Experts Share Best Practices in Preventing Pressure Ulcers

<p>Hospital-acquired pressure ulcers are a costly, adverse event. The National Pressure Ulcer Advisory Panel estimates that U.S. healthcare systems spend $11 billion treating each year treating pressure ulcers; the cost to treat each pressure ulcer and related complications can range from $500 to $70,000.&nbsp; Outside of the financial cost, pressure ulcers can have a devastating effect on patients&mdash;from the risk of developing cellulitis or infection of joints and blood, to increased length of stay and higher risk of death from associated complications.</p>

By Karin Lillis

Hospital-acquired pressure ulcers (HAPU) are a costly, adverse event. The National Pressure Ulcer Advisory Panel estimates that U.S. healthcare systems spend $11 billion treating each year treating pressure ulcers; the cost to treat each pressure ulcer and related complications can range from $500 to $70,000. Outside of the financial cost, pressure ulcers can have a devastating effect on patients—from the risk of developing cellulitis or infection of joints and blood, to increased length of stay and higher risk of death from associated complications.

Since 2008, the Centers for Medicare and Medicaid Services (CMS) stopped paying for additional costs related to hospital-acquired pressure ulcers, and the agency considers stage 3 and 4 pressure ulcers as a “never” event.

Wound care experts from three healthcare organizations share best practices from their facilities.
Pressure Ulcer Prevention Team
Peninsula Regional Medical Center in Salisbury, Md., cut the rate of hospital-acquired pressure ulcers among its patients by more than half—in less than a year. At one point, Peninsula Regional reported that 3.1 percent of its patients developed pressure ulcers over a one-year period. During a single-day sample taken, the number was nearly 1 in 10 patients (9.5 percent).

After developing a pressure ulcer prevention team, the hospital’s average annual pressure ulcer rate dropped to 1.2 percent; another single-day sample taken showed just 2.9 percent of patients were diagnosed with HAPU.

“It’s amazing how we’re much more proactive. We’ve created an environment where we prevent pressure ulcers the best we can, instead of reactively handling them after one has occurred,” says Debra Sheets, MN, RN, NEA-BC, director of special projects at Peninsula Regional.

The hospital created a multidisciplinary pressure ulcer prevention team that included nurses (“skin champions”) from all hospital units, two physicians, a physical therapist, a clinical nurse specialist, a coding specialist, a clinical analyst from the performance improvement department, and a certified wound care nurse from the hospital’s wound care center, Sheets says. The team was first tasked with finding the reasons behind the relatively high number of HAPU.

The team found four key elements that drove Peninsula Regional’s high rate of hospital-acquired pressure ulcers: “confusion and errors with our treatment versus prevention order sets; lack of physician documentation regarding ‘present on admission’ status; lack of staff knowledge regarding the appropriate recognition of ‘wounds’ versus pressure ulcers and staging of pressure ulcers; and computerized documentation processes that were very confusing and difficult to follow,” Sheets writes in a report for the Maryland Patient Safety Center.

“The solutions we came up with were designed to be integrated into our process, rather than ‘extra’ things the care team had to do,” Sheets says.

Sheets and her team developed several solutions. First, Peninsula Regional changed pressure ulcer prevention treatment from a physician order set to nursing protocol that any RN can order when he or she encounters a high-risk patient. The hospital also required all bedside RNs to undergo a 4-hour training on preventing and staging pressure ulcers.

The hospital also had a decision support tool built into its electronic medical record system. “There was a way for the system to alert us to all of the different patients who were at high risk for pressure ulcers,” Sheets says. “You could see a system alert that flagged a patient as high-risk and tell whether the prevention protocol was implemented.” Additionally, an automated order set now requires doctors to document whether a pressure ulcer is present on admission.

The hospital also does quarterly pressure ulcer surveys for NDNQI, and bedside nurses are trained to detect and stage wounds, Sheets says. The hospital also created a database that included the number of patients admitted with pressure ulcers, documented at-risk patients, those who were evaluated on a daily basis, and patients who had a nursing-documented pressure ulcer.

“We also did a lot with reorganizing the storage of the equipment and supplies. We looked at what the nurses needed. You have to make it as easy as possible for that nurse to provide good skin care,” Sheets says. “You really have to involve the staff. They have the best ideas, and they know the barriers at the bedside.”

Streamlining Protocol
Megan Anderson, BSN, RN, CWOCN, and her colleagues looked at the lengthy documentation and intervention process that nurses had to complete every time they detected a patient who was at risk for a pressure ulcer. Staff at North Memorial Medical Center in Robbinsdale, Minn., had to carry out a pressure ulcer prevention bundle that included 37 interventions—from a document that was several pages long.

