RESUMEN
BACKGROUND & PROBLEMS: Our unit recorded 21 cases of pressure sores from January 2011 to June 2011. The resulting pressure-sore incidence density of 0.74% exceeded the Taiwan Clinical Performance Indicator (TCPI) for medical centers (0.62%) as well as the mean incidence density for our unit (0.55%) during the same period in 2010. PURPOSE: We developed this project to decrease the incidence density of pressure sores at our pediatric-surgical-intensive-care unit from 0.74% to 0.31%. RESOLUTIONS: Strategies implemented included: 1. providing on-the-job education; 2. providing bedside teaching; 3. developing a series of pictures to illustrate proper sitting, lying, and changing positions and the proper fixation of catheters; 4. implementing a reminder mechanism; 5. introducing pressure-preventing devices; 6. and establishing an audit team. RESULTS: Incidence density decreased from 0.74% (Jan. to Jun. 2011) to 0.18% (Mar. to Jul. 2012). CONCLUSIONS: We demonstrated that the developed improvement program effectively reduced the incidence density of pressure sores and increased the quality of nursing care.