1. Griffin, Bevette RN, CWON
  2. Cooper, Hoa RN, BSN, MHSA
  3. Horack, Cassandra RN, BSN
  4. Klyber, Melissa RN, CWOCN, BSN
  5. Schimmelpfenning, Deb RN, CWON, BSN


The Institute for Healthcare Improvement challenges clinicians and administrators to raise care quality through its 5 Million Lives Campaign, a sequel to the 100,000 Lives Campaign. Here, learn how one facility decreased hospital-acquired pressure ulcers, a constant nursing challenge.


Article Content

Healthcare has made great pharmacological and technological leaps over the last several years. Today's nurses are prepared for the sickest of patients with the most advanced treatments. But there's one thing that hasn't changed: basic bedside care, which can prove especially challenging in light of increasing patient acuity and staffing shortages.

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Nearly 1 million people develop pressure ulcers annually, while approximately 60,000 acute care patients die from related complications.1 Long-term-care facilities face rigid federal guidelines for prevention and treatment of pressure ulcers, known as the F-tag 314. Failure to comply with these regulations can result in heavy monetary fines or closure of the facility.2 The National Quality Forum and the Centers for Medicare & Medicaid Services focus greater efforts to eliminate hospital-acquired pressure ulcers.3


Case study

In 2001, OSF Saint Francis Medical Center (OSF SFMC), Peoria, Ill., was dealing with a pressure ulcer incident rate of 9.4%. (See "OSF Saint Francis hospital-acquired pressure ulcers.") In response, administrators turned to 6 Sigma methodologies to reduce incidence by 50%. The 6 Sigma team developed and implemented the following tools and processes:


[black diamond] skin breakdown prevention protocol


[black diamond] use of the Braden Scale


[black diamond] purchase of pressure redistribution mattresses


[black diamond] scheduled audible reminders to turn patients


[black diamond] Save Our Skin (SOS) prompts and SOS champions for each patient care unit


[black diamond] pressure ulcers reported as "never events."



Currently, we have a skin breakdown prevention protocol that incorporates best-practice guidelines from the Agency for Healthcare Research and Quality (AHRQ) and the Wound, Ostomy and Continence Nurses Society (WOCN) on the prevention of pressure ulcers. A Braden Scale score is done on all adult patients upon admission and every 24 hours afterwards. The skin breakdown prevention protocol is initiated on any patient with a Braden score of 18 or less. The protocol includes placing an SOS sign on patients' doors that helps identify them for being at risk.


The AHRQ clinical practice guidelines on pressure ulcer prevention recommended that initial pressure ulcer risk assessment be completed on admission, with reassessment based on patient condition.


Total skin assessment is done every 24 hours, with special attention to bony prominences, especially the coccygeal/sacral skin and heels. TED hose and socks must be removed to assess heels. If a pressure ulcer is found, it's staged and documented. If there's no documentation of the pressure ulcer within 24 hours of patient admission, the pressure ulcer is considered hospital acquired (incidence).4


OSF SFMC protocol includes moisture management for incontinent patients. This entails using dry-flow pads under the patient to wick the urine or stool away from the skin. Premoistened disposable barrier wipes are used to help cleanse, deodorize, and protect the perineal skin from the effects of urine and/or stool. Other aspects of the protocol instruct to use moisture barriers, skin sealants, and fecal incontinence pouches for stool incontinence.5


Pressure redistribution mattresses help minimize pressure under all adult patients. This simplifies and standardizes selection issues. The protocol instructs nurses to order a low-air-loss mattress/bed if the patient has an existing Stage III or IV pressure ulcer. Again, the goal is to reduce the pressure exerted on the bony prominences.3


Direct caregivers are pulled in many directions and may forget it's time to reposition their at-risk patients. As such, the Medical Center plays a small segment of the Olympic theme song overhead every 2 hours as a reminder. Nurses also carry pagers and receive a page every 2 hours to turn and reposition their patients. In addition, a lift team covers the hospital 24/7, rounding every 2 hours in all the ICUs to help mobilize patients. The team remains available by pager to the general units to assist with the same tasks.


