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Off the Back Campaign and Rock Jar Tool

Young Female Doctor Senior Asian Couple
Monday, February 25, 2019

San Antonio Regional Hospital is committed to evidence-based practices when it comes to patient care.

With this commitment, San Antonio Regional Hospital looks at ways to engage staff members in order to reach their goal in reducing hospital-acquired pressure injuries (HAPI). In 2018, they focused on reducing HAPIs within their critical care patient population. With the bedside nurses input, they started a campaign in the Surgical Intensive Care Unit (SICU) called “Off the Back.” The basic idea was no patient in the SICU would be left in supine position during the every two hour turning cycle. 

Education was sent to the entire SICU staff, which stated the goal, the expectation, and plans to measure the outcomes. The following where the expectations:

  • All patients will be turned every two hours from side to side.
  • Even hemodynamically unstable patients can be turned at least 10 degrees.
  • Wedges or pillows will be used to position patients at least 20 degrees.
  • Offloading must occur so the pressure area is not against any surface.
  • Skin information questionaires and comfort glides can be used for the patients at high-risk of HAPIs whenever possible.
  • It is the responsibility of the nursing team to turn patients, not the lift team.
  • Patients on specialty low air loss beds also need to be turned every two hours.

Each of these expectations came from the front-line critical care nursing team, which provided buy-in from staff members to reach the end goal of reducing HAPIs in the SICU. For real-time feedback, the SICU staff came up with the “Rock Jar” idea, because their nursing team “rocks” when it comes to their care for the patient and skin. Once the jar was full, the unit would have a celebration with a party.

Each day the wound care team sends out a fall out list for opportunities to start processes, which reduce pressure injuries on high-risk patients. Each morning, the nursing director of wound care reviews the fall out list. If SICU was not on the list for skin, they would receive a rock in their jar. If SICU was on the list, the wound care team would lose a rock from the jar. It sounds simple, but the team was so engaged with the rock. Each morning the team would wait to see if the nursing director was placing or pulling a rock from the jar. As the jar began to fill, the number of HAPIs began to drop.

The chief nursing officer recognized the SICU team for their significant reduction in not only HAPI but in reportable injuries with a HealthCare Reliability Organizing (HCRO) in Action award. This further energized the SICU staff to continue to fill the jar. They were so engaged, they began videotaping the morning rock placement, or pull, to share with nursing staff members to keep everyone informed.

The results of their “Off the Back” campaign and “Rock Jar” staff engagement tool was so impressive, it has spread to all their critical care units. San Antonio Regional Hospital is still seeing a reduction in HAPIs and reportable injuries in their critical patient population. The goal is to go hospital-wide with the campaign and use the rock jar in areas that need staff member engagement. 

For more information, please contact Christina Mallon, BSN, RN, Nursing Director of Wound Care, at San Antonio Regional Hospital, at