Best Practices: CKHS Skin Care Bundle for Pressure Ulcers Receives National Attention - Crozer-Keystone Health System - PA

Best Practices: CKHS Skin Care Bundle for Pressure Ulcers Receives National Attention

Crozer-Keystone’s Skin Care Committee has developed a skin care bundle for the prevention of pressure ulcers that has captured the attention of the national Wound, Ostomy and Continence Nurses Society. A poster describing the bundle has been accepted for presentation at the WOCN national conference to be held in June 2010.

The committee began work on the bundle in 2008 amid growing concern in the national healthcare arena about the prevalence of pressure ulcers in hospitals across the country. The Center for Medicare and Medicaid Services ruled that it would no longer reimburse acute care facilities for the cost of treating hospital-acquired ulcers, which may run up to $50,000 per patient. In addition, the National Quality Forum defined the formation of a new pressure ulcer during hospitalization as “a hospital-acquired condition (HAC) that is high cost and high volume and may be preventable with implementation of evidence-based guidelines,” according to a 2009 report in Ostomy Wound Management. It is widely agreed that a pressure ulcer is a serious complication that decreases a patient’s quality of life and may impede overall healing, requiring significant nursing time and incurring considerable treatment costs. 

Jo-Zetta Shawl, RN, 

The CKHS Skin Care Committee sought prevention solutions. Spearheaded by Jo-Zetta Shawl, RN, MHA, NEA-BC, assistant vice president of Patient Services at Delaware County Memorial Hospital, and the system’s certified wound ostomy continence nurses (WOCNs), the group researched best practices and developed a protocol that includes an algorithm, WOCN and physician order set, and skin care bundle for prevention to be implemented by bedside nurses.  

Skin Algorithm

The skin algorithm is based on the Braden Scale for skin risk assessment.  All patients are assessed upon admission. Any patient admitted with a Braden scale of 18 or less, a measure that is evidence based, is started on the skin care bundle.  To ensure documentation of patients who have pressure ulcers upon admission, the committee provided a “Dear Doctor” sticker for nurses to place on the physician order sheet, signaling the physician to examine the patient and document the ulcer.  All hospitalized patients are assessed with the Braden Scale daily. 

WOCN/Physician Order Set

The committee introduced a combination WOCN/physician order set. The top portion comprises preventative measures that WOCNs can write without a physician’s order.  At the bottom is a physician order section where the WOCN can recommend orders for the physician to write.

Skin Care Bundle

The skin care bundle includes the following preventive measures:


  • Keep HOB elevated ‹30 degrees if medically allowable.
  • Turn patient every two hours (30 degrees side lying position, if medically allowed).
  • Keep heels elevated off bed surface.
  • When OOB in chair, reposition patient every hour.
  • Incontinence Care
  • Catheter strap holder or Flexitrack leg strap to secure Foleys.
  • Use skin cleanser and barrier after each episode.
  • Fecal incontinence collector (pouch).
  • Use diaper only when OOB or traveling.

Bedside kardexes have been provided with the algorithm on the back and wound care and preventive care on the front.


Since implementation at Delaware County Memorial Hospital in May 2009, use of the skin care bundle for patients with a Braden Scale rating of 18 or less has more than doubled, increasing from about 20 percent initially to 44 percent as of December 2009 and continues to improve. In March 2010, DCMH had zero incidence of pressure ulcers.

From July 2009 through March 2010, Crozer and Springfield had zero incidence of pressure ulcers. During the same period, use of the skin care bundle at Crozer averaged 76 percent; Springfield achieved 96.5 percent usage. Adoption has also been increasing steadily at Taylor since implementation last year. 

CKHS Skin Care Committee

Maureen Ingram, RN, BC, MSN, CWOCN (DCMH)

Kathy McLaughlin, RN, CWOCN (Taylor)

Cindy Reigart, RN, BSN (Crozer BTC)

JoZetta Shawl, RN, MHA, NEA-BC

Janet Slaven, RN, CWOCN, CIT (Crozer)

Eileen Young, RN, MSN

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