The VCU Pressure Ulcer Summit-Developing Centers of Pressure Ulcer Prevention Excellence: A Framework for Sustainability.

Hospital-acquired pressure ulcer occurrences have declined over the past decade as reimbursement policies have changed, evidence-based practice guidelines have been implemented, and quality improvement initiatives have been launched. However, the 2006-2008 Institute for Healthcare Improvement goal of zero pressure ulcers remains difficult to achieve and even more challenging to sustain. Magnet hospitals tend to have lower hospital-acquired pressure ulcer rates than non-Magnet hospitals, yet many non-Magnet hospitals also have robust pressure ulcer prevention programs. Successful programs share commonalities in structure, processes, and outcomes. A national summit of 55 pressure ulcer experts was convened at the Virginia Commonwealth University Medical Center in March 2014. The group was divided into 3 focus groups; each was assigned a task to develop a framework describing components of a proposed Magnet-designated Center of Pressure Ulcer Prevention Excellence. Systematic literature reviews, analysis of exemplars, and nominal group process techniques were used to create the framework. This article presents a framework describing the proposed Magnet-designated Centers of Pressure Ulcer Prevention Excellence. Critical attributes of Centers of Excellence are identified and organized according to the 4 domains of the ANCC model for the Magnet Recognition Program: transformational leadership; structural empowerment; exemplary professional practice; and new knowledge innovation and improvements. The structures, processes, and outcome measures necessary to become a proposed Center of Pressure Ulcer Prevention Excellence are discussed.

Prevention and management of incontinence-associated dermatitis.

Perineal dermatitis, recently relabelled 'incontinence-associated dermatitis' (IAD), is an inflammation of the skin that occurs when urine and/or stool comes into contact with the skin. It can range in severity from erythema with or without loss of skin integrity to infection. IAD affects as many as 41% of adults in long-term care; it is costly, painful and, for the most part, preventable. An effective plan of care for individuals with IAD must include assessment and management of incontinence aetiology, perineal skin and risk assessment, gentle cleansing and moisturization, application of skin barriers and treatment of secondary infection, and the use of containment devices if indicated.

Preventing skin tears in a nursing and rehabilitation center: an interdisciplinary effort.

Skin tears are painful, traumatic wounds that result from the separation of the epidermis from the dermis. To assess the clinical effectiveness of a preventive skin care protocol, 13-month retrospective pre-intervention data collection followed by 15-month post-intervention skin tear incidence data collection was conducted among all patients in a 209-bed urban nursing and rehabilitation center. The preventive skin care strategies implemented - staff education, skin sleeves and padded side rails for high-risk patients, gentle skin cleansers, and lotion - were selected by facility staff members and the multidisciplinary skin team. Nosocomial skin tear data were obtained by reviewing incident reports. Following implementation of the prevention protocols, the number of skin tears changed from a mean of 18.7 to a mean of 8.73 per month (P <0.001). The average monthly reduction in nosocomial skin tears was projected to reduce the dressing and labor costs of managing these wounds an average of 1,698 dollars per month (18,168.60 dollars annually). The results of this study confirm previously reported research suggesting that the effects of implementing a comprehensive skin care protocol can persist, reducing the incidence of nosocomial skin tears and their associated risks and costs. Prospective cost-effectiveness studies to confirm these findings are needed.

Evaluation of a once-daily moisturizer used to treat xerosis in long-term care patients.

