On one medical-surgical unit, we noticed an increase in pressure injuries, especially deep tissue injuries (DTI). This made the unit council look at current organizational practices for pressure injury prevention to see where we could change or improve on those practices to help our unit.
After performing a literature search on the best practices for pressure injury prevention, we determined an evidence-based intervention to add to our skin care regimen in hopes of decreasing our DTI rates to zero. When our unit researched pressure injury prevention, it became clear that we were already on target with the interventions we were using as an organization. Our unit council asked “what could we do on our unit specifically to improve our patient outcomes?” A common theme that came up was the inability of staff to know who had skin issues that would require help from other staff.
Design: The first intervention implemented was the development and use of a patient-focused education pamphlet on skin care and prevention practices. The unit council developed the script and design for the patient focused pamphlet. The entire staff was then educated with the pamphlet, the reason for use, and the importance of educating patients on the skin care practices in the pamphlet.
Then one of our staff came up with another great idea to help improve all staff recognition and awareness of patients with skin issues or poor skin integrity. The idea was to create a “PUP” magnet to go on the doorframes of the patient rooms. Staff though this would be an easy way to alert all staff that the patient required frequent turning and repositioning. “PUP” standing for pressure ulcer prevention, was borrowed from the old terminology. Staff felt that our organization had achieved wonderful results with using other types of magnets, so why not try these “PUP” magnets to help improve our floors outcomes? The CNS then educated staff one-on-one and via electronic education in newsletters/emails on what the magnets meant and how to use them to delineate those patients requiring Q2 hour or greater frequency turns/repositioning and/or those patients with increased or greatest risk for skin breakdown.
Evaluation/outcomes: Our unit has not had any pressure injuries for 18 months. Our rate has been zero for HAPI and UAPI. We have been able to sustain this project and practice change for our goal length of time and beyond. The magnets have raised staff awareness of patients that require extra attention and interventions to protect their skin. The unit has been able to maintain the 0% rate for both UAPI and HAPI for 18 months straight! This has been the best outcome we have seen for any intervention that we have tried on our unit. The staff are proud of this accomplishment, and this helps to keep everyone engaged in this practice change.