This quality improvement program sought to reduce the incidence of pressure ulcer development in a 14-bed adult intensive care unit (ICU) in Australia. Skin surveys were conducted during a 2-year period, with 601 skin surveys being performed during 22 audits. The Waterlow Pressure Ulcer Risk Assessment Scale was used to assess patients in the ICU. Data were collected monthly on the number, stage, and location of pressure ulcers and the strategies used to prevent pressure ulcers before and after a quality improvement initiative aimed at reducing pressure ulcers. The intervention included reminders about how to obtain devices to relieve pressure ulcers, feedback on rates of occurrence, one-on-one clinical instruction on methods to reduce development of pressure ulcers, and focused preventive interventions such as a “pillow campaign” that encouraged use of a pillow under the lower part of each leg...

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