Skin Care Vigilance in the ICU

Talk with any WOCN nurse and you’ll learn prevention is infinitely better than treatment. Nowhere is this more apparent – and important – than in critical care.

Skin integrity in the ICU has become a hot topic as admission acuities become higher and reimbursements for never events and hospital-acquired pressure ulcers (HAPUs) are cut off.

For ICU nurses – and their skin care teams – prevention is worth far more than a pound of cure.

Staff Empowerment

When the number of HAPUs in critical care at the University of Chicago Medical Center (UCMC) kept rising and chart audits focused on wound documentation, risk assessment and pressure-ulcer intervention showed inconsistent and incomplete information, Christine Baker, MSN, APN, CWOCN, skin care clinical nurse specialist at UCMC, knew ICU staff nurses were where the rubber met the road.


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Along with a team of ICU staff nurses and skin care team members, Baker developed a pilot program to prevent HAPUs in the ICU.

Eight skin care team nurses completed extensive training, then served as expert role models and leaders for the other nurses in the ICU. They participated in joint patient rounding, provided evidence-based education on skin and wound assessment, documentation, pressure-ulcer risk and interventions and performed chart audits to evaluate progress.

The goal, Baker noted, was to give nurses the tools they need to prevent HAPUs and empower them to use them.

“Nurses can feel hamstrung because they don’t always know what to do, and they feel they can’t take a leading role or to be watchful or that HAPUs are unpreventable,” she said. “It starts at the bedside.”

Working Together

Baker piloted the program across all six UCMC critical care unit with eight ICU skin care team members. Each worked as a staff nurse most shifts, but put in two shifts per month as a skin care nurse on their unit. On those days, they rounded with the nurses, bed to bed.

“They did an evaluation with the staff nurse, and were able to impart a lot of education without instruction, but through discussion of what both the skin care nurse and the staff nurse saw,” Baker said. “The information passes between each through conversation, peer to peer.”


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After observing the entire unit, the skin care nurse does a mini-chart audit to ensure what she observed was what had been documented, using the Braden Scale to make sure appropriate interventions were implemented and documented. Unit education also was provided through a series of 18 learning modules, to be used by staff nurses room-side.

The units offered a different focus every week, highlighting skin assessment, wound identification, pressure ulcer staging, would differentiation, wound care and pressure ulcer interventions – all the things that would full circle give the nurse the tools to provide appropriate care. The modules go hand-in-hand with a skin and wound page on the hospital’s intranet, filled with photos, definitions, clinical practice guidelines, a list of all the products available for use, as well as support services available.

Still, the best resource for staff nurses continued to be the skin care team member on the unit.

“In reality, most staff nurses don’t have time to browse online, so the skin care team member brings the information to the unit in a way staff nurses can easily access it, peer to peer,” Baker said. “A big part is to make sure the staff is aware of what’s available for preventive measures. When you hear from your peer, it reinforces what the options are, so they’re more readily integrated into everyday care.”


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Nurses in Action

At Huntington Memorial Hospital in Pasadena, CA, Heather A. Raygoza, BSN, RN, WOCN, and the skin and wound resource team were faced with an increase of HAPUs on the 30-bed critical care unit.

Even though some contributing factors were out of the nurses’ control (including hemodynamic instability, poor perfusion, impaired sensitivity and nutrition and increased issues related to moisture), the team was determined to implement changes that were within the control of CCU staff nurses.

A three-pronged CCU action plan was developed resulting in a decrease in HAPUs on the unit by more than 50 percent.

“First the team implemented a new turning protocol incorporating a visual inspection of the patient’s skin, as well as a review of their specific needs based on the Braden Scale during hand-off report,” Raygoza said.
“Then, team members worked one-on-one with bedside nurses on how and when to assess and document pressure ulcers. Lastly, team members rounded weekly on both day and night shift, educating bedside nurses and working with them to assess the patient for pressure ulcer prevention and treatment.”


The new protocol requires bedside nurses to work together to turn their patients at change of shift and at transfer. This provided nurses with assistance for their first turn of the shift and gave them additional time to complete their assessment and documentation before the next turn was due 2 hours later.

