Reducing the incidence of pressure ulcers in critical care units: a 4-year quality improvement

Quality problem: Critical care patients often have several risk factors for pressure ulceration and implementing prevention interventions have been shown to decrease risk. Initial assessment: We identified a high incidence of pressure ulcers in the four adult critical care units in our organization. Therefore, avoiding pressure ulceration was an important quality priority. Choice of solution: We undertook a quality improvement programme aimed at reducing the incidence of pressure ulceration using an evidence-based bundle approach. Implementation: A bundle of technical and non-technical interventions were implemented supported by clinical leadership on each unit. Important components were evidence appraisals; changes to mattresses; focussed risk assessment alongside mandating patients at very high risk to be repositioned two hourly; and staff training to increase awareness of how to prevent pressure ulcers. Evaluation: Pressure ulcer numbers, incidence and categories were collected continuously and monitored monthly by unit staff. Pressure ulcer rates reduced significantly from 8.08/100 patient admissions to 2.97/100 patient admissions, an overall relative rate reduction of 63% over 4 years. The greatest reduction was seen in the most severe category of pressure ulceration. The average estimated cost saving was 2.6 pound million (range 2.1- pound 3.1) pound. Lessons learned: A quality improvement programme including technical and non-technical interventions, data feedback to staff and clinical leadership was associated with a sustained reduction in the incidence of pressure ulceration in the critically ill. Strategies used in this programme may be transferable to other critical care units to bring more widespread patient benefit.