The pruritic, erythemic, dry, scaly, cracked, or fissured skin characteristic of xerosis is a result of the loss of natural moisturization factors and barrier abilities, as well as epidermal water loss. To determine if a new 24-hour moisturizer provides clinical benefit by reducing dry skin, scratching, and erythema, a 5-day prospective study was conducted that involved 16 residents (6 men, 10 women) with end-stage renal disease (average age 76 years) in a long-term care facility unit with an 18% prevalence of xerosis. Extent of xerosis was measured by evaluating each of the symptoms (dry scaly skin, erythema, and pruritus) using a four-point ordinal scale where 0 = absence of symptom and 3 = severe symptom. Photographs and patient comments were obtained at the time of the assessments on Day 1 (before the first product application) and on Day 5 (after four once-daily applications). One resident was discharged before the day 5 evaluation. Resulting data from the 15 patients completing the study were analyzed using a paired-sign test. Reduction in dry, scaly skin, erythema, and pruritus were statistically significant (P < 0.001, P < 0.001, and P = 0.016, respectively). Implementing a 24-hour moisturizer was found to significantly decrease symptoms of xerosis. Additional study to further validate use of the product in this and other settings where patients experience dry, red, itchy skin is warranted.

A review of perineal skin care protocols and skin barrier product use.

Perineal skin damage secondary to incontinence is painful, prevalent, and preventable. Skin care professionals consider regular application of skin protectants for patients with incontinence the standard of care for preventing perineal skin injury secondary to incontinence. Although protocols to improve care exist, the extent to which they are implemented and followed has not been documented. A study was conducted to ascertain the extent to which perineal skin care protocols are consistent with Wound, Ostomy and Continence Nurses Society Clinical Practice Guidelines and to estimate the level of compliance related to the use of protective perineal skin barriers. A convenience sample of 76 perineal skin care protocols was obtained from acute care (n = 55), long-term care (n = 9), and nondisclosed types of extended care facilities (n = 12). All protocol interventions were compared to the Wound, Ostomy and Continence Nurses guidelines. Healthcare Products Information Services data were used to obtain the total amount of skin protectants sold to US healthcare facilities in 2002. Skin protectant use was compared to previously published urinary and fecal (urofecal) incontinence prevalence data. All 76 protocols lacked one or more of the interventions considered important in perineal skin care. Although 75% of the protocols included the use of skin protectants, Healthcare Products Information Services data and urofecal prevalence data suggest underutilization of skin protectants; an estimated 10 cents per day versus an anticipated average cost of 23.5 cents per application is being spent. Further study is warranted and necessary to ensure the application of evidence-based protocols of care in practice.

Clinical and cost effectiveness of a cleanser protectant lotion for treatment of perineal skin breakdown in low-risk patients with incontinence.

Perineal dermatitis due to urinary and/or fecal incontinence is a common problem. A multicenter, open label, phase II product evaluation was conducted to determine the effectiveness of a new cleanser protectant lotion in reducing perineal erythema and pain in patients at low-risk for perineal dermatitis and to compare the cost of this product to standard protocols of care. Nineteen elderly patients (14 male, 5 female, mean age 73.1 years) participated in the study. Average baseline scores for erythema and pain were 2.3 (+/- 0.5) and 1.5 (+/- 1.0), respectively (scale 0 to 4). After 7 days, both scores were significantly lower (mean scores 0.6 +/- 0.8 and 0.3 +/- 0.8, respectively; P < 0.01). Based on an average of 2.6 perineal episodes per day, the one-step product evaluated would cost $136 per patient/year less than standard protocols of care while reducing caregiver time (average 23 seconds per episode of care). Optimal perineal care may reduce the incidence of complications; studies to ascertain the safety and effectiveness of commonly used products and procedures are needed.

Validity and reliability of the Perineal Assessment Tool.

This study was conducted to evaluate the validity and reliability of an instrument designed to measure risk of perineal skin injury in hospitalized individuals. Interrater reliability of the Perineal Assessment Tool was examined by correlating the scores calculated by a wound, ostomy and continence nurse compared to those calculated by staff RNs and LPNs using the same tool with the same patient. Content validity was assessed by obtaining level of agreement ratings from 102 wound, ostomy, and continence nurses. Good correlation between the expert and staff nurse scores was found (r = .970, confidence intervals = 95%, P = .923 to .988 or P < .0001). Average perineal assessment tool subscale level of agreement scores ranged from 7.66 to 8.4 (range 1 = strongly disagree to 10 = strongly agree) and the median score for all subscales was 9. The results obtained are encouraging and justify additional reliability and validity studies.