Universal Pressure Ulcer Prevention Bundle with

Proactive WOC Nurse Support

North Memorial Medical CenterRobbinsdale, MN

This study was supported by Sage Products, LLC - WOCN® Society CCI Grant for Universal Pressure Ulcer Prevention Bundle with WOC Nurse Support.  The content is solely the responsibility of the authors and does not necessarily represent the official views of the Center for Clinical Investigation of the Wound, Ostomy and Continence Nurses Foundation, or the corporate sponsor. 

Three Intensive Care Units:

Cardiovascular

Trauma-Neuro

Medical-surgical

Pressure ulcers in critical care is a significant issue

Rates range from 14% to 42% (Brown, Donaldson, Bolton, & Aydin, 2010; Cox, 2011; and Lahmann, Kottner, Dassen, & Tannen, 2012).Critical care units in 196 hospitals reported an average rate of 7.79%-13.89% for stage II or greater (Brown, et.al).

• High-risk patients (APACHE II scores greater than 15) admitted to an ICU have a documented incidence of 52 pressure ulcers per 1000 patient–days (Riley, Karakousis, Schrag, & Stawicki, 2007).

• Minnesota Department of Health reported 68% (n = 33) of stage III and IV pressure ulcers from October 6, 2011-January 6, 2012 in Minnesota occurred while patients were in critical care (MDH, 2012).

North Memorial Estimated an incidence of 9% in critical care units based on historical data from

quarterly prevalence and incidence studies.

Study Goal: Decrease Pressure Ulcer Rate from 9% to Less than 3%

Current Hospital Standard

Pressure Ulcer Prevention of the Critically Ill Patient Protocol

31 Interventions

WOC Nurse Consult based on Braden Score of 12 or less

• Dependence on Nursing to initiate WOC Nursing consult

• Cumbersome for staff to sort through lengthy protocol

• Not visible on unit

The Beginning of a vision:

WOC NursingLeadershipNursingSkin TeamCliniciansCenter for Clinical Excellence

Current Standard

Universal Pressure Ulcer Prevention Bundle (UPUPB)

According to Gray-Siracusa and Schrier (2011), a bundle is a standard set of three to five interventions nurses implement collectively in a consistent manner to improve positive outcomes.

S

A

F

E

R

Skin emollients twice daily

Assessment head to toe

Floating of heels bilaterally

Early identification of pressure sources and need for specialty bed

Reposition patient and devices

Proactive WOC Nursing Support

• Twice weekly rounds• At the elbow education• Provide support for advanced prevention and

wound care interventions• Reinforce nursing use of bundle elements

Study phasesPre-intervention phase: • No change to standard of care, data collected to reflect

current standardIntervention phase:• introduction of SAFER bundle• initiate twice weekly WOC rounds• NDNQI pressure ulcer training modulePost-intervention phase:• Collect data related to bundle adherence and WOC rounds

Study objectives

1.Consistent use of SAFER bundle2.Focus on sources and duration of

pressure3.Initiate bundle interventions proactively

prior to WOC consult4.100% compliance with NDNQI learning

module

Universal Care Bundle

Interactive Bi-weekly WOC Nurse Rounding

Enhanced Knowledge and Skills

All Critical Care Patients Are At Risk

Decreased Incidence

Decreased Degree of Injury

Improved Adherence to Standards

.

• Pressure ulcer rate for the baseline study was 15%.

• Eighteen patients had 28 ulcers, with 6 patients having multiple ulcers

Preliminary Findings for the Pre-intervention

Phase

• Introduction of bundle components• Introduction of twice weekly WOC

nursing rounds• NDNQI learning module

The Intervention phase

WOC rounding focus

• 204 rounds over 6 month period• Devices targeted due to pre-intervention data• Collaboration• Culture change and rapport building• Assist to remove barriers to assessment/adherence • Prevention, prevention, prevention!!!!!!

The post-intervention phase

3 patients developed pressures = 2.3% incidence

• Stage I sacral• Stage I left leg (device related)• Stage II buttocks

Adherence to safer skin bundle

Composite adherence scores were not significantly different

Statistically significant changes occurred in elevation of heels and repositioning

Assessment, use of emollients, and identification of pressure were not significantly different

• Combination of the universal pressure ulcer prevention bundle and proactive WOC nursing rounds was effective in decreasing pressure ulcers.

• Presence of the WOC nurse on the unit was a core implementation component.

• Lack of change in the composite bundle adherence scores may indicate a bundle will not decrease pressure ulcers without the ongoing WOC nurse presence.

The result…