REDUCING HOSPITAL-ACQUIRED PRESSURE ULCERS BY 40%: INTRODUCING A SKIN BUNDLE PROJECT

Hospital-acquired pressure ulcers (HAPUs) are a major healthcare issue that lead to significant patient suffering as well as exorbitant health care expense. The Centers for Medicare and Medicaid Services (CMS) identify HAPUs as Never Events, or events that should not occur while in the hospital, and as such, no longer provide reimbursement for care related to HAPUs. In 2013, there were 26 HAPUs on the spinal cord injury (SCI) unit at a 219-bed urban hospital. The goal of this Doctor of Nursing Practice project was to decrease HAPUs by 40% over 12 months on the SCI unit through the introduction of a skin bundle. The quality improvement (QI) skin bundle involved providing nursing education, new skin care products, a revised Braden Risk Assessment Scale, and a root cause analysis HAPU tool. HAPU data was abstracted from the electronic health record and verified by the wound nurse. Appropriate measures of central tendency were calculated to describe the sample and report the results. The results showed that HAPUs decreased by 65.4% over the 12 month period of the project. By using a multimodal approach (a skin care bundle), nurses have the opportunity to mitigate the occurrence of this Never Event. Strategies to sustain the gains achieved include continued monitoring by staff, feedback from the administration, and peer review to ensure accurate documentation.