Focus on Skin Care Drives Down Hospital-Acquired Pressure Ulcer Rates

Mary Maroney, RN, MSN, FNP-BC (left) and Susan Solmos, RN, MSN, CWCN (right). Prospective skin care team members received the first intensive education session, consisting of 8.5 hours of classroom work and skills validation. This will be followed up with three clinical rotations totaling 12 hours of additional training. Apart from the yearly course, every new hire within the past 14 months has undergone a one-hour skin care training session.

Susan Solmos, RN, MSN, CWCN (left) and Mary Maroney, RN, MSN, FNP-BC (right). Prospective skin care team members received the first intensive education session, consisting of 8.5 hours of classroom work and skills validation. This will be followed up with three clinical rotations totaling 12 hours of additional training. Apart from the yearly course, every new hire within the past 14 months has undergone a one-hour skin care training session.

When Susan Solmos, RN, MSN, CWCN, joined University of Chicago Medicine in April 2013, one of her missions was to figure out why the medical center’s rates of hospital-acquired pressure ulcers (HAPU) where higher than industry benchmarks.

After months of talking with staff, conducting SWOT (strengths, weaknesses opportunities, threats) and other analyses to identify causes for the high rates, she made an important observation.

“Our care was much better than what our rates would lead you to believe,” said Solmos, a clinical nurse educator at the Center for Nursing Professional Practice and Research (CNPPR).

With all the discussions and detective work, Solmos, a certified wound care nurse, noticed a number of gaps in then-current practices, including:

  • a high rate of moisture-associated skin damage (MASD), which can increase a patient’s risk for pressure ulcers, was often incorrectly diagnosed and coded as HAPU
  • a lack of new-hire training on HAPU/MASD prevention
  • challenges in diagnosing MASD versus HAPU
  • lack of individualized prevention plans for patients based on the Braden subscale
  • a lack of patient and family education.

She devised a multidisciplinary approach to education and treatment to channel the good work already being done into lowering these ulcer rates, a closely watched quality metric.

Six months after a HAPU Prevention Bundle of evidence-based practices was fully implemented at the end of last year, HAPU rates were down 70 percent and are now approaching zero.

“It really speaks to the dedication and passion of people who are staff nurses and also have an interest in skin care,” Solmos said.

FY2014 prevalence rates

FY2014 prevalence rates

Over the past several years, the hospital had been able to lower rates for a time, only to see gains level out. Around 2007, for example, the addition of new therapeutic mattresses helped lower pressure ulcers. But then gains stalled.

Solmos was joined in her efforts this past March by Mary Maroney, RN, MSN, FNP-BC, an experienced nurse and wound care APN with the CNPPR. Together they provide wound consultations across the Bernard A. Mitchell Hospital, Comer Children’s Hospital and the Center for Care and Discovery.

They’ve also enhanced the skin care team – staff nurses who serve as experts in their units in identifying HAPUs and MASD, and who offer leadership to ensure best practices are followed.

Solmos and Maroney focus on staff education throughout the three hospitals, relying on a variety of methods, such as computer-based and live in-services training.

A key factor behind the improvements has been the Start Your Engines: Count Down To Zero HAPU!! program.

In May, prospective skin care team members received the first intensive education session, consisting of 8.5 hours of classroom work and skills validation. This will be followed up with three clinical rotations totaling 12 hours of additional training. Apart from the yearly course, every new hire within the past 14 months has undergone a one-hour skin care training session.

HAPU photo

Nine members of the skin care team have been elevated to the senior skin care team, where they also focus on driving organizational change for improvements across the entire institution.

UCM conducts monthly HAPU prevalence surveys in order to stay on top of skin conditions and make mid-course corrections to improve results.

“Monthly is what we as a hospital decided to do to keep an eye on our rates,” said Maroney.

The prevalence surveys assess every patient in every hospital every month. And skin assessments are done at admitting and at the start of every shift.

As part of the broader education mission, the Senior Skin Care team will conduct so-called Pit Stops. These quick-hit training sessions will focus on one particular aspect of skin care, with the goal being to provide valuable training with minimal disruption.

“Wound care has become an area of specialized clinical focus for both physicians and nurses,” said Solmos.

The improvements in individual metrics have been reflected in dramatic gains in national patient quality and safety benchmark scores. In 2011, for example, UCM was ranked 91 out of 120 academic medical centers within the University HealthSystem Consortium (UHC). In 2013, that number rose to 18th , reflecting improvements in not only HAPU but falls with injuries, and  accidental puncture and lacerations.  We are also one only 251 hospitals in the U.S. to have maintained an A grade in safety from the prestigious quality monitoring organization the Leapfrog Survey Group since grading began several years ago.

The improvements in individual metrics have been reflected in dramatic gains in national patient quality and safety benchmark scores. In 2011, for example, UCM was ranked 91 out of 120 academic medical centers within the University HealthSystem Consortium (UHC). In 2013, that number rose to 18th , reflecting improvements in not only HAPU but falls with injuries, and accidental puncture and lacerations. We are also one only 251 hospitals in the U.S. to have maintained an A grade in safety from the prestigious quality monitoring organization the Leapfrog Survey Group since grading began several years ago.

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