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RRP 09-112 – HSR Study

RRP 09-112
Preventing Pressure Ulcers in VA Hospitals
Dan R. Berlowitz, MD MPH
VA Bedford HealthCare System, Bedford, MA
Bedford, MA
Funding Period: October 2009 - September 2011
Preventing pressure ulcers in hospitalized patients remains a national priority. Every year, tens of thousands of patients develop these mostly preventable skin lesions along with the accompanying pain, increased healthcare utilization, and associated risk for serious infections. The knowledge to prevent most pressure ulcers exists and was disseminated in clinical practice guidelines published over 15 years ago. Yet what is unknown is how best to implement these best practices in the standard hospital environment. Increasingly, successful interventions to improve pressure ulcer prevention have relied on toolkits and "bundles" of preventive practices that should be commonly implemented. Recognizing the strength of this evidence, we proposed to build off of an existing AHRQ grant in tailoring a pressure ulcer prevention toolkit for VA hospitals.

Specific objectives included:
1)Provide additional VA-specific input into the development of the pressure ulcer prevention toolkit.
2)Implement a quality improvement project using the pressure ulcer prevention tools in a two VA hospitals.
3)Assess VA-specific lessons learned during the quality improvement project through formative and summative evaluations.

This project built off the AHRQ toolkit grant by adding a second VA site (West Haven VA) to the planned study hospitals that already included VA North Texas, and by planning to conduct a more in-depth evaluation at both VA sites. Toolkit development was to take place through the implementation of multidisciplinary improvement teams at each site that would use the proposed tools in their quality improvement activities. Feedback was then sought on staff ability to use various tools, important challenges and obstacles that occurred during implementation and on the benefits of external facilitation during the implementation process. This feedback was incorporated into a final version of the toolkit. Additionally, pressure ulcer rates were to be tracked at the hospitals.

Experiences with the quality improvement initiative at the two VA sites were very different. VA West Haven, which is the inpatient facility within the 8 campus VA Connecticut Healthcare System, serves veterans in Connecticut and southern New England. The pressure ulcer prevention project at VA West Haven was led by the Wound Care nurse responsible for inpatient services. VA West Haven started its pressure ulcer prevention efforts by creating an implementation committee, including nurses, CNAs, and other relevant groups (e.g. nutrition). With support from the local QI office, the first step of the implementation committee was to do a gap analysis using a modified version of the "Current Process Analysis" tool in the Toolkit. Based on the results of this process mapping, VA West Haven identified different areas for improvement for which individual team members in participating units were responsible. In addition to the process mapping, the project leader at VA West Haven assessed staff attitudes and increased pressure ulcer awareness in the facility through ongoing formal and informal staff education. As part of its pressure ulcer improvement efforts, VA West Haven also adopted new skin care products and support mattresses, created an online skin and wound care competency module and developed a patient education booklet. To track pressure ulcers facility-wide, the WOCN created a wound-tracking sheet which is filled out daily on patients and distributed to a large distribution list comprised of dietitians, nurse managers, and unit supervisors each week. The implementation team is no longer meeting, but many of its members have now joined the facility's skin team, which has rejuvenated the skin team as it takes on-going responsibility for monitoring progress. During the one-year evaluation, quarterly pressure ulcer rates beginning in January 2010 were 2.67%, 2.36%, 1.32% and 2.31%.
VA North Texas is a large, multi-site hospital with its primary campus located in Dallas. Despite strong interest from the medical center director in this initiative, due to frequent changes in key team members complicated by the medical center director's departure, the quality improvement initiative never got underway. The evaluation of the effort was also limited as it required over one year to obtain IRB approval. Two educational sessions were conducted by study team members with the hospital clinical staff which were much appreciated but an active improvement team never formed and pressure ulcer rates were not reported.
Based on feedback obtained during the quality improvement initiative from the participating sites, numerous changes and modifications were made to the toolkit. After further feedback was obtained from the study expert panel, which included VA clinicians recommended by the VA Office of Nursing Service, the completed toolkit was made available on the AHRQ website at

The toolkit is now publically available and AHRQ reports frequent downloads. Rates of pressure ulcers were somewhat reduced at VA West Haven although whether these improvements would be sustained was unclear.

External Links for this Project

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Journal Articles

  1. Niederhauser A, VanDeusen Lukas C, Parker V, Ayello EA, Zulkowski K, Berlowitz D. Comprehensive programs for preventing pressure ulcers: a review of the literature. Advances in Skin and Wound Care. 2012 Apr 1; 25(4):167-88; quiz 189-90. [view]
  2. Suen W, Parker VA, Harney L, Nevin S, Jansen J, Alexander L, Berlowitz D. Internal medicine interns' and residents' pressure ulcer prevention and assessment attitudes and abilities: results of an exploratory study ? Ostomy/wound management. 2012 Apr 1; 58(4):28-35. [view]
Center Products

  1. Berlowitz DR, VanDeusen Lukas C, Parker V, Neiderhauser A, Logan C. Preventing pressure ulcers in hospitals: A tool kit for improving quality of Care. 2011 Apr 1. [view]
VA Cyberseminars

  1. Berlowitz DR. Preventing Pressure Ulcers and Falls in Healthcare Settings: Webinar #6. [Cyberseminar]. 2011 Sep 9. [view]
Conference Presentations

  1. Ayello E, Berlowitz DR. AHRQ Pressure Ulcer Toolkit. Paper presented at: Advances in Skin and Wound Care Clinical Annual Symposium; 2011 Sep 10; Washington, DC. [view]
  2. Berlowitz DR. Improving Pressure Ulcer Care: A research perspective. Paper presented at: Massachusetts Senior Care Association Annual Conference; 2012 Jun 20; Newton Lower Falls, MA. [view]
  3. Berlowitz DR. Putting Together a Pressure Ulcer Prevention Toolkit for AHRQ. Paper presented at: American Geriatrics Society Annual Meeting; 2010 May 12; Washington, DC. [view]

DRA: Aging, Older Veterans' Health and Care
DRE: Prevention, Research Infrastructure
Keywords: Long-term care, Nursing
MeSH Terms: none

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