Resource Nurse Program.A Nurse-Initiated, Evidence-Based Program to Eliminate Hospital-Acquired Pressure Ulcers

PROFESSIONAL PRACTICE
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
136 J WOCN ■ March/April 2014 Copyright © 2014 by the Wound, Ostomy and Continence Nurses Society™
J Wound Ostomy Continence Nurs. 2014;41(2):136-141.
Published by Lippincott Williams & Wilkins
Resource Nurse Program
A Nurse-Initiated, Evidence-Based Program to Eliminate
Hospital-Acquired Pressure Ulcers
Nancy Beinlich Ⅲ Anita Meehan
■ ABSTRACT
This article describes the process used to establish a system-
wide, sustainable team of staff nurses to serve as unit-based re-
source nurses charged with aiding colleagues in the assessment,
treatment, and prevention of pressure ulcers. A multidisci-
plinary program was developed to address barriers in prevent-
ing hospital-acquired pressure ulcers, including incomplete
knowledge of causative factors, confusion in determining
wound etiology, incorrect staging, inaccurate Braden Scale
scoring, and inconsistent application of evidence-supported
prevention interventions. The Resource Nurse Program was ini-
tiated in a community-based 511-bed, acute care teaching hos-
pital located in the Midwestern United States.
KEY WORDS: cost analysis, peer-to-peer learning, pressure ulcer
prevention, resource nurse, HAPU
Ⅲ Nancy Beinlich, MSN, RN, CWON, Director, Wound Center, Akron
General Medical Center, Akron, Ohio.
Ⅲ Anita Meehan, MSN, RN-BC, CNS, ONC, Clinical Nurse Specialist,
Gerontology, Akron General Medical Center, Akron, Ohio.
The authors declare no conflicts of interest.
Correspondence: Nancy Beinlich, MSN, RN, CWON, Akron General
Medical Center, 400 Wabash Ave, Akron, OH 44307 (nancy.
beinlich@akrongeneral.org).
DOI: 10.1097/WON.0000000000000001
■ Introduction
Preventing hospital-acquired pressure ulcers (HAPUs) is of
paramount importance as healthcare providers focus on
challenges related to providing high-quality, cost-effective
care. A growing aging population, with associated in-
creases in prevalence of chronic diseases and advancing
technology that increases survival rates for victims of
major trauma, all contribute to an increasing number of
patients at risk for pressure ulcer (PU) development.1,2
Pressure ulcers represent a significant economic burden to
the healthcare system; analysis of Medicare data finds that
these wounds account for approximately $2.3 billion to
3.6 billion dollars in healthcare costs each year.3
Given the significant economic and healthcare burden
associated with PUs, providers are challenged to look for
cost-effective ways to prevent these lesions, especially
when they are hospital acquired. Hospital acquired pres-
sure ulcers are defined as a nurse-sensitive quality care
indicator, implying that good nursing care can prevent
their development.4
A pilot survey of nurse's knowledge
related to PU management conducted by Ilesanmi and
associates5
reports that effective prevention demands ade-
quate knowledge of evidence-supported assessment and
prevention strategies as opposed to reliance on traditional
or ritualistic practices.
Wound, ostomy and continence (WOC) nurses possess
advanced knowledge in the assessment, treatment, and pre-
vention of PUs and serve as an important resource for staff
nurses. The specialized practice of the WOC nurse focuses
on identification of population trends, planning and imple-
mentation of quality improvement strategies, and evalua-
tion of outcomes.6 While the WOC nurse is an effective
resource for preventing PUs, there are insufficient numbers
of these specialized clinicians, and not enough time to edu-
cate the number of staff required to effectively assist in
decreasing these preventable wounds in the acute care set-
ting.7 Monitoring risk and reduction of PUs also requires
organizational support and unit-level interactions.8
In 2009, while reviewing charts during clinical wound
rounding, an advanced practice WOC nurse from the wound
center of a 511-bed hospital located in the Midwestern
United States identified inconsistencies in both Braden Risk
Assessment scores and initiation of appropriate interven-
tions by staff nurses. During the same time period, the
Centers for Medicare & Medicaid Services publically reported
a change in policy that impacted reimbursement for treat-
ment of HAPUs. These 2 events served as the impetus for
development of a Resource Nurse program at our facility.
