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Jt Comm J Qual Patient Saf. 2006 Sep;32(9):488-96.

Eliminating facility-acquired pressure ulcers at Ascension Health.

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Patient Care Services, St. Vincent's Medical Center, Jacksonville, Florida, USA.



In 2004, as part of Ascension Health's "Healthcare That Is Safe" initiative, St. Vincent's Medical Center, as an alpha site, was charged with defining best practices to eliminate facility-acquired pressure ulcers. A comprehensive plan, including the "SKIN" (Surfaces, Keep the patients turning, Incontinence management, Nutrition) bundle, was developed.


The incidence of pressure ulcers decreased from > 2% to < 1% from December 2004 through February 2006. No new Stage III or IV facility-acquired pressure ulcers occurred between August 2004 and February 2006. Weekly SKIN operations meetings and use of the SKIN process tool ensured that all at-risk patients were receiving appropriate interventions. REPORTING AND SPREAD: The alpha site work and SKIN bundle were presented to all 67 Ascension Health acute care facilities at a rapid-design-format Pressure Ulcer Summit in mid 2005. All acute care facilities agreed to a single model of care using the SKIN bundle and common measures of quality and performance.


The St. Vincent's alpha site initiative in pressure ulcer prevention, enabled it to identify at-risk populations, implement appropriate actions, and achieve positive, measurable, meaningful results.


The SKIN program was adopted and is being implemented throughout Ascension Health.

[Indexed for MEDLINE]

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