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PROTECTING PATIENTS FROM HARM: Preventing pressure ulcers in hospital patients

Ayello, Elizabeth A. RN, APRN, BC, CWOCN, PhD, FAAN, FAPWCA; Lyder, Courtney H. RN, ND

doi: 10.1097/01.NURSE.0000291986.93689.01

Follow these six steps to maintain moisture balance and keep your patient's skin intact.

Nurses and hospitals are feeling the pressure to prevent these painful and costly complications. Follow the six steps detailed here to keep your patient's skin intact. This is the third article in a series highlighting practice initiatives promoted in the Institute for Healthcare Improvement's 5 Million Lives Campaign.

Elizabeth A. Ayello is a faculty member at Excelsior College School of Nursing; clinical associate editor for Advances in Skin & Wound Care; president of Ayello, Harris and Associates in New York, N.Y.; and a member of the Nursing2007 editorial advisory board. Courtney H. Lyder is a professor in the school of nursing of the University of Virginia at Charlottesville.

Dr. Ayello has received honorariums or is on the speakers bureau for Smith & Nephew, Hill-Rom, Organogenesis, Sage, KCI, Hollister, and the New Jersey Hospital Association (grant partially supported by 3M Health and Healthpoint). Dr. Lyder is on the speakers bureau for ConvaTec, KCI, and Hill-Rom.

DESPITE NATIONAL GUIDELINES on preventing and treating pressure ulcers, these wounds are becoming increasingly common in hospitalized patients. An estimated 2.5 million patients are treated each year in U.S. acute care facilities for pressure ulcers.1 An estimated 60,000 patients die each year of pressure ulcer complications, and the cost of treating these wounds is estimated at $11 billion per year.2

Because pressure ulcers can lead to pain, loss of function, infection, extended hospital stay, and increased costs, the Centers for Medicare and Medicaid Services has proposed that, starting in October 2008, it discontinue extra payments to facilities to cover the cost of pressure ulcers patients develop during hospitalization.3 So facilities will need to develop aggressive programs for preventing pressure ulcers. More recently, the Institute for Healthcare Improvement (IHI) has made preventing pressure ulcers one of 12 interventions in its 5 Million Lives Campaign.4 This article is the third in a five-part series focusing on the current IHI campaign. (See About this series.)

The good news is that many pressure ulcers are preventable. In this article, we'll look at the IHI's recommended steps for preventing pressure ulcers and discuss how two successful pressure ulcer prevention programs influenced those recommendations. (See Exemplars of success in pressure ulcer reduction.) Let's start by reviewing pressure ulcers and the steps that IHI recommends to prevent and manage them.

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Pressure ulcers: What lies beneath

Pressure ulcers usually occur over bony prominences such as the sacrum or heels, where unrelieved pressure damages underlying tissue. Friction and shear, combined with pressure, also can cause a pressure ulcer, according to the revised definition from the National Pressure Ulcer Advisory Panel (NPUAP). (See Setting the stage for more on pressure ulcer staging.) Muscle and subcutaneous tissue are more susceptible to pressure than skin, so the damage can be worse than you might think from initial appearance.

The staging system used for pressure ulcers was developed in the late 1980s by an NPUAP consensus conference and revised in February 2007. Nurse-researchers have developed several different risk assessment scales for clinicians to use to identify patients at risk for pressure ulcers, and the Agency for Healthcare Research and Quality (formerly Agency for Health Care Policy and Research) developed guidelines for pressure ulcer prevention and treatment.5-9 Additional guidelines have been developed by the Wound, Ostomy and Continence Nurses Society and the Wound Healing Society.10,11

Pressure ulcers in hospitalized patients are now reportable in several states. In New Jersey, pressure ulcers have been designated as a preventable adverse event (also called “never events”). New Jersey hospitals must report within 3 working days any Stage III or IV pressure ulcers acquired after a patient is admitted to a health care facility.12

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Following IHI's recommendations

The IHI recommendations for preventing pressure ulcers start with identifying patients at risk and reliably implementing prevention strategies for all patients identified as being at risk. These two steps are further broken down into six essential elements of pressure ulcer prevention, with suggested processes to achieve each element.4 Let's look at each step more closely.

