EVERY YEAR in the United States, an estimated 2.5 million patients are treated for pressure ulcers in acute care facilities. The estimated cost of managing a single full-thickness pressure ulcer is as high as $70,000, and the total cost for treating pressure ulcers in the United States is estimated at $11 billion/year.1
Our 166-bed acute rehabilitation hospital found that a standardized approach to pressure ulcer risk assessment and prevention dramatically reduced hospital-acquired pressure ulcers and improved patient clinical outcomes. This article describes what we did.
A pressing problem
In June 2007, our facility noticed an upward trend in pressure ulcers, mainly in patients on the orthopedic and multimedical units. The patient population at our facility includes but isn't limited to patients with stroke, traumatic brain injury, amputation, spinal cord injury, multiple sclerosis, hip fracture, Parkinson disease, and burns.
An interdisciplinary team was developed to evaluate the current wound management assessment, documentation, and education processes. Team members included the clinical wound specialist, assistant director of nursing, nurse managers, staff nurses, rehabilitation nursing technicians (unlicensed assistive personnel), therapists, physiatrist, and dietitian.
The team took an in-depth look at each hospital-acquired pressure ulcer case in 2007 and gathered information about the circumstances that may have led to the skin breakdown. Of the many issues discovered, one of the most significant was misidentification of pressure ulcers present on admission: If the admission clinician doesn't do a thorough skin assessment, an existing pressure ulcer may be missed at patient admission. When the pressure ulcer is later found, it's considered a hospital-acquired condition. Under the new reimbursement rules from the Centers for Medicare and Medicaid Services, facilities aren't reimbursed for the costs of managing pressure ulcers acquired after admission.
Also, daily RN skin assessments were incomplete and often not inclusive. Healthcare providers at times incorrectly documented other skin conditions, such as denuded skin, as pressure ulcers. Also, many pressure ulcers were incorrectly staged.
Other issues that stood out were fragmentation in documentation (too many places to document), a lack of understanding of what constituted a thorough visual head-to-toe skin assessment, incomplete and inaccurate assessments, incomplete pressure ulcer prevention protocols, lack of transcription of the interventions to the appropriate document, and inconsistent documentation of interventions.
The team also wanted to take a more comprehensive look at the consistency of prevention interventions occurring at the bedside. A patient with a pressure ulcer or at risk for a pressure ulcer is put on our pressure ulcer prevention protocol, a standard care plan with basic interventions for preventing and treating pressure ulcers. The plan is individualized to the patient's needs, and further interventions may be added to the nursing care plan as needed.
The pressure ulcer prevention protocol, used for patients with a Braden Scale score of 18 and below (the best score on the scale is 23), consists of interventions that correlate with the Braden score on each of the six subscales. Examples of interventions include turning and repositioning every 2 hours, toileting programs, and specialty bed and heel protection.
In response to the team's findings, our facility also took actions in these areas:
* Education. Staff-development sessions on proper assessment, staging, and accurate completion of the pressure ulcer prevention protocol are offered on orientation, annually, and on an individual basis as needed. Other information is available on a website link available to staff on each unit. Rehabilitation nursing technicians were trained in proper incontinence care and pressure ulcer prevention strategies. A renewed emphasis on education for rehabilitation nursing technicians highlighted the importance of their role at the bedside in pressure ulcer prevention. Physical and occupational therapy staff also received education on the pressure ulcer prevention protocol and pressure ulcer staging.
* Documentation. The documentation process was streamlined so that all wound care was documented on one form. This improved compliance with documentation almost immediately. Timely and accurate completion of documentation increased from 60% to 90% within the first 90 days.
* Workshops. We revised the wound-care workshop that nurses attend during orientation, given by the clinical wound specialist to emphasize accurate identification and staging of pressure ulcers, and the importance of detailed documentation. This education is reinforced after 2 months, when each nurse attends wound rounds with the wound team and spends one-on-one time with the clinical wound specialist to practice pressure ulcer staging and perform wound assessments.
* Case studies. Case studies are completed by the wound nurse and nurse managers on all patients with hospital-acquired pressure ulcers to identify trends, practice issues, and areas for follow-up. These data are presented to unit staff and skin-/wound-care committee members. Reporting hospital-acquired pressure ulcers is encouraged as an opportunity for education and improved patient care, not a reason to discipline staff because a pressure ulcer wasn't prevented.
* Setting benchmarks. We revised hospital and unit rate goals after averaging the previous 3 years of pressure ulcer data. Report cards were posted on the units so staff could see what their unit rate was in comparison to other units. This let staff be more cognizant of pressure ulcer development and the interventions being used to decrease that rate.
* "Walk rounds." Once the documentation was in place, the committee decided to evaluate compliance at the bedside with the pressure ulcer prevention protocol. Formal weekly "walk rounds" were conducted by the committee to spot-check interventions being performed during each shift. Increased observation has resulted in increased compliance.
* Survey. All staff members were asked to identify barriers to performing skin prevention interventions. When the staff indicated that some patients didn't like the feel of heel pressure-relieving boots, we started trials with pillows to float heels off the bed. The outcome thus far has been positive: Patients find them to be much more comfortable, they aren't as cumbersome for staff to use, and they're more economical. Proper pillow positioning is included during hourly rounds to ensure heel protection. What's more, the use of pillows was as effective as pressure-relieving boots in reducing heel pressure ulcers.
* Newsletter. To maintain the focus on the treatment of hospital-acquired pressure ulcers as a "top-of-mind" issue for all personnel, the team published quarterly newsletters that are attached to paychecks. These newsletters outline findings, results, and new initiatives in pressure ulcer management.
* Brochure. We developed a patient/family education brochure on preventing and treating pressure ulcers to review with the patient and family. Prevention interventions are also reviewed on admission with the patient. This has increased patient/family involvement in the patient's overall plan of care.
As a result of this effort, our facility's hospital-acquired pressure ulcer rate dropped 82.8% in 1 year—from 2.8% in June 2007 to 0.48% in June 2008. By September 2009, the rate had dropped again, to 0.46%—a pressure ulcer rate well below the national average. More importantly, in the last year, no patients on our neurobehavioral stroke unit have developed pressure ulcers, despite their limited mobility and other medical challenges.
By adopting a zero-tolerance philosophy for hospital-acquired pressure ulcers, we've made great strides and are prepared to tackle the ongoing challenge of continuously improving and maintaining quality patient care.