■ Intervention
A multidisciplinary program was developed to address bar-
riers in preventing hospital-acquired pressure ulcers, includ-
ing incomplete knowledge of causative factors, confusion in
determining wound etiology, incorrect staging, inaccurate
JWOCN-D-12-00102R1.indd 136JWOCN-D-12-00102R1.indd 136 2/22/14 9:15 PM2/22/14 9:15 PM

J WOCN ■ Volume 41/Number 2 Beinlich and Meehan 137
Braden scoring, and inconsistent application of evidence-
supported prevention interventions. This model assists in
changing practice by supporting an interdependence of
peers learning and teaching each other in pursuit of a com-
mon goal of improving patient outcomes, in this instance,
decreasing hospital-acquired pressure ulcers.9
The proposal to create a Resource Nurse pilot program at
our facility was initially presented to our Nursing Practice
Council, which approved additional development. The
chief medical officer and senior vice president of nursing
also approved the proposal. Financial support was provided
through the Wound Center operating budget, which contin-
ues to fund the program. Resource Nurses are compensated
at their hourly rate for completing 12 hours of peer educa-
tion monthly. In addition, a quarterly incentive is awarded
to participants who complete the required v36 hours of edu-
cation per quarter. Resource Nurse time is beyond the par-
ticipants’ scheduled hospital shifts. The pilot program began
with 6 resource nurses, representing 5 medical-surgical units
and 2 intensive care units. These units were selected because
they were identified by quarterly incidence and prevalence
data as the units with the highest number of HAPUs.
The program director is a master's-prepared WOC
nurse, who, in consultation with a gerontological clinical
nurse specialist, developed the educational curriculum
using current evidence and adult-learning methods. The
teaching provided to Resource Nurses consists of a combi-
nation of interactive Web-based and classroom instruc-
tion, hands-on learning, and preceptor-guided clinical
observation. The course includes evidence-supported risk
assessment modalities, identification and staging of
wounds, accurate wound documentation, prevention of
and intervention modalities for PU, principles and treat-
ment of moisture-associated skin damage, and age-related
PU risk factors. In addition, the hospital librarian provides
a course on the use of software programs to enhance the
Resource Nurses’ access to the professional literature.
We believe that ongoing mentoring and learning
opportunities are essential for the long-term success and
stability of our Resource Nurse program. Time is allocated
to familiarize Resource Nurses with the responsibilities of
their new role (Table 1). The program director facilitates a
mandatory monthly meeting that focuses on unit out-
comes and shared accomplishments, along with challenges
and barriers to prevent these wounds. These meetings are
also used to critique pertinent journal articles and discuss
opportunities for advancing program outcomes. These
meetings are considered essential because they provide the
opportunity to share unit experiences with each other,
which has been shown to enhance and stimulate process
improvement ideas and impact desired outcomes.10
■ Program Outcomes
The Resource Nurse program facilitated clinically relevant
practice improvements that impacted the moisture manage-
ment of skin, identification of HAPU risk factors, and pres-
sure redistribution sleep surfaces. After completing the
educational program in 2009, Resource Nurses began to
question existing clinical practices, linking environmental
factors to skin breakdown. Environmental factors included
both direct care techniques and corporate components, such
as hospital-provided mattresses or seating surfaces and mois-
ture climate control products.8 For example, they observed
that bed-making practices included multiple linen layers
that reduced specialty surfaces ability to redistribute pressure
and maintain optimal skin microclimate.11
In 2010, the Resource Nurses recognized that peers were
frequently identifying incontinence-associated dermatitis
(IAD) as stage I or stage II PU. While IAD is a risk factor for PU
development, we believe it is essential for nurses to differen-
tiate these conditions since their prevention and treatment
are not identical.12,13
Incorrect identification of IAD has neg-
ative implications when reporting outcomes to the Nursing
Dataset for Nursing Quality Indicators and other regulatory
agencies such as the Centers for Medicare & Medicaid
Services. Our hospital utilizes the Iowa Model of Evidence-
Based Practice14
as a guide in using research findings for qual-
ity improvement initiatives. The Iowa Model guides the
nurse in identifying problem and knowledge-based triggers,
assembling and critiquing literature, identifying priorities for
the organization, forming a team, initiating a change in prac-
tice, and evaluating the practice change using standardized
measures of practice. This issue was a priority for the hospital
due to recent federal regulatory reimbursement changes.
