By Cindy Barefield, BSN, RN-BC, CWOCN
Like many hospitals, Houston Methodist San Jacinto Hospital uses national benchmarks such as the National Database of Nursing Quality Indicators (NDNQI®) to measure quality outcomes. Based on benchmark reports that showed an increased trend of pressure ulcers in critically ill patients in our hospital, the clinical nurses in our Critical Care Shared Governance Unit-Based Council (CCSGUBC) identified an improvement opportunity.
As a certified wound, ostomy, and continence nurse (CWOCN), I serve as a resource for the critical care units, so I worked with the council on the initiative. We used the Prosci ADKAR® change model to guide the project. This model incorporates five steps to ensure a smooth change process: Awareness, Desire, Knowledge, Ability, and Reinforcement.
Step 1: Awareness
The first step for the CCSGUBC was to raise awareness of the need for change. During a meeting, we reviewed occurrences of hospital-acquired pressure ulcers so members would know the problem.
Step 2: Desire
Awareness prompted council members to embrace the need for change to improve patient outcomes. Their desire for change fueled a discussion of opportunities for improvement.
Step 3: Knowledge
Knowledge was the next step in the change process. Clinical nurses identified the need for additional resource nurses for each shift to help with pressure ulcer staging and skin care. This led to the development of “skin care champions,” who act as resource nurses for the clinical area. Clinical nurses interested in the project volunteered for the new role. Currently, there are seven skin care champions.
The skin care champions participated in an interprofessional education program led by the CWOCN, a physical therapy/
clinical wound specialist, and a clinical dietitian. Topics included wounds, pressure ulcers, nutrition and wound healing, incontinence-associated dermatitis, and an overview on documentation of pressure ulcers. A review of current literature on best practices with skin care bundles also was included.
To provide additional educational support, all critical care nurses were given access to free NDNQI Pressure Ulcer Training modules via the hospital intranet.
The skin care champions embraced the challenge of creating a skin care bundle. As nurses with critical care experience, they were familiar with bundles for catheter-associated urinary tract infection and ventilator-associated pneumonia. They had implemented these best practices to improve patient outcomes and were eager to do the same for pressure ulcer prevention. They were confident that the success of the skin care bundle depended on synergy of all components as a whole rather than on a single component.
During an interactive session, the skin care champions developed the components of the skin care bundle based on a literature review for topics of importance to their patient population. They chose the following topics: Support surface, Keep repositioning, Incontinence management, Needs/risks, and Improve documentation, which form the acronym SKINNI. “What’s the SKINNI?” has become a common question at our organization. The energy and enthusiasm for this nurse-led initiative have been widespread.
One challenge the skin care champions faced was adding documentation for the new skin care bundle to the electronic medical record (EMR). The clinical dietitian on the project team and a technologically savvy skin care champion collaborated to create a process that clinical nurses could use when documenting.
Step 4: Ability
Ability was the next step in the change process. At this stage, the skin care bundle was integrated into nursing practice. The team has developed many innovative ways to keep the focus on the new process:
- The skin care champions and the nurse leader of the project wear a large button that reads “What’s the SKINNI?” to raise awareness about the skin care bundle throughout the organization. The stick figure used with the message has become a symbol for the project.
- Small cardboard signs taped at each computer have the same “What’s the SKINNI?” message to remind nurses to document the skin care bundle.
- The leader of the CCSGUBC and I send frequent e-mails with reminders and reinforcement messages.
Step 5: Reinforcement
As with any change, reinforcement and sustainability of this new practice are necessary to achieve quality outcomes. We’re using several reinforcement strategies, including:
- The skin care champions and I provide peer-to-peer feedback informally and face-to-face using criteria specific to the skin care bundle.
- A Life Saver® candy with a card that says “You are a Life Saver® for your patient today” is given to clinical nurses who correctly document the skin care bundle in the EMR. This provides reinforcement for the change in practice. Life Saver® cards are distributed as needed at the discretion of the skin care champions.
- The skin care champions conduct monthly pressure ulcer surveys to evaluate outcomes and share the results with the nursing team.
Skin care champions and members of the CCSGUBC presented the project for the hospital-system Shared Governance Conference. It was a great opportunity to share best practices with nurse colleagues. Over the past year, we have also been pleased to validate a significant decrease in the rate of pressure ulcers in critically ill patients.
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Gray-Siracusa K, Schrier L. Use of an intervention bundle to eliminate pressure ulcers in critical care.
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Hiatt, Jeffrey. ADKAR®:A model for change in business, government and our community. Loveland, Col.: Prosci Learning Center Publications; 2006.
Institute for Healthcare Improvement. How to guide: Prevent pressure ulcers. Cambridge, MA: Institute for Healthcare Improvement; 2011. www.ihi.org/resources/Pages/Tools/HowtoGuidePreventPressureUlcers.aspx
Cindy Barefield, RN is a certified wound, ostomy, and continence nurse at Houston Methodist San Jacinto Hospital in Texas.
DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.