Preventing pressure ulcers at Beverly Hospital

202-bed acute care facility in Montebello, California

Stephanie discovered a problem in her first week on the job at Beverly Hospital: pressure ulcers. 38 of them had been reported in a single month. Beverly Hospital was struggling with a pervasive pressure ulcer problem.
Stephanie Wilcher

Stephanie Wilcher
Senior VP of Operations and Patient Services

Pressure ulcers develop quickly and can be difficult to identify early. Patients with pressure ulcers experience longer lengths of stay, readmission, and even death in some cases. A single pressure ulcer is costly to treat and can also result in reimbursement penalties ranging from $2,000 to $70,000[1].

When Stephanie met with her team, she found that they had already put a few logical prevention tactics into place, but the change hadn’t been meaningful or sustained.

Stephanie recognized that Beverly Hospital needed a new approach to pressure ulcers.

She wanted to learn what strategies and tactics had worked for other organizations, but didn’t know where to start—until she learned her organization had an Advisory Board membership.

Anne Herleth

Anne Herleth
Senior Consultant

Stephanie connected with Anne, a researcher at Advisory Board and an expert on nursing. She sent Stephanie a study detailing nine proven strategies for preventing pressure ulcers, as well as an in-depth presentation of the study that her teammate recorded. Stephanie and her directors watched the presentation together and learned about best practices for training nurses, integrating staging guidelines into workflow, using the Braden scale to simplify interventions, and supporting their staff.

Now, the Beverly leadership team had a plan.

Armed with this new knowledge, they quickly built and implemented a strategy involving staff education, organization-wide collaboration, clear accountability and a culture of prevention. Specific tactics included:

    “Before the standard, there was no standard.”

    — Emmanuel Samoy
    Special Care Programs Director (and Stephanie's teammate)

  • Clear care parameters — staff members now have crystal clear direction on turn frequency, and when to order specialized beds, a nutrition bundle, or incontinence care.
  • Unambiguous accountabilities — every group touching patients has clear responsibilities. For example, ICU nurses must perform a head-to-toe skin check at every shift change.
  • A daily discussion of high risk patients — every morning, a multidisciplinary team that includes nursing, wound care, nutrition, physical therapy and respiratory therapy discusses high-risk wound patients, reviews care parameters, and confirms accountability for each required care element.
  • Wound Tuesdays — a nursing director conducts rounds on all wound patients every Tuesday, and teaches nurses in the moment. The wound care nurse takes pictures of all wounds an uploads them into the EMR.
  • A human connection to the problem — nursing leaders remind all staff members to imagine how they would feel if their family members developed a preventable wound in a hospital. Repeated, empathic communication keeps staff from treating pressure ulcers like "just another work problem."

In their first month after implementing the new strategy and tactics, Stephanie’s hospital reported only 7 pressure ulcers—and after just six months, Beverly Hospital eliminated pressure ulcers completely.


Safeguard your organization against never events

Advisory Board researchers work with dozens of executives and clinicians at hospitals across the country to discover proven best practices. Together with our members, we created the standard to safeguard against pressure ulcers and patient falls.

Stephanie and her team used this research to create a plan that eliminated pressure ulcers within six months. With this study, you can eliminate never events too.

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