After reviewing the literature, Resource Nurses provided unit-
based education related to differentiating between IAD and
a PU. They also pilot tested a practice change, which involved
creating an evidence-supported nursing policy for bed
TABLE 1.
Resource Nurse Role Responsibilities
Unit-based in-service programs relating to incontinence-associated
dermatitis and pressure ulcer prevention
Braden Scale checks/rounding on units, reviewing results/
interventions with individual staff at bedside
Quarterly participation in Nursing Dataset for Nursing Quality
Indicator pressure ulcer prevalence study
Participation in root cause analysis for hospital-acquired pressure ulcers
Monthly meeting with CWON/program director and geriatric CNS;
education and review of activities, program planning/goals,
process improvement initiatives
Providing quarterly unit journal club meetings relating to
incontinence-associated dermatitis and pressure ulcer prevention
Individualized unit educational bulletin boards
Participation in annual nursing grand rounds
Involvement in Lean/Six Sigma processes pertaining to maintaining
patient function
Participation in ongoing quality improvement programs/studies in
preventing pressure ulcers

138 Beinlich and Meehan J WOCN ■ March/April 2014
making. The policy reduced the number of linen layers used
when making a bed, optimizing the pressure-redistribution
qualities of the sleep surface.10 The use of a quilted under pad,
chux pad, and bath blanket (for patient lifting) was elimi-
nated in favor of a single contour sheet and single layer draw
sheet. Adult incontinence briefs, commonly used for bedrid-
den and incontinent patients, were replaced with a polymer-
based disposable under pad. These interventions reduced
both moisture- and pressure-associated skin breakdown. A
review of chart audit data focusing on WOC consultation for
IAD revealed 56 consults for dermatological/rash (used as a
proxy for IAD) in 2009. Thirty consultations occurred in
2010 and 1 occurred in 2011; these changes represent a 98%
decline over 3 years.
During the same time period, Resource Nurses partici-
pated in a root cause analysis to investigate key factors con-
tributing HAPU development in our facility.15 A data
collection tool was developed to trace probable contributing
factors in patients who developed pressure-related wounds.
Analysis showed that patients who developed HAPUs in our
facility tended to be older and immobile for greater than
3 hours (usually due to admission via our emergency depart-
ment, longer surgical procedures, or time spent in the post-
anesthesia care unit). Based on consultation with a geriatric
clinical nurse specialist, Resource Nurses also examined
HAPU development in patients with indwelling urinary
catheters. Data collection began in the second quarter of
2009 and ended in 2012. Analysis revealed that the 67% of
patients who developed a HAPU had an indwelling urinary
catheter in place on the day prevalence was measured. While
more research is required to ascertain casualty, existing evi-
dence suggests that they are associated with an increased
likelihood of HAPU occurrence.16,17
In addition, a literature review retrieved an article that
reviewed ﬁndings from animal model and human subjects
suggest that a period of immobility that lasts for more than
3 hours increases the likelihood of PU formation, and the risk
is higher when this period is extended.17
They also retrieved
a randomized trial that found that the use of a viscoelastic
operating room (OR) mattress resulted in fewer PUs when
compared to a standard surgical mattress.18
Therefore, Resource Nurses initiated a limited pressure-
mapping project comparing the 2-inch mattress used in
our ORs to a 4-inch Viscoelastic mattress. An outside ﬁrm
was engaged that specialized in pressure mapping to assist
with data collection and analysis. The 4″ surface was com-
pared to the surface used in cardiac cases, a 2″ mattress,
heating blanket, and gel overlay. The comparison data
showed that the 4-inch Viscoelastic mattress outper-
formed our hospital-owned mattress (Table 2). The data
obtained from this project encouraged administration to
purchase 2 new OR mattresses for patients undergoing
extended surgical procedures. Ultimately, all OR table sur-
faces were replaced with the 4-inch Viscoelastic mattress,
except for 2 ORs in the third quarter of 2012. Data col-
lected to evaluate the effect of these changes revealed a
decrease of 85% and 80% in occurrence of HAPUs in the
ICU in 2011 and 2012, respectively, and a decrease of 63%
and 100% on the orthopedic unit in 2011 and 2012,
respectively. The general surgery unit experienced a 100%
decrease in HAPUs in both 2011 and 2012 (Figure 1).