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1. Conduct a pressure ulcer admission assessment for all patients

When a patient is admitted, assess his skin for existing pressure ulcers and perform a risk assessment to determine if he's at risk for developing a pressure ulcer. A patient who has a pressure ulcer on admission is at risk for developing more pressure ulcers. Risk factors for pressure ulcers include advanced age, immobility, incontinence, inadequate nutrition, sensory deficiency, comorbid conditions, circulatory abnormalities, and dehydration. Use a validated pressure ulcer risk assessment tool such as the Braden Scale.

Remember that it's not just about the total risk assessment score. Your pressure ulcer prevention interventions should be targeted for a patient with a low score in any of the risk subcategories. Remember that patients in the emergency department (ED) who've been admitted to the hospital also need a pressure ulcer risk assessment. The ED staff can perform this assessment while the patient is waiting for his bed to be ready.

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2. Reassess risk for all patients daily

The IHI is among the first to recommend daily assessment for pressure ulcer risk, recognizing that because of the acuity and complexity of hospitalized patients, the risk profile can change during hospitalization.

To ensure daily reassessment of pressure ulcer risk, facilities should choose a standard, validated reassessment tool and adapt it for fast and easy clinical use (for example, with check boxes and short phrases for easy documentation). Documentation forms could include prompts to remind clinicians to perform a daily pressure ulcer risk assessment. The facility's policies and procedures should indicate who and which shift is responsible for doing the daily assessment. Remember that any time the patient's condition changes, he should be reassessed for pressure ulcer risk.

Once a patient is identified as at risk for pressure ulcer development, let the whole health care team know. All levels of staff should be educated about pressure ulcer risk factors and the process for implementing prevention strategies. Additional visual clues, such as stickers in the patient's medical record or color markings on the patient's ID band, can help remind staff that the patient is at risk for pressure ulcers.

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3. Inspect skin daily

This is especially important for patients at high risk for skin breakdown. All staff members should inspect the patient's skin—when assisting the patient to a chair or during bathing, for example. Pay particular attention to his sacrum, back, buttocks, heels, and elbows. Always look at the skin beneath tubes and other devices that could cause an ulcer. In obese patients, skin injuries can occur from the skin-to-skin contact in areas such as the breast, abdomen, and knee. Remember that skin integrity can deteriorate within hours. Report changes in skin integrity to the appropriate staff member so interventions can be started immediately. Follow your facility's policy for documenting any pressure ulcers you find.

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4. Manage moisture

A moist environment helps wound healing, but excess moisture can lead to rashes and faster skin breakdown. Clean the patient's skin at routine intervals and any time he's incontinent. Watch for excessive moisture caused by incontinence, perspiration, or wound drainage. Use an appropriate cleaning agent that won't irritate or dry the skin, applying it gently without undue rubbing.

Many skin care products can protect the skin from excess moisture. Keep supplies at the bedside for incontinent patients. Provide underpants that wick moisture away from the skin, clean soiled skin promptly, and apply a topical moisture barrier to protect the skin and prevent skin breakdown.

Dry skin also is susceptible to breakdown. If the patient's skin is dry and fragile, apply moisturizers.

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5. Optimize nutrition and hydration

Poor nutrition and dehydration can contribute to pressure ulcers. Unintentional weight loss may be an indication that the patient is at nutritional risk. Document the patient's nutritional intake and notify the health care provider or nutritionist if his intake is inadequate. Use supplements as needed. One strategy to increase caloric intake is to use an isotonic nutritional supplement rather than water when administering medications to the patient. Respect the patient's dietary preferences as much as medically possible. Monitor hydration status and offer water (if appropriate) whenever he's repositioned.

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6. Minimize pressure

Patients with limited mobility are at particular risk for pressure ulcers: Long periods of low pressure are as dangerous to tissue as short periods of high pressure. Most patients should be turned or repositioned every 2 hours, but those with very fragile skin or little subcutaneous tissue may need to be repositioned more frequently. Use alerts and cues to remind staff to turn the patient. To protect his skin during turning, use lift devices or drawsheets, heel and elbow protectors, or sleeves and stockings.

