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Journal of Nursing Administration:
doi: 10.1097/NNA.0000000000000095
Departments: Magnet(R) Perspectives

Hospital-Acquired Pressure Ulcers: Magnet Nurses Making a Difference

Brindle, C. Tod MSN, RN, ET, CWOCN, CLIN IV

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Author Information

Author Affiliation: Nurse Clinician Wound Care Team, Virginia Commonwealth University Medical Center, Richmond.

The author declares no conflicts of interest.

Correspondence: Mr Brindle, Virginia Commonwealth University Medical Center, Wound Care Team, 1250 E Marshall St, Main Hospital, 4th Floor, Suite 4-300, MCV Campus, PO Box 985869, Richmond, VA 23298 (

The year 2014 is being earmarked as the Magnet Recognition Program’s® year of charting a new course in its work on nursing-sensitive indicators. On the heels of the January Ambulatory Measurement Summit, a group of clinical experts met to explore nursing strategies to further reduce hospital-acquired pressure ulcers (HAPUs). The Virginia Commonwealth University Pressure Ulcer Summit (VCU_PUS) was organized and endorsed by Virginia Commonwealth University (VCU) Medical Center, the American Nursing Credentialing Center® (ANCC), the Magnet Commission, the American Nurses Association®, and the University of Nebraska Medical Center. The unique origin of the VCU_PUS came following my honor of receiving the award as the 2014 ANCC-Magnet National Nurse of the Year in exemplary professional practice. Having an audience with some of the ANCC and Magnet Commission Leaders inspired me to question, “How do we take prevention to the next level?” As a certified wound ostomy continence nurse, our society’s passion to influence the nation and the globe through comprehensive collaborative nurse-driven initiatives fueled the conception of this summit.

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The HAPU nonpayment regulatory changes implemented by the Centers for Medicare & Medicaid Services in 2008 were the catalyst for many organizations to improve HAPU rates.1 Concurrently, the nursing community identified pressure ulcers (PUs) as a nursing-sensitive quality indicator. The goal for the summit was both bold and poignant: To develop a framework by which facilities could develop and sustain PU prevention programs, with true interprofessional collaboration, across the globe.

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The VCU Pressure Ulcer Summit

PUs are not solely a nursing problem; they are a product of organizational culture change, bound by the concept of mutual accountability. An organization’s PU champions are required to accurately assess and classify pressure injury, collect data, and, most importantly, report on a regular basis to executive administration. Conversely, a facility’s leadership team must review the data, identify obstacles for improvement, promote the dissemination of best practices and processes, and remove the barriers to quality care. Nursing should lead the charge, but we can’t fix the problem alone. We need executive administration to be our biggest cheerleaders, our strong arm of support, our partners in prevention. We need to use data to properly allocate resources and recruit interprofessional champions. We need quality equipment and products to ensure positive outcomes. Nurses have led major quality and process improvement projects within their healthcare organizations, and yet challenges of sustainability, risk adjustment, and unavoidability persist.

Understanding the need for a collaborative solution, the chief executive officer and chief nursing officer of VCU Medical Center provided the resources to host the summit of 55 international experts in PU prevention, quality improvement, informatics, and regulatory and accreditation, representing the disciplines of nursing, medicine, physical therapy, and research. The content experts for the VCU_PUS were charged to address 1 of these 3 foci: sustainability, risk adjustment, and unavoidability.

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Despite excellent guidelines developed by professional organizations and regulatory bodies, the struggle to sustain PU prevention initiatives across the healthcare landscape remains. While these guidelines provide excellent resources for evidence-based practice, the challenge lies in operationalizing them. Could a framework delineating the interprofessional role and organizational structure of top-performing hospital PU programs be developed for use by other organizations seeking excellence in HAPU prevention sustainability? The development of this framework was 1 of the primary goals of VCU_PUS subcommittee 1.

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Risk and Severity

The question of risk adjustment and PU severity was a secondary summit focus. Risk adjustment is a corrective methodology designed to account for differences in risk between specific patients. Therefore, developing a risk adjustment tool would provide a leveling of the playing field by capturing the true difficulties in preventing PUs in identified high-risk patient groups. In large academic medical centers, with high patient acuities, equally high PU rates may indicate relative patient risk more than poor practice. Risk adjustment tool development is VCU_PUS subcommittee 2’s goal.

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This group addressed the well-published and controversial standing that not all PUs are avoidable.2 The definition of an unavoidable PU is “a PU that can develop even though the provider evaluated the individual’s clinical condition and PU risk factors; defined and implemented interventions consistent with individual needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate.”2(p29) As the patient migrates through the healthcare system, how do clinicians with competing demands recall, deliver, and document evidence-based interventions? Checklists improve safety and reliability in the aviation and construction industries and have been suggested for use in healthcare by leading surgeons and the World Health Organization.3,4 Summit subcommittee 3 decided setting- and department-specific prevention checklists should be developed. Furthermore, a gap in research was identified related to our understanding of unavoidable PUs, terminal tissue injuries, and differential diagnosis of uncharacteristic skin injury, necessitating the development of a database for future research.

The gathering of national experts in a summit forum has proven to be a model that optimized expertise efficiently and effectively. Among the most noteworthy attendees were the 12 staff nurses from VCU’s unit-based skin champion team. Their voice in the roundtable discussion held equal weight to the scholarly experts, freely objecting or confirming bedside experience versus expert opinion. The VCU_PUS identified areas of opportunity, research gaps, and practice innovations. The high-quality deliverables developed by VCU_PUS attendees were aimed at providing clinical guidance and creating new knowledge. The overarching goal of this innovative summit, led and designed by nurses, is to demonstrate the ability to achieve and sustain HAPU reduction outcomes, capturing the power of Magnet® to unify and deliver a framework for change and the application of evidence spanning care settings, states, and countries.

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1. Centers for Medicare & Medicaid Services. Hospital acquired conditions. 2012. Accessed May 15, 2014.

2. Black J, Edsberg LE, Baharestani MM, Langemo D, Goldberg M, et al. Pressure ulcers: avoidable or unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference. Ostomy Wound Manage. 2011; 57 (2): 24–37.

3. Gawande A. The Checklist Manifesto. New York, NY: Metropolitan Books; 2009.

4. Haynes AB. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009; 360: 491–499.

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