Initial successes led to a desire to add new Resource
Nurses in additional areas with a high risk for PU develop-
ment. In early 2011, 8 additional staff nurses from the emer-
gency department, perioperative and operative care settings,
neuroscience intensive care step-down units, and the health
system’s rehabilitation facility joined the program.
Despite initial education and changes in multiple
aspects of HAPU prevention, Resource Nurses observed
ongoing variability in Braden Scale scores and inadequate
knowledge of differential diagnosis of stage I and II PU
versus IAD. Acting under guidance of the program direc-
tor, the Resource Nurses developed two 30-minute con-
tinuing education programs. One highlighted the proper
FIGURE 1. Surgical HAPU prevalence. ICU indicates intensive
care unit; HAPU, hospital-acquired pressure ulcer.
TABLE 2.
Pressure Mapping Using Heating Blanket and Gel
Overlay
2″ mattress
4″ Viscoelastic
Mattress
Head, mm Hg
Average 15.73 7.59
Maximum 64.53 20.61
Scapula, mm Hg
Average 7.13 4.62
Maximum 20.72 10.46
Sacrum, mm Hg
Average 7.46 4.39
Maximum 34.93 13.52
Heels, mm Hg
Average 17.66 18.06
Maximum 40.95 40.24

use of the Braden Scale for Pressure Sore Risk and the other
focused on differential diagnosis of IAD versus PU, along
with preventive interventions. These programs were
offered to all staff on their units, including professional
nursing staff and housekeeping and nursing assistants.
The educational sessions included PowerPoint presenta-
tions, interactive discussion, and demonstration of avail-
able products for prevention and/or treatment.
In order to demonstrate their support of peer-to-peer
learning, unit directors assisted the Resource Nurses in
scheduling learning times for the staff. The Resource Nurse
scheduled multiple program times during a 3- to 4-hour
period during day and evening shifts; this schedule
allowed education of 2 to 4 staff members while their
peers cared for patients. This education model allows for
improved staff attendance at educational programs, given
that it is very difﬁcult to allow staff to be away from the
unit for extended periods of times. Approximately 350
employees attended the sessions across the health system.
This strategy was selected because it has been shown that
offering education at the unit level promotes a spirit of
inquiry for nurses to embrace evidence-supported prac-
tices, and it enhances patient outcomes.19
Resource Nurse team members also developed a
30-minute educational program that was incorporated
into the medical/surgical core course and provided to new
RNs during their orientation process. This program
focused on the Resource Nurse program, Braden Scale for
Pressure Sore Risk, and preventive/treatment strategies for
PU or IAD. Resource Nurses also provide education to
nursing assistants at their monthly meetings.
■ Impact on PU Prevalence and Occurrence
Data from our PU prevalence study revealed a steady de-
cline in HAPU prevalence since the inception of the pro-
gram in 2009 (Figure 2). For example, data from 2009
through 2012 revealed a 77% decrease in the number of
HAPUs (Figure 3). Data from the Nursing Dataset for
Nursing Quality Indicator survey tool suggest that nurses
were independently initiating prevention strategies earlier
in the patient stay, and more consistently recognizing pa-
tients at higher risk for HAPU development.
