The bundle used in the study involved five steps:
• Comprehensive skin assessment during admission, transfer and discharge
• Using OR beds with pressure-redistributing mattresses
• Scheduled turns with pressure points relief
• Prevention hand-off between providers
• An assessment for pressure ulcers on daily rounds
Six months after implementing the bundle, the rate of hospital-acquired pressure ulcers dropped from 3.37 to 1.45. After 14 months, pressure ulcer rates remained low.
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