
Patient Population: Geographic Location > City
Stage of Care: Acute care
Setting of Care: Hospital Inpatient - Hospital Type > Community hospital,
Patient Care Process Preventive Care Processes > Primary
prevention; Active Care Processes: Diagnosis
and Treatment > Infection control; Patient safety;
Care Management Processes > Coordination of
care; Procedure and policy compliance
IOM Domains of Quality: Patient-centeredness; Safety
Organizational Processes: Organizational culture change; Process improvement
Developer: Saint Vincent's Medical Center


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: