RESUMO
BACKGROUND: In 2004, as part of Ascension Health's "Healthcare That Is Safe" initiative, St. Vincent's Medical Center, as an alpha site, was charged with defining best practices to eliminate facility-acquired pressure ulcers. A comprehensive plan, including the "SKIN" (Surfaces, Keep the patients turning, Incontinence management, Nutrition) bundle, was developed. RESULTS: The incidence of pressure ulcers decreased from > 2% to < 1% from December 2004 through February 2006. No new Stage III or IV facility-acquired pressure ulcers occurred between August 2004 and February 2006. Weekly SKIN operations meetings and use of the SKIN process tool ensured that all at-risk patients were receiving appropriate interventions. REPORTING AND SPREAD: The alpha site work and SKIN bundle were presented to all 67 Ascension Health acute care facilities at a rapid-design-format Pressure Ulcer Summit in mid 2005. All acute care facilities agreed to a single model of care using the SKIN bundle and common measures of quality and performance. DISCUSSION: The St. Vincent's alpha site initiative in pressure ulcer prevention, enabled it to identify at-risk populations, implement appropriate actions, and achieve positive, measurable, meaningful results. CONCLUSION: The SKIN program was adopted and is being implemented throughout Ascension Health.
