Hospital Acquired Pressure Ulcer Prevention: Admission Bundle

Abstract

Background: The development of a pressure ulcer is detrimental to the patient, their family, providers, and hospital-based systems. Pressure ulcer development is not only costly but they are associated with an increase in morbidity and mortality. Hospital acquired pressure ulcers (HAPUs) are prevalent nationally and their incidence was on the rise in the state of Maryland as of 2015. Local Problem: In 2017, a heart/vascular unit within a community hospital in Maryland identified the development of HAPUs among five patients, with one patient ultimately succumbing to their pressure ulcer due to sepsis from infection in their HAPU. In 2018 five HAPUs were identified prior to implementation in September 2018. Aims/Objectives: In order to reduce rates of HAPUs on this unit and improve patient care, an evidence-based admission bundle was implemented. Specific aims for this project included an increase in compliance with aspects of the bundle, and an increase in nurse knowledge and confidence post implementation of the bundle. Methods/Interventions: After a survey of current practice completed by staff revealed knowledge gaps and specific areas for improvement, an educational online module was developed and an evidence-based admission bundle was implemented. The admission bundle included a two-skin assessment upon admission with a turning schedule for every patient, with sacral preventative dressings and pressuring reducing mattresses recommended based upon a patient’s Braden Scale scores. The Plan-Do-Study-Act model was utilized to help facilitate implementation. Results: Prior to implementation of the bundle, there was 100% completion of education by the nursing staff. There was an overall 79.7% compliance with the two-nurse skin assessment and a 56.5% compliance rate with the use of sacral preventative dressings. In regards to the pressure reducing mattresses, 31 out of the 33 patients were either in a pressure reducing mattress at time of audit or had an order placed. This yielded a 93.9% compliance rate with this aspect of the bundle. There was a 54.5% compliance rate with the turning schedules posted in patient’s rooms. During the implementation period, six pressure ulcers were identified. Based on the postimplementation survey of current practice, there was little change in knowledge and confidence levels. Conclusions: Compliance rates with the admission bundle varied among the different aspects. There was higher compliance with the skin assessments and use of pressure reducing beds, however there were lower compliance rates with the sacral preventative dressings and turning schedules. Knowledge and confidence levels with HAPUs did not change dramatically post implementation with the HAPU admission bundle. There was an increase in HAPUs during the implementation period of this bundle which could correlate to low compliance with several aspects of the bundle as well as the low levels of change measured in nurse knowledge and confidence levels regarding pressure ulcer prevention. Implications: The use of a nurse-driven admission bundle can promote early identification of risk and lead to early implementation of preventative measures to stop HAPUs before they start.