Changes in the Rates of Reported Pressure Ulcers in Response to a Regional Critical Care Quality Improvement Project

We used patient safety incident reports to monitor rates of pressure ulcers in response to a skin care bundle introduced at the start of 2012 across the North West of England. The bundle incorporated skin surface interface, patient positioning, incontinence and skin management and improved nutrition. We compared changes in the rates of index sores (category two to four ulcers involving the sacrum, buttocks, genitals or heals) with other sores and wounds. Rates of all reported pressure ulcers increased from 4.1 to 7.0 per 1,000 days between 2009 and 2012 (p<0.001) while the rate of ‘index sores' decreased from 3.1 to 2.0 per 1,000 days between 2011 and 2012 (p<0.001). There was a wide variation in reported pressure ulcers between different units (interquartile range 2.1 to 9.9 per 1,000 days). A care bundle can reduce the rates of significant pressure ulcers. Without ensuring reliable compliance, wide variation remains between units.