Date of Graduation

Spring 5-19-2016

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Reducing the Incidence of Hospital-Acquired Pressure Ulcers by Enhancing the Role of Unit-Based Skin Champions


Hospital Acquired Pressure Ulcer continues to be an alarming issue in today’s healthcare systems. Often preventable, it is a significant nursing role and a frequently used benchmark for quality care. Studies have shown that hospital-acquired pressure ulcer (HAPU) complications have been associated with “up to 60,000 deaths each year in the United States” (AHRQ, 2014). A major health problem, it presents grave consequences on the patient’s well-being, significant treatment and recovery delays, increase length of inpatient stays, and have become a “never” event from the standpoint of Medicare reimbursement.

A 175-bed general medical-surgical hospital in Southern California was challenged with an increasing HAPU incidence in 2014-2015. With a higher older adult population, the hospital sought to reduce HAPU prevalence by reviving the Skin Task Force and enhancing the role of Unit-Based Skin Champions. Focused on raising awareness, increasing education, improving documentation and communication, and implementing various preventive practices, sixty-two (62) skin champions underwent training and education. Their presence empowered staff to utilize and implement evidence-based preventive skin care protocols, optimized consistency of practice, performed root cause analysis, conducted prevalence studies, identified barriers in care delivery, and provided expert advice to peers (Bergquist-Beringer, S., et al., 2009). While a review of literature strongly suggest a multifaceted program, the Skin Champions drove practice changes at the bedside and contributed to positive outcomes. By April 28, 2016, HAPU incidence was reduced to one. Although at its early stages, elements that significantly contributed to the program’s success include strong leadership, peer to peer involvement, communication, and an emphasis on personal responsibility. With ongoing training and support, the Skin Champions will continue to drive pressure ulcer prevention best practices at the point of care until goal of zero HAPU is reached.