Objective: Nosocomial pressure ulcers result in physical and emotional distress for patients and increased health care time and resources. In response to the 1999 Institute of Medicine Report, “To Err is Human,” our hospital initiated 15 teams to reduce errors, including one to decrease nosocomial pressure ulcers.
Design: Team members critically analyzed the literature. Best practice was associated with identifying patients at risk for skin breakdown using the Braden Scale, versus another scale we were using. The literature and peformance improvement data also prompted a major revision to our Skin Integrity Care Standards.
Population: Patients are assessed using the Braden Scale upon admission and then daily.
Concept: Based upon the Braden assessment, the Skin Integrity Standards are implemented. Standards permit the nurse to implement specific treatment guidelines for skin tears and Stage 1 ulcers, and include a decision tree describing the indications for specialty beds.
Methods: Post implementation, we focused on process evaluation. Team members used an inter-rater reliability method to evaluate if nurses completed the Braden scale and instituted associated skin care standards correctly. Results showed 71% compliance with daily Braden Scale scoring and 41% incidence of correct Braden Scale scoring. Multiple, ongoing strategies have been implemented to improve this data.
Findings: The overall rate for nosocomial pressure ulcers has continuously declined. The rates for 5 of the last 6 months were at or below control limits.
Conclusions: Evidence prompted a change in our skin assessment tool and Skin Integrity Standards of Care. This change was associated with a decreasing trend in nosocomial ulcer rates.
Implications: Evidence-based practice changes must consider process as well as outcome evaluation. Our staff nurses are conducting monthly process evaluations of compliance with and correctness of Braden Scale scoring, with intent to improve the same and thus, further decrease nosocomial pressure ulcers.
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Sigma Theta Tau International
9 July 2003