Because heel ulcers are the second most prevalent pressure ulcer, and can be difficult to heal, remember to use heel protectors or heel lift suspensions. Make sure you know if the support surface your patient is on has a built-in heel-pressure-relieving function, and, if so, use it.

Never drag the patient. Keep the head of the bed at 30 degrees or less (unless contraindicated) to reduce pressure, friction, and shearing forces on his sacrum.

Use pillows and cushions to help relieve pressure. Specialty pressure-relieving support surfaces, such as mattresses, should be used when appropriate. A good support surface redistributes pressure without harming skin, keeps the patient's skin dry and doesn't make him sweat, and doesn't promote bacterial growth. Make sure the bed can accommodate the patient's weight, and use a bed designed for bariatric patients if indicated. Make sure you know how to operate the bed or support surface correctly.

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Taking a load off

Preventing pressure ulcers isn't a new concern, but how to do it effectively has been a topic of interest for hundreds of years. By building on successful pressure ulcer prevention programs, the IHI's approach offers a practical tool kit for reducing pressure ulcer incidence by one-third in the next few years.

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Exemplars of success in pressure ulcer reduction

When the IHI developed its recommendations for preventing pressure ulcers, it looked to two success stories: the New Jersey Hospital Association (NJHA) and the St. Louis, Mo.-based Ascension Health system.

No ulcers in New Jersey

Using the theme “No Ulcers,” the NJHA developed a series of educational programs, an e-mail information distribution list, and monthly conference calls with leading national and international pressure ulcer experts. “No Ulcers” is an acronym for Nutrition and fluid status, Observation of skin, Up and walking or turn and position, Lift (don't drag) skin, Clean skin and continence care, Elevate heels, Risk assessment, and Support surfaces for pressure redistribution.

The NJHA's 125 care partners from hospitals, long-term care, home health care, and rehabilitation and other facilities sought to reduce pressure ulcers by 25% in 1 year. Quality improvement data reports from collaborative partners, as well as pressure ulcer knowledge, were collected. An important focus was on communication and changing institutional culture to support pressure ulcer reduction. After 20 months of data reporting, a 70% reduction in pressure ulcer incidence and 30% reduction in pressure ulcer prevalance were reported among reporting partners across the care continuum, according to an article in The New York Times. Education programs and conference calls raised the knowledge level for nurses involved in the collaborative program; certified nurses had the highest scores.

Focusing on SKIN at Ascension

Ascension Health, the largest not-for-profit health care system in the United States, has 70 acute care hospitals, long-term-care facilities, and rehabilitation hospitals in 20 states and the District of Columbia. The system chose pressure ulcer prevention as one of its eight targeted care areas for a quality improvement effort launched in February 2004.

Nurses throughout Ascension Health created and implemented care methods under the SKIN (Surface selection, Keep turning, Incontinence management, and Nutrition) bundle. The SKIN bundle was tested in all of Ascension's acute care and long-term-care facilities and has reduced pressure ulcer incidence to about 1.4 per 1,000 patient days systemwide. Six of the system's hospitals had no acquired pressure ulcers for 1 year. Almost all the pressure ulcers that did occur were Stage I or II, as most Stage III and IV ulcers were eliminated.

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Setting the stage

In February 2007, the NPUAP revised the classic definition of a pressure ulcer and expanded the staging system to six categories. A pressure ulcer is now defined as a localized injury to the skin or underlying tissue, usually over a bony prominence, as a result of pressure in combination with shear or friction.

