MICU "Under Pressure" Team Seeks to Decrease Pressure Ulcer Prevalence

Meg Nemitz, Beth Melanson, Kim Pritchard and Katie O'Connell are leading the MICU's efforts to reduce pressure ulcer prevalence.

What began as four nurses in the MICU serving as unit-based skin champions has transformed into a multi-faceted quality improvement project to reduce pressure ulcer prevalence. 

The MICU, which cares for some of the hospital's most critical patients, was experiencing higher rates of pressure ulcers than other ICUs in surrounding hospitals. A group of nurses formed to determine what was causing this and ultimately reduce the rates. After their initial successes, Associate Chief Nurse of Quality and the Center for Nursing Excellence Deborah Mulloy, PhD, RN, CNOR, applied for a "Clinical Scene Investigators" (CSI) grant from the American Association of Critical Care Nurses, to help gain resources and funding for the project.

"Pressure ulcers and their associated complications are well-documented contributors to increased length of stay and increased health care costs," said Mulloy. "Pressure ulcers in critical care patients are a significant problem, with published rates estimated as high as 40 percent."

Once the project received the grant, Katie O'Connell, BSN, RN, Beth Melanson, MS, RN, ACNS-BC, CWCN, CCRN, Meg Nemitz, BSN, RN, CCRN, and Kim Pritchard, RN, CCRN, began collecting baseline data on pressure ulcers in June. They also started to plan for clinical interventions to reduce prevalence, which would begin in October.  The interventions included education, practice changes and product trials. 

Education

The team came up with a unique way to ensure that all nurses would be able to attend a 30-minute educational session on preventing and identifying pressure ulcers. "One of the four of us leads the session, and the other three go out to the floor and cover for three nurses so they can attend," said Melanson. "They know us and trust us to take care of their patients."

In addition, funds from the grant were used to offer meals during each educational session. Once nurses completed the session, they received a fleece BWH vest with the project name "Under Pressure" embroidered on the front. The sessions were also open to patient care assistants and Float Pool nurses. 

The team also implemented weekly multi-disciplinary skin rounds, which includes checking each patient from head to toe for a mini pressure ulcer prevalence survey. Feedback on the rounds has been positive. 

"The housestaff have been very receptive and appreciate the education on assessment, staging and treatment of pressure ulcers," Melanson said.

Practice Changes

To immediately identify pressure ulcers upon admission, the team put into place "four eyes on admission." This requires two nurses, or a nurse and a physician, to assess a new patient for pressure ulcers and sign off on an assessment.

In addition, the educational sessions emphasized that patients should be turned, or have their weight shifted, every two hours to prevent pressure ulcers from occurring. 

Review of Support Surfaces and New Products

The MICU has Stryker® mattresses, which offer pressure redistribution, but the nurses learned they weren't using the beds to their full potential. 

"We were using too much linen on the bed - each layer under the patient adds pressure and can cause skin to break down," said Nemitz. "Less is best."

The initial data the team collected also helped them realize that many pressure ulcers are caused by equipment, not just surfaces, like beds. Foley catheters, pulse oximeters on patients' fingers, ear probes and other equipment actually cause skin to break down, said Melanson.

The team is also beginning trials of new products that could assist with this issue, including an endotracheal tube holder that helps reduce breakdown around the mouth by supporting the tube and keeping it from moving, and protecting the skin around the endotracheal tube with a pad. 

The team also is trialing a border sacrum foam dressing that helps prevent development of pressure ulcers at the sacrum.

Staff Engagement

Although post-intervention data has yet to be collected, the project has already had a positive effect on the unit. 

"Buy-in has been incredible," said Nemitz. "People appreciate our efforts, and they know we are credible because we work side-by-side with them as staff nurses every day. I think there is something to be said for the peer-to-peer element."

Melanson added, "The heightened awareness among staff is significant. People are talking with each other more about skin care and pressure ulcers."

MICU Nursing Director Kathleen Leone, MBA, BSN, RN, said the team's energy and enthusiasm have quickly spread through the unit.  "Staff have responded so well to the coaching and instruction of their peers, and appreciate their knowledge and experience," she said. "The fact that they are so accessible to their colleagues as issues come up in the course of care helps us quickly move the new information into practice. It's a powerful message to the nurses that they have the ability to identify and intervene on issues and demonstrate improved outcomes from those interventions."

The team is grateful for the support from their colleagues in the MICU, who have embraced the project and made it a success to date.

Ongoing Support

Through the CSI grant, the team attends monthly conferences for 18 months at MGH, BIDMC, NWH, SSH, Bay State Medical and Tufts. "There are teams of four nurses from each hospital, and we talk about our projects and receive great feedback from other critical care nurses," said Melanson.

Leone points out that while the grant provided extra support, nurses can take on these types of projects without outside funding. "It is within their scope, skill set and power to do this work in their own unit, seeking answers to problems that impact their clinical areas," she said. 

The team hopes to present their findings at an upcoming Nursing Grand Rounds to share what they have learned with their BWH colleagues, and also is considering presenting at the National Teaching Institute conference in 2015. 

"These four MICU nurses have put a tremendous amount of work into developing a program in Pressure Ulcer Prevention, and their accomplishments to date are unmatched," said Mulloy.