“We had to come up with a simpler protocol,” Anderson says. “It was just a lot for the nurses do get through. We looked at the highest level of intervention and condensed them to just a handful.”

Anderson and her colleagues decided to target three of the hospital’s critical-care units during a two-phase project. During the first phase, the team reviewed the comprehensive pressure ulcer protocol in use at the time—which included the lengthy bundle and a consult with a wound care nurse before treatment was rendered. The second phase targeted a universal pressure ulcer prevention bundle with a proactive wound care nurse. The new bundle included five evidence-based interventions regardless of the patient’s risk for pressure ulcers, Anderson says.

“The goal of the project was to create simpler protocol and give the bedside nurse tools so they didn’t have to wait for the wound care nurse to come in and tell them what to do,” she says.

The process was so much easier, she notes. “There were large, visible signs in every room and the staff didn’t have to go through several pages to complete the evaluation,” Anderson says. Anderson and another wound care nurse rounded regularly as well. “It made a difference—if a nurse didn’t complete the assessment and then saw the wound care nurse, it jogged their memory,” she says.

Anderson describes the project as “absolutely successful. On the critical care units we monitored, we ended up at 2.3 percent at the end of the project. Before the hospital launched the streamlined bundle, 27 patients on the units developed pressure ulcers, most of them device-related.
“After we rolled out the education and launched the initiative, we had three pressure ulcers,” she says.
The hospital has since adopted the pressure ulcer prevention bundle facility-wide.

The Turn Team
Mary Still, MSN, APRN, ACNS, ANP-BC, CCRN, a critical-care clinical nurse specialist with Emory Healthcare in Atlanta, led a project that showed that a dedicated turn team “dramatically decreased the incidence of pressure ulcers.” Specifically, Still and her team report a marked decrease of stage 1 and stage 2 ulcers in lower-risk patients.

“On my unit (a surgical ICU) we had a very high pressure ulcer rate—and it wasn’t getting any better,” Still says. “We had done multiple things to try to improve that rate—including daily rounds with staff at the bedside. We had to figure out where we were missing the mark. No matter what we did, it was impossible for the bedside nurse alone to turn patients every two hours sufficiently.”

The 20-month study included 507 patients on a 20-bed surgical ICU who all were assessed for pressure ulcers. Before Still and her colleagues launched the turn team, the hospital reported 42 hospital-acquired pressure ulcers—mostly stage 2 wounds on the sacrum and buttocks—among 278 patients. After a two-person team of patient care associates (PCAs) began turning patients every two hours, that rate dropped to 12 pressure ulcers among 229 patient, Still notes.

First, Still’s team provided online pressure ulcer prevention and staging training for the surgical ICU’s registered nurses and PCAs. Next, they created a “turn team” that consisted of two PCAs, who were responsible for turning or repositioning “all hemodynamically stable patients around the clock,” every two hours. Emory’s surgical intensive care unit eventually changed the team to one bedside RN and one PCA.

“We went from 42 pressure ulcers down to 10 or 12. It was a huge improvement – particularly with early stage ulcers. That was important—we were able to prevent pressure ulcers from happening,” Still says.
Currently, the turn team now standard on Emory’s intensive care units—and Still reports the practice continues to be successful. Of 485 opportunities to monitor patients for risk as part of National Database of Nursing Quality Indicators data collecting, staff only detected 19 hospital acquired pressure ulcers.
 “One of the most efficient things we did was make it a task. If you have in your chart you have to turn the patients every two hours, it becomes a habit. Just like checking vitals. Developing a process of care allows you to sustain the type of changes that we made—simply seeking a huge reduction in pressure ulcers was a nurse satisfier,” Still says.

Karin Lillis is managing editor of EndoNurse, an Informa Exhibitions publications.

Anderson M. (2012). Universal pressure ulcer prevention bundle with WOC nurse support. Retrieved from

National Pressure Ulcer Advisory Panel. (2015). Updated research priorities identified for pressure ulcer prevention, treatment & policy. Retrieved from

Sheets D. (2011). A multidisciplinary approach to hospital-acquired pressure ulcer reduction. Retrieved from:

Still M, et al. (2013). The turn team: A novel strategy for reducing pressure ulcers in the surgical intensive care unit. J Am Coll Surg 2013;216:373-379. Retrieved from:

U.S. Centers for Medicare and Medicaid. (2008). State Medicaid director letter. Retrieved from:

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