St. John Medical Center is a 650+ bed teaching hospital located in Tulsa,
OK. Our Adult Intensive Care Unit (AICU) is a 22 bed unit with the
average age of 62.4. Our Apache score is 62.43 vs 58 at other facilities.
AICU admitted 1915 patients into the unit last year. The top 5 admission
diagnosis were: Respiratory, Acute MI, Sepsis, CV-other, and Bacterial
Pneumonia.
Our Problem
Total Skin Inspection every 2-4 hours
Is there breakdown or pressure ulcers ?
Keep HOB no higher than
30 degrees to prevent shear
1000-1300 Rotation per sport bed
1700-1800 Manual turn
1800-2100 Rotation per sport bed
2100-2200 Manual turn
2200-0100 Rotation per sport bed
0100-0200 Manual turn
0200-0500 Rotation per sport bed
Staff meetings and specific unit education
Bulletin board with monthly reports
Nursing pods with posted monthly reports and WOW turn schedule
•
Clinical Educator
•
Nurse Manager
•
Critical Care Nursing Director
•
Vice President of Nursing
•
Medical Director of Quality and Safety
Incontinent Moisture
Urine or Stool
Skin intact
Foam Cleanser #1
& Aloe Vesta
Protective Ointment
#3
Skin not intact
Foam Cleanser
#1 & Critic Aid
Moisture Barrier
Hospital vs AICU (PU Incidence)
Hosptial Acquired Pressure Ulcer
35
33
30
•
Staff nurse developed unique turn schedule
Staff nurses made overhead announcements during scheduled manual turns
Yes
25
2
3
20
Total HAPU
UBC agreed that the problem must be addressed
•
18
•
ICU educator developed and provided extensive education, assisted with auditing staff
performance with one-on-one instruction
Develop individualized
plan for treatment and
prevent further pressure
ulcers
•
Fluidized-gel head pillow, heel protectors (prevention & treatment), turning wedges
•
Skin Care Algorithm: aids in skin care product/interventions based on risk assessment
Evaluation Process:
Dryness
Flakey, Less Pliable
Bathing
Aloe Vesta Body Wash
& Shampoo #1
Nutrition Altered
Pre-albumin <18
Dietitian Consult
Help with menu
selection
•
CWOCN evaluated see all patients with low Braden every 2-3 days
•
Variances were written on all newly developed pressure ulcers
•
Educator and manager made intermittent rounds
•
Manager asked to look at pressure ulcers found by CWOCN
Predicted Outcomes:
Encourage oral intake
Apply Duoderm Extra
Thin or Tegaderm
*Change Duroderm and
Tegaderm every 3 days and prn.
*Call wound care office at
X42871 for questions.
Patient: Maintain intact skin during ICU stay
Nurse: Perform thorough skin assessment each shift, document and report alterations in skin
integrity to CWOCN, follow turn schedule, utilize skin care algorithm and pressure relieving
devices.
Organizational: Reduce ICU acquired pressure ulcer prevalence by 50% within 6 months.
19
28
17
15
Personnel and Material Resources:
Apply Aloe Vesta Skin
Conditioner #2
Flexi-seal
Rectal Tube
•
•
Dedicated ICU Certified Wound Ostomy Continence Nurse (CWOCN) rounded on all
patients with low Braden every 2-3 days
No
To prevent friction:
Apply Duoderm Extra
thin or Tegaderm to
bony prominences such
as heels and elbows
0900-1000 Manual turn
Nurse Buy-in:
Assess for Risk Factors
Are signs and symptoms present ?
If heels are red or
boggy apply Heel -lift
boots
0600-0900 Rotation per sport bed
Presented data to Unit-based Council (UBC)
Leadership Support From:
Skin Care Algorithm
Moisturize with Aloe
Vesta Skin
Conditioner #2
0500-0600 Manual turn
•
In 2008 CMS instituted non-payment for
nosocomial pressure ulcer treatment of Stage
III and IV pressure ulcers. While national
standards recommend Q 2 hour turning as a
prevention strategy, the ICU is using CLRT to
prevent/treat pulmonary complications. The
challenge is to prevent pressure ulcers while
rotating a patient 18 hours/day.
Reposition with pillows
every 2-4 hours.
•
•
Significance
Use a full sheet to
reposition pts
Increase Awareness of Problem:
Stop rotation and manually turn the patient on the following
schedule:
•
A performance improvement project was
developed to increase nursing awareness of
risks for pressure ulcer development in the ICU
while using continuous lateral rotation therapy
(CLRT). This aggressive campaign introduced
tools/interventions to reduce pressure ulcer
incidence in this high risk group.
Shear/Friction
Manual Turn with CLRT Schedule
Assess skin and document in Cerner by 1000 & 2200 daily.
Purpose
Pressure
Melissa Dimick MS, RN, CCRN and Janet Nowland MS, RN, CWOCN
Solution: Ware on Wounds (WOW)
The incidence of pressure ulcer development in
our Medical Intensive Care Unit peaked at 50%
July 2008. Staff felt the continuous lateral
rotation beds not only prevented pulmonary
complications but also prevented pressure ulcer
development.
St. John ICU
Skin Care Algorithm
War on Wounds in the Adult Intensive Care Unit
17
17
9
14
12
10
12
15
13
10
9
5
6
0
Aug-08
Sep-08
12
12
7
2
Jul-08
14
13
6
5
16
18
Oct-08
Nov-08
4
4
Dec-08
Jan-09
2
Feb-09
Mar-09
Apr-09
May-09
2
2
Jun-09
Jul-09
Month
AICU HAPU Housew ide HAPU
References
Ballard, N., McCombs, A., DeBoor, S., Strachan, J., Johnson, M., Smith, M. et al. (2008).
Journal of Nursing Care Quality, 23(1), 92-96.
Bours, G., de Laat, E., Halfens, R., &Lubbers, M. (2001). Prevalence, risk factors and
prevention of pressure ulcers in Dutch intensive care units. Intensive Care Medicine 27(10),
1599-1605.
Clark, H., Bradley, C., Whytock, S., Handfield, S., van der Wal, R., Gundry, S. (2005).
Pressure ulcers: Implementation of evidence-based nursing practice. Journal of Advanced
Nursing, 49(6), 578-590.
Elliott, R., McKinley, S., & Fox, V. (2008). Quality improvement program to reduce the
prevalence of pressure ulcers in an intensive care unit. American Journal of Critical Care
17(4), 328-334.
IHI.org (n.d.). 5 million lives campaign. Retrieved on September 3, 2009 from
http://www.ihi.org/IHI/Programs/Campaign/
Russell, T. & Logsdon, A. (2003). Pressure ulcers and lateral rotation beds: A case study.
The Journal of Wound, Ostomy, Continence Nursing, 30(3), 143-145.