While prevalence data are the most commonly used
approach for benchmarking HAPUs with other hospitals,
we have also found that measuring HAPU occurrence is
equally useful for determining costs associated with HAPU
end determination of effective strategies for their preven-
tion. We measure HAPU occurrences throughout the cal-
endar year, which provides a more longitudinal
measurement that the monthly point prevalence data
generated by the PU prevalence study program. Data anal-
ysis prior to and following initiation of the Resource Nurse
program revealed a 44% reduction in HAPU occurrence
between 2009 and 2012 (Figure 4). Root causes analysis of
the rise of HAPU occurrence from 2009 to 2010 was attrib-
uted to increased consistency when reporting following
the interdiction of a new form and associated education
that emphasized the need to accurately measure HAPU
occurrence. This increase in reporting was also attributed
to the actions of the Resource Nurse program director who
reviewed all reports with quality improvement staff to
FIGURE 4. HAPU incidence. HAPU indicates hospital-acquired
pressure ulcer.
FIGURE 2. HAPUs prevalence. HAPU indicates hospital-acquired
pressure ulcer.
FIGURE 3. HAPUs by quarter prevalence. HAPU indicates
hospital-acquired pressure ulcer.

140 Beinlich and Meehan J WOCN ■ March/April 2014
verify that each was accurate and excluded any wounds
relating to moisture-associated or friction skin breakdown.
■ Cost
Potential cost savings related to HAPU prevalence were
estimated by determining the number of patients at risk
for developing PU using a cumulative Braden Scale score
of 18 or less, minus the number of patients who actually
developed a HAPU (Figure 5). Additional costs were pro-
vided by the facility's financial department and based on
estimate direct costs, and the mean increase in length of
stay; this figure was based on an average based on HAPU
and PU present on admission. Even when the cost of the
Resource Nurse program was subtracted from the potential
cost saving, our financial department calculated a net re-
duction in cost of $447,456 in 2010, $794,280 in 2011,
and $504,000 in 2012 (Figure 6).
Actual cost savings were calculated using 2 outcome
measures: HAPU prevalence and occurrence from 2009 to
2012. Prevalence data revealed 43 fewer HAPUs, resulting
in an annual cost reduction of $135,880. Comparison of
occurrence data revealed 19 fewer HAPUs, revealing an
annual cost reduction of $51,236. Even when the cost of
the Resource Nurse program over a 3-year period was con-
sidered, the total cost savings for the hospital was approx-
imately $95,120 (Figure 7).
■ Conclusions
Today's healthcare environment demands quality improve-
ment programs that demonstrate sustainable improvement
in quality and financial benefit.20 Our experience suggests
that the development of the Resource Nurse program re-
duced the prevalence and occurrence rates of HAPU in our
health system as well as costs related to HAPU develop-
ment. We have observed that the creation of the Resource
Nurse fostered teamwork and encouraged collaboration
and critical inquiry, resulting in sustainable changes in
clinical practice. We have observed that the creation of the
Resource Nurse program fostered teamwork and encour-
aged collaboration and critical inquiry, resulting in sustain-
able changes in clinical practice, as evidenced by the
continued decrease in HAPU prevalence through the first
FIGURE 7. Actual variable cost savings.FIGURE 6. Potential financial savings.
FIGURE 5. Hospital-acquired pressure ulcer (PU) prevalence outcomes.

2 quarters of 2013 (Figure 8). The Resource Nurse program
continues to be a hospital supported and funded program.
KEY POINTS
✔ The Resource Nurse program encourages staff nurses to
explore causative factors related to PU development.
✔ Peer-to-peer learning/teaching is an effective strategy to
reach bedside nurses.
✔ Resource Nurses are empowered to change practice.
✔ The Resource Nurse program is a cost-effective way to
reduce HAPUs.
■ References
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FIGURE 8. HAPUs first- and second-quarter prevalence. HAPU
indicates hospital-acquired pressure ulcer.

Resource Nurse Program.A Nurse-Initiated, Evidence-Based Program to Eliminate Hospital-Acquired Pressure Ulcers

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Resource Nurse Program.A Nurse-Initiated, Evidence-Based Program to Eliminate Hospital-Acquired Pressure Ulcers