Case Studies

Decreasing Pressure Ulcers Through Skin Care

The Problem

According to a 2006 study published in Nursing Management, 60,000 U.S. hospital patients die each year from complications related to hospital-acquired pressure ulcers. Pressure ulcers, if not properly treated, can lead to blood and bone infections, infectious arthritis and scar carcinoma, among other complications. Buena Vista Regional Medical Center's services include Hope Harbor, a 10-bed geriatric psychiatric unit offering comprehensive medical and psychiatric evaluations, counseling services and physical therapy. Because the unit's elderly patients are often cognitively impaired and must be regularly encouraged to be physically active, the entire population at any given time is at increased risk for pressure ulcers, according to Michele Kelly, RN, director of quality and control.
An internal analysis revealed that the skin care treatment regimens critical to preventing pressure ulcers were not being applied comprehensively, and also found there were no consistent methods for tracking compliance.

The Solution

In 2007, Buena Vista decided to implement the Institute for Healthcare Improvement's bundle for pressure ulcer prevention, consisting of six elements:

  • Assessment and reassessment;
  • Daily skin inspection;
  • Management of moisture;
  • Optimizing nutrition; and
  • Hydration and minimizing pressure.

The hospital created a multi-disciplinary work group, Prevent Ulcer Development Specialists, to analyze problems with compliance, develop new evidence based guidelines and spread best practices to frontline nurses.

Additional Resources

Webinars December 13th, 2017

Equity of Care Webinar SeriesPart 2: Aligning Diversity and Inclusion, Community Engagement, Busi......

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Webinars November 20th, 2017

Equity of Care Webinar SeriesPart 1: Aligning Diversity and Inclusion, Community Engagement, Busi......

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Webinars November 17th, 2017

Transportation and the Role of Hospitals This AHA webinar on “Transportation and the Role of Hos......

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