The IHI's campaign focuses on the fact that in most cases, pressure ulcers are preventable. However, if they do occur, stage pressure ulcers using the NPUAP's recently revised system:

  • Suspected deep tissue injury—a purple or maroon localized area of discolored intact skin or blood-filled blister, caused by damage to the underlying soft tissue from pressure or shear. The area may be painful, firm, mushy, boggy, warmer, or cooler, compared with adjacent tissue. In patients with dark skin tones, deep tissue injury may be difficult to detect, but may start with a thin blister over a dark wound bed. The wound may evolve and become covered with thin eschar. Even with optimal treatment, the wound may evolve rapidly, exposing additional layers of tissue.
  • Stage I pressure ulcer—intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler, compared with adjacent tissue. This stage may be difficult to detect in patients with dark skin tones.
  • Stage II pressure ulcer—partial-thickness loss of dermis presenting as a shiny or dry shallow open ulcer with a red-pink wound bed, without slough or bruising. (Note that bruising indicates suspected deep tissue injury.) May also present as an intact or open/ruptured serum-filled blister. Stage II shouldn't be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.
  • Stage III pressure ulcer—full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, and muscle aren't exposed. Slough may be present but doesn't obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Stage III pressure ulcer varies depending on its anatomic location. On the bridge of the nose, ear, occiput, and malleolus, which lack subcutaneous tissue, these ulcers are shallow. Extremely deep Stage III pressure ulcers can develop in areas of significant adiposity.
  • Stage IV pressure ulcer—full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining or tunneling. As with Stage III pressure ulcers, Stage IV pressure ulcers vary in depth depending on their location. Because these ulcers extend into muscle and supporting structures, the patient also is at risk for osteomyelitis.
  • Unstageable pressure ulcer—full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) or eschar (tan, brown, or black). The true depth and stage of the ulcer can't be determined until enough slough and eschar are removed. Stable eschar on the heels provides a natural biologic cover and shouldn't be removed.
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About this series

This article is the third in a five-part series examining new interventions recommended by IHI's 5 Million Lives Campaign, which challenges American hospitals to adopt 12 changes in care that save lives and prevent injuries. The goal is to prevent 5 million incidents of medical harm in a 2-year period (December 2006 to December 2008).

The 5 Million Lives Campaign incorporates the six interventions from the 100,000 Lives Campaign plus six new interventions, as follows.

Six interventions from the 100,000 Lives Campaign:

  • Deploy rapid response teams.
  • Prevent ventilator-associated pneumonia.
  • Prevent adverse drug events.
  • Prevent central line infections.
  • Prevent surgical site infections.
  • Deliver evidence-based care to treat acute myocardial infarction.

Six new interventions from the 5 Million Lives Campaign:

  • Reduce surgical complications by reliably implementing all the changes in care recommended by the Surgical Care Improvement Project.
  • Prevent harm from high-alert medications, starting with a focus on anticoagulants, sedatives, opioids, and insulin.
  • Prevent pressure ulcers by reliably using science-based guidelines for their prevention.
  • Deliver reliable, evidence-based care for heart failure to avoid readmissions.
  • Reduce methicillin-resistant Staphylococcus aureus infection by reliably implementing scientifically proven infection control practices.
  • Get boards on board by defining and spreading the best-known leveraged processes for hospital boards of directors, so that they can become far more effective in accelerating organizational progress toward safe care.

In the August and September issues of Nursing2007, we examined the IHI's interventions for reducing surgical complications and preventing harm from high-alert medications. Next month, we'll discuss heart failure recommendations. For a detailed look at the 100,000 Lives Campaign from a nursing perspective, see the six-part Best-Practice Interventions series appearing in the January through June issues of Nursing2006.*

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About the IHI

Founded in 1991 and based in Cambridge, Mass., the IHI is a not-for-profit organization that leads the improvement of health care throughout the world by inspiring change, cultivating innovative concepts for improving patient care, and implementing programs for putting these ideas into action to achieve breakthrough results. Its highly successful 100,000 Lives Campaign was a nationwide initiative to radically reduce morbidity and mortality in American hospitals. Building on the successful work of health care providers all over the world, the campaign promoted the widespread deployment of best practices proven to save lives. The IHI estimates that facilities participating in the 100,000 Lives Campaign avoided more than 122,000 unnecessary deaths during the 18-month campaign period (December 2004 to June 2006). The successor to the 100,000 Lives Campaign—the 5 Million Lives Campaign—aims to reduce medically induced harm in addition to continuing to fight needless deaths. To learn more, contact the IHI at 1-866-787-0831 or visit

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