“Creating a team approach really improved communication between day and night shifts,” Raygoza said. “The nurses use Braden Scale categories to determine the plan of care for their patients for the shift, which directs them to other aspects of the care plan, such as sedation and checking meds. Reviewing the care plan at the bedside contributes to a thorough review of the patient and allows updating of the plan as identified.”


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Zero Tolerance

Calling skin a “barometer for other body systems,” Raygoza noted the skin experiences duress in a critically ill patient, which may result in impaired skin integrity. The skin care team works to educate bedside nurses to assess skin integrity based on Braden Scale categories.

“We wanted nurses to view the overall picture of the patient,” she said. “We use the Braden Scale as guide to identify patients at risk for skin impairment and try to prevent skin breakdown by addressing factors in each category.

“When we make rounds we ask questions geared to identify factors contributing to impaired skin integrity,” Raygoza continued. “For example, nutrition concerns or problems with incontinence are discussed and the team determines appropriate interventions. The plan is communicated to the other members of the healthcare team. By addressing the issues as a team, we can prevent pressure ulcers.

“Research has shown patients who develop a full-thickness HAPU in the acute care setting have a 180 mortality rate as high as 75 percent,” she added. “A thorough understanding of the prevention, assessment and outcomes of HAPUs really contributes to providing the best care possible. Our goal is to prevent HAPUs from developing in our critical care unit.”

Changing Perceptions

In June 2011, when Mary K. Naccarato, MSN, CCNS, CEN, joined the staff at Imperial Point Medical Center of Broward Health System in Fort Lauderdale, FL, as a CNS, her focus was to improve patient care, cut costs and increase reimbursements. She honed in on cutting HAPUs in the 10-bed ICU. She reached out to Barbara Donnelly, MHSA, BSN, RN, CCRN, ICU manager, Bob Michel, BSN, RN, CCRN, assistant nurse manager and ICU staff nurses to change the trend.

What she found was a perception among staff that while pressure ulcers were unfortunate, they also were nearly unpreventable given the high acuity of the patients on the unit. After changing that mind-set, implementing new prevention protocols led to great success.


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“In the past, ICU nurses had a perception that HAPUs could and would happen, and would be hard to take care of,” Michel agreed. “We changed our patient care through additional education and the way we assessed the patient’s skin on admission, including taking photos, which helps us to see what they came in with and allows us to follow those areas through their stay.”

One step involved putting an antimicrobial soft silicone foam dressing on the coccyx of every patient, then checking under the dressing twice daily. Air-filled vinyl boots that had been used to prevent pressure ulcers gave way to less high-tech, but more effective treatments, including putting pillows or folded bath blankets under the legs of patients. Frequent turns became so routine patients expected their nurses to come in every 2 hours.

“They already had the knowledge and knew what to do, so it was a way of adjusting it depending on the patients needs,” Naccarato said. “For example, a turn may not be a total turn to one side, but might be a bath blanket underneath. Just simple variations, but when we’re all singing the same song, it has worked tremendously.”

Group Effort

That “song” recently led to more than 100 days with no HAPUs. Donnelly said staff hold each other accountable and are proud of each other in turn. It was not an easy task.


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“The nurses set our first goal: 7 days,” Naccarato said. “When we reached that, we added another 7, then another, then to 30 days, then 45, then 60, then we jumped to 100. We got into the 90s several times before we had a HAPU, so hitting 100 has been rewarding for the staff. It means their work is paying off for their patients.”

Naccarato began rounding to offer assistance to the staff, looking at the sickest patients and those who were at greatest risk for a HAPU. She worked with nurses to see what interventions were implemented and what more could be done. Staff selected “turn buddies” who could help them during the shift and took ownership in skin care prevention.

“Skin sneaks up on you if you’re not being proactive,” she said. “It’s just part of total ICU care, but the nurses have raised skin to the level of other organs. It’s on the front burner on the assessment. It’s not bells and whistles, just focused nursing care.”

“Education was a key,” Michel said. “When Mary first came, one big thing that helped was the way she came in and introduced what she was going to be doing. She got right in there with us, taking the time to educate us as we did our job. She made us understand what she was doing for us and for our patients and made us want to join with her to make it work. It was a win-win for everyone.”

Candy Goulette is regional editor at ADVANCE.

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