How a Busy Hospital Reduced Its Rate of Hospital-Acquired Pressure Ulcers to Zero

By Sylvia Foley, AJN senior editor

A skin lesion monitoring form accompanies a patient. Photo courtesy of NHCH.

A skin lesion monitoring form accompanies a patient. Photo courtesy of NHCH.

In 2009, when one of the world’s largest cardiac care hospitals experienced a spike in the number of surgeries performed and a corresponding rise in hospital-acquired pressure ulcers, many people were concerned. The hospital—Narayana Hrudayalaya Cardiac Hospital (NHCH) in Bangalore, India—soon initiated a program to address the problem, and nursing superintendent Rohini Paul was tasked with designing and implementing effective preventive strategies. In this month’s CE feature, “Sustaining Pressure Ulcer Best Practices in a High-Volume Cardiac Care Environment,” Paul and colleagues describe what happened next. Here’s a brief overview.

Baseline data showed that, over the five-month observation period, an average of 6% of all adult and pediatric surgical patients experienced a pressure ulcer while recovering in the NHCH intensive therapy unit (ITU). Phase 1 implementation efforts, which began in January 2010, focused on four areas: raising awareness, increasing education, improving documentation and communication, and implementing various preventive practices. Phase 2 implementation efforts, which began the following month, focused on changing operating room practices. The primary outcome measure was the weekly percentage of ITU patients with pressure ulcers.
By July 2010, that percentage was reduced to zero; as of April 1, 2014, the hospital has maintained this result. Elements that contributed significantly to the program’s success and sustainability include strong leadership, nurse and physician involvement, an emphasis on personal responsibility, improved documentation and communication, ongoing training and support, and a portfolio of low-tech changes to core workflows and behaviors. Many of these elements are applicable to U.S. acute care environments.

The authors emphasize the importance of “absolute transparency and personal accountability” in ensuring the program’s sustained success. As one senior nurse said, “It was the personal responsibility that started making a difference. Now everybody’s aware, everybody’s cooperative and on their toes, and we have no skin ulcers.”

For more details, read the article, which is free online. And please share your experiences and insights with us below.

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2016-11-21T13:04:10+00:00 August 8th, 2014|nursing perspective|7 Comments

About the Author:

Former senior editor at AJN.

7 Comments

  1. nicole jensen April 18, 2016 at 11:31 am

    Decubitus ulcers have been a life threatening condition that causes pain and skin degradation among patients universally. In the ICU, maintaining skin integrity among malnourished, non-mobile, dehydrated, and obese patients is a challenge that I am are presented with throughout my shift. Due to the failure to prevent these ulcers, increases in hospital costs and prolonged hospital stays are complications that result from these debilitating wounds. It is appreciated that nurses live in the solution and follow measures that prevent patients to acquire pressure ulcers. Due to the increase in decubitus ulcers in Bangalore, India at the Narayana Hrudayalaya Cardiac Hospital (NHCH), you were able to take better precautions in reducing the increase in pressure ulcers. By taking action in developing awareness, providing education, advancing documentation and communication, implementing various preventive practices, and changing operating room practices you were able to reduce your percentage to zero. I admire the effort and motivation that allowed you reduce pressure ulcers in your hospital.

  2. Stephanie Martin July 20, 2015 at 10:18 am

    Pressure ulcers have always been a major ordeal for hospitals and health care facilities. This article points out how important it is in working on how to prevent hospital-aquired pressure ulcers. These incidents not only affect the patient, but the hospital also suffers financially. The Narayana Hrudayalaya Cardiac Hospital (NHCH) in India recognized the importance of this issue and established programs/protocols to ensure 0% occurrences of skin ulcers. The system of pressure ulcer prevention is started upon admission, and carried out until discharge. Keeping the staff educated, and informed of policies and procedures is extremely important to keep everyone on the same page. The dedication provided by the nursing staff is truly admirable.

  3. Kristen G. April 20, 2015 at 10:01 am

    From this article I understand that implementing an evidence-based pressure ulcer prevention program dramatically reduces the occurrence of hospital-acquired pressure ulcers. In the U.S., hospitals have decent ulcer prevention programs and very low incidences of pressure ulcer cases, however, I have never heard of absolutely zero cases. That is marvelous! This tells us that it is entirely possible to prevent patients from ever getting pressure ulcers during their stay in any hospital worldwide. Completely eliminating the cases of hospital-acquired pressure ulcers is a notion we must instill in our healthcare teams to be motivated and proactive about ulcer prevention. Consistently aggressive programs are sure to eliminate cases altogether, improving the hospital experience of the patient as well as reducing treatment costs.

  4. Melissa S April 16, 2015 at 11:52 am

    On the cardiac floor that I work on in Florida we often receive patients with pressure ulcers but very seldom do we have patients acquire ulcers while under our care. Reason being we have a protocol for patients with a braden scale less than 18. They are provided with an “air” mattress, special skin care items and other devices to elevate heels and protect pressure points. It is the responsibility of not only nurses but CNAs to assess patients skin especially bony prominences every shift. The floor has a very low pressure ulcer incidence but no pressure ulcers would be better. This article gives very useful feedback on what NHCH has done to prevent ulcers and I will be sharing it with my staff at our text meeting.

  5. Amarily Barahona April 11, 2015 at 9:19 am

    Pressure ulcers have become a major ordeal in hospitals and health care facilities throughout the United States. Staff awareness and continuing education on this issue is a fantastic way to get everyone involved in patient care. It is great how NHCH was able to work together and decrease the risk of pressure ulcers in the hospital. All health facilities should incorporate similar methods in order to achieve the best patient care results throughout the entire spectrum. I enjoyed this article very much and am amazed on the results!

  6. Elvira Hernandez November 24, 2014 at 9:10 pm

    Following up on patients is equally important as facilitating initial care. This pertains to anything from post-admin of medication to periodical vital signs. This article on preventing pressure ulcers in Bangalore, India is important because pressure ulcers are a reoccurring trend in nursing homes and ICU.The Narayana Hrudayalaya Cardiac Hospital (NHCH) in India recognized the issue that their patients were suffering from pressure ulcers and established programs/protocols to ensure 0% occurrences of skin ulcers. I especially like that this hospital has kept their 0% occurrence record going throughout the following years. I admire the staffs dedication to their patients and resiliency in the matter.

  7. Amelia M. Cabral August 8, 2014 at 6:45 pm

    Preventing pressure ulcers has always been a goal of nurses. “Back in the day” we posted turning charts over the patients beds and all pressure ulcers were followed by the Infection Control Nurse. We also documented any patients arriving with an ulcer, heel, buttocks etc. The sores were all measured and documented on the record. Everyone was aware!

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