Zeroing in on Pressure Ulcers

Ascension Health, the largest Catholic healthcare system with 500 locations in 20 states and the District of Columbia, spread success from one quality improvement project to another. Their Journey to Zero (that is, zero preventable injuries or deaths) initiative held from 2003 to 2008 reduced adverse events in eight clinical topic areas and saved more than 2,000 lives per year. They expanded the project to further improve pressure ulcer prevention which was one of the initial Journey to Zero foci.

According to Helana Shanks of Ascension’s St. Vincent Medical Center (SVMC) in Jacksonville, Fla., resources were dedicated to pressure ulcer prevention in response to the fact that nearly 60,000 U.S. hospital patients die each year from complications related to hospital-acquired pressure ulcers. Without proper treatment, severe complications can arise, including blood and bone infections, infectious arthritis, holes below the wound that burrow into bone or deeper tissues, and scar carcinoma, a form of cancer that develops in scar tissue. Each year, U.S. acute care facilities spend $2.2 to $3.6 billion to treat pressure ulcers.

The Journey to Eliminate Pressure Ulcers

As part of Ascension Health’s Journey to Zero initiative, in 2004 SVMC began focusing on ways to eliminate facility-acquired pressure ulcers. The hospital’s key steps included:

• Gaining the leadership team’s commitment
• Creating a multidisciplinary improvement team
• Identifying best practices
• Developing the SKIN Bundle™
• Pilot-testing interventions
• Spreading best practices to all Ascension Health facilities

Collaborating on a Blueprint for Improvement

Representatives from the Institute for Healthcare Improvement, Ascension Health, and the Wound, Ostomy and Continence Nurses Society met with SVMC’s leadership team in June 2004 to discuss best practices for pressure ulcer prevention and to create a blueprint for change. They developed a comprehensive plan to guide staff that included a set of interventions called the SKIN Bundle™:  

• Surface Selection – making sure the patient is on the correct type of mattress
• Keep Turning – repositioning the patient at least every two hours
• Incontinence Management – keeping the patient clean and dry
• Nutrition and Hydration – paying attention to weight loss, hydration status, supplement and meal intake

Nurses received training on the SKIN Bundle™ through bedside teaching, newsletters, self-study modules, posters, pocket references and clipboard reminders. Weekly SKIN operations meetings kept the program on track.

Facilitating Cultural Change by Empowering Staff

The leadership team experienced initial pushback from SVMC staff. Some nurses believed that pressure ulcers were unavoidable in critically ill patients and that maintaining heart and lung function was more important than skin care. The leadership team refused to accept this traditional view and changed its expectation from “critically ill patients will leave the organization alive” to “critically ill patients will leave the organization alive and without a pressure ulcer.” Leadership made it clear that the initiative would represent a groundbreaking change in patient care.

The real key to cultural change was not raising the expectations of nurses, however, but empowering them. Nurses played an influential role from the start of the project. Their knowledge, opinions and experience were valued and contributed to enhancing the improvement model. Seeing their ideas put into action, the nurses became advocates for pressure ulcer prevention.

To further bolster support, the leadership team offered nurses advanced education to earn designation as a “SKIN champion.” During the weeks that they achieved zero facility-acquired pressure ulcers, nurses received fun, low-cost incentives to recognize and further encourage a job well done.

Redefining the Nation’s View of Pressure Ulcers

SVMC’s improvement initiative was a success; the incidence of pressure ulcers decreased from greater than 2% to less than 1% from December 2004 to February 2006. As a result, all 67 Ascension Health facilities nationwide committed to implementing the SKIN Bundle by 2006. The table below reflects the significant improvement associated with SKIN Bundle adoption between 2004 and 2010. In 2010, the entire Ascension Health system experienced 12 weeks with zero pressure ulcers.

Two corollary projects sparked by Ascension Health’s study indicated that while the majority of pressure ulcers are avoidable and a program aiming for a rate of zero is a worthwhile effort, there are some pressure ulcers that cannot be avoided. Skin, like any other major organ system, may fail and some pressure ulcers are not preventable. Through the SKIN initiative, Ascension Health continues to strive toward zero on a daily basis in order to prevent avoidable pressure ulcers. 

According to David Pryor, M.D., Ascension Health’s chief medical officer, the system’s next goal is to achieve "Healing Without Harm" by 2014. Success will make it the first large, high-reliability healthcare organization in the United States.