Patients are assessed for risk of developing pressure ulcers preoperatively. If they're considered at risk, an SOS sticker is placed on their chart and follows them to the OR and recovery room. This sticker reminds caregivers to take the necessary precautions.


WOCN nurses lead the hospital's SOS team, which meets monthly to review new evidence-based practices, products, and recommendations for practice changes. The team, consisting of an SOS member from each adult unit, also conducts quarterly prevalence and incidence study of pressure ulcers. The SOS team member is the unit champion who brings evidence-based practice changes to the nursing unit. The goal is for the SOS member to be responsible for unit performance audits, reviewing/educating peers, and encouraging specific practice changes at the unit level. The champion is also responsible for sharing results with the process owner (nursing patient care manager) and helping the process owner with action plans for continued improvement.


To ensure quality patient care, the team also measures process performance on the individual units. The four indicators for the performance audits include:


1. Initiate prevention protocol.


2. Provide patient/family education.


3. Turn/tilt patients every 2 hours.


4. Place SOS signage on patient's door.



Chart audits are done monthly until 90% compliance is achieved on the four indicators and the prevalence and incidence study results are equal to or less than the 3.5% target. (See "Getting staff buy-in.") When the target is reached, audits are reduced to quarterly. If the performance measure drops below 90%, monthly audits return until 90% compliance is once again achieved. The key to long-term success is the process owner (patient care manager) and the unit staff taking an active role in and accountability for continuous improvement. (See "Outcomes.")


In 2003, our medical center developed a list of "never events"-instances that should never occur during a patient's hospital stay. Stage 3 and 4 pressure ulcers are never events. We modeled our list after the National Quality Forum Safe Practices and present results monthly to the Medical Center Quality Safety Board, Medical Executive Committee, Professional Staff Quality Improvement Committee, and the OSF Healthcare Corporate Office.



Implementation of a comprehensive pressure ulcer prevention program has demonstrated sustained improvements. Our program is an ongoing process preparing for the future challenges in healthcare. Targets include:


[black diamond] decreasing the number of pressure ulcer cases


[black diamond] improving patient safety


[black diamond] increasing service quality


[black diamond] limiting complications due to hospital-acquired pressure ulcers


[black diamond] reducing costs by more than 3 million dollars annually.



Getting staff buy-in

The process needs to be streamlined to ensure compliance. Consider taking the following measures:


[black diamond] Make it easy to follow the prevention protocol.


[black diamond] Use pressure-reducing mattresses under all adult patients and use all-in-one incontinence wipes.


[black diamond] Turn/reposition on the even hours with a musical cue as a reminder.


[black diamond] Make the initiative public and visible. Practice "transparency": Publish quarterly data for everyone to see with the accountability of an action plan for failure to meet target.


[black diamond] Select champions on each unit to provide expert knowledge and support.


[black diamond] Tell the story of success: Publish results, mentor other hospitals, etc.



The "right thing"

Providing evidence-based patient care is the right thing to do and, in turn, benefits everyone involved by increasing patient safety through higher care quality and reducing healthcare costs from patient complications. Other benefits include enhanced staff satisfaction from streamlined work processes and from knowing that they're providing optimal care to every patient, every time.




1. Institute for Healthcare Improvement. Relieve the pressure and reduce harm. May 21, 2007. Accessed at: and [Context Link]


2. Wound, Ostomy and Continence Nurses Society (WOCN). Guidelines for Prevention and Management of Pressure Ulcers. Glenview, Ill: WOCN Society; 2003. [Context Link]


3. CMS Manual System. Pub. 100-07 State Operations Provider Certifications. Appendix PP, F-Tag 314 Current Guidance to Surveyors. [Context Link]


4. Courtney B, Ruppman J, Cooper H. Save our skin: initiative cuts pressure ulcer incident in half. Nurs Manage. 2006;37(4):36-45. [Context Link]


5. The Clinical Practice Guideline from the Agency for Healthcare Research and Quality (Guideline No. 15: treatment of pressure ulcers; Guideline No. 3: pressure ulcers in adults: prediction and prevention). Accessed at: [Context Link]