Patients in the critical care setting are generally at high risk for developing pressure ulcers. Immobility, reduced nutritional intake, and poor tissue perfusion are aspects of the ICU experience that contribute to the potential for skin breakdown. St. John Medical Center (Figure 1) reports the prevalence of hospital-acquired pressure ulcers (HAPUs) to the National Database of Nursing Quality Indicators® (NDNQI®). In 4Q07, HAPU prevalence in the Adult Intensive Care Unit (AICU) was 25%; in the Surgical Intensive Care Unit (SICU) it was over 28%. The Neuro/Trauma Surgical Intensive Care Unit (NTSICU) opened in January 2008 with a limited number of beds. When the unit was fully open in 3Q08, HAPU prevalence on this unit reached 30%. Figure 2 profiles these three units.

Witnessing the upward trend in HAPU, the AICU focused on pressure ulcer prevention, with other units following their lead. Interventions in three primary areas led to rapid and sustained decreases in the incidence of HAPU: introduction to the philosophy and role of the Wound Care Team; changes in skin care practices; and point-of-care education for critical care nurses.

In late 2006, a newly hired nursing director was given oversight of the Wound Care Team (WCT). Assessing the activities of this team, she discovered that the focus was on treatment of existing wounds with no attention given to prevention. Networking within the nursing academic community, she recruited a certified wound, ostomy, and continence nurse who was

ready to facilitate a shift in paradigm from treatment to prevention.

The CWOCN was hired in August 2007 and became the Team Leader of the WCT. She began evaluating practice and establishing credibility among her peers by becoming a frequent, friendly, and helpful visitor at the bedside. She identified inconsistencies in the methods used to conduct quarterly HAPU prevalence surveys. She also assessed the need to make prevention of pressure ulcers more of a priority in the ICU setting. She began publishing monthly reports that compared the number of pressure ulcers in the AICU against house-wide occurrence based on variance reports generated by the WCT. (Members of the WCT are alerted whenever a patient has a Braden score of less than 14. If a pressure ulcer is discovered in the WCT assessment that follows, a variance report is completed.)

The major impetus for change came in July 2008 when the monthly reports published by the CWOCN revealed that 50% of pressure ulcers acquired at the hospital occurred in the AICU (Figure 3). At this time, the clinical educator for the AICU was looking for an outcomes project to meet academic requirements. The climate was ripe for change; the AICU’s War on Wounds began with the CWOCN and the clinical educator leading the ranks.

The CWOCN and clinical educator observed several factors likely to have a causal relationship with the high rate of pressure ulcers in AICU: