NEW ORLEANS — A team of nurses reduced the incidence of hospital-acquired pressure ulcers by 50% and cut associated costs by about $700,000 a year by introducing new products, interventions, and incentives in the critical care unit.

"Before we started this, nurses knew it was an issue, but had the mindset that pressure ulcers were expected with a critical care patient; it was fine as long as the patient survived," said study author Christina Dunn, RN, from the Eskenazi Health Center in Indianapolis.

The change in mindset did not happen overnight. It took a while to convince nurses that they could prevent hospital-acquired pressure ulcers and to understand that ulcers are expensive, Dunn told Medscape Medical News.

"It's been almost a 3-year process. Today, for most of the nurses in our hospital, attention to hospital-acquired pressure ulcers has become part of daily care," she explained. "But we do annual education to keep nurses thinking about it."

The results of the study were presented here at the American Association of Critical-Care Nurses 2016 National Teaching Institute and Critical Care Exposition. They were also published in the March issue of the American Journal of Critical Care (2016;25:152-155).

Hospital-acquired pressure ulcers have been under the microscope since 2008, when Medicare announced that it would not reimburse for late-stage pressure ulcers. The average cost of a pressure ulcer is $38,700, according to the National Database of Nursing Quality Indicators.

Because of this, Dunn and her colleagues decided to try to reduce pressure ulcers in their facility.

 
How often do we look at patients and think, how's the skin?
 

Skin is the first line of defense for a human body; it regulates temperature and prevents fluid loss," said study coauthor Rachel Culpepper, RN. "Nurses are quick to check a patient's heart and other vital organs, "but how often do we look at patients and think, how's the skin?" she asked.

A retrospective assessment of pressure ulcer incidence reports from 2011 identified 45 cases, which would have cost the Eskenazi Health Center about $1,741,500. "That's a lot of money," Culpepper said.

In January 2013, the team implemented the Save our Skin project, with a goal to cut the incidence of pressure ulcers in the hospital by 50% within 12 months.

The nurses worked on a Braden algorithm, revised the skin care protocol, put resource books in every patient's room, and did rounds to help other nurses. They also worked on making the nurse's job easier. They instituted the use of fluidized positioners, which made it easier to turn and position patients, and purchased a camera for accurate wound documentation.

It was tough to get buy-in, Culpepper reported. But the team offered incentives and posted incidents of pressure ulcers in the intensive care unit.

In April, when results were not as good as expected, new wound care dressings were introduced.

By the end of 2013, the team had achieved their goal of a 50% reduction in hospital-acquired pressure ulcers. In fact, the incidence was 69% lower in 2013 than in 2011 (17 vs 45 of patients), despite a 22% increase in patient load.

The team estimates that their initiative has saved the hospital about $700,000 annually. And length of hospital stay for patients with pressure ulcers continues to decline each year.

Some Pressure Ulcers Unavoidable

There are still some patients with comorbidities that make it hard to completely eliminate pressure ulcers. "We also have a lot of patients who come in malnourished, with diabetes, drug abuse. And we see patients who are homeless," Dunn explained. "The trauma patients — gunshot wounds, stabbings, car accidents — are all high risk."

"This is a problem everywhere, said Chris Chrisman, RN, from the Penn State Milton S. Hershey Medical Center in Pennsylvania. "Not having buy-in from the nurses is a valid concern."

It often depends on how many patients you have. "We don't always think, this guy needs to be turned. It's not top of mind," he said. "Most nurses are not aware of how serious a pressure ulcer can be. It can become infected and lead to increased hospital days. You can go from a little red area to an open wound quickly — sometimes in a day or two."

Some new products and technologies chart patient activity, remind nurses that a patient needs to be turned, or alert nurses that they need to be mobilized, Chrisman pointed out. "It's important we keep it in the fore. Changing positions needs to be reinforced," he said.

The AACN Clinical Scene Investigator Academy provided a $10,000 grant to implement a bedside nurse-led quality improvement program. Ms Dunn, Ms Culpepper, and Mr Chrisman have disclosed no relevant financial relationships.

American Association of Critical-Care Nurses (AACN) 2016 National Teaching Institute and Critical Care Exposition. Presented May 18, 2016.

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