CMS to Put Pressure on Providers for Decubitus Ulcer Prevention

Pressure ulcers are usually expensive, painful and preventable. They are also one of the conditions for which the Centers for Medicare & Medicaid Services (CMS) will not reimburse, unless it is proven that the patient had the condition upon hospital admission.

This change will go into effect in October 2008, and affects reimbursement for urinary catheter infections, coronary artery bypass graft infections, and other illnesses and adverse events. Since pressure ulcers are common and expensive to treat, the reimbursement changes could have massive repercussions on hospital budgets.

Pressure ulcers are areas of localized damage to the skin and underlying tissue and are caused by pressure or friction,1 and are also known as pressure sores, bed sores and decubitus ulcers. Elderly and/or immobile patients are the most frequent victims, even though a wealth of mattresses, seat cushions and other products are available to prevent pressure ulcers. More so, there is widespread clinical knowledge about how to prevent these wounds, and yet they occur anyway.

In 2007, CMS reported 257,412 cases of preventable pressure ulcers as secondary diagnoses.1 The average cost for these cases was $43,180 per hospital stay.1 The incidence of new pressure ulcers in acute-care patients is around 7 percent, with wide variation among institutions, according to a consensus paper from the International Expert Wound Care advisory panel.

The CMS changes were authorized by Congress in the Deficit Reduction Act of 2005, and are meant to prevent conditions for which there are “widely accepted evidence-based guidelines,” says Ellen Griffith, a CMS spokesperson.

CMS is not asking hospitals to be guarantors against all possible adverse occurrences during a hospital stay, Griffith says.

“It is simply asking hospitals to make sure that hospital staff do what they should be doing anyway — like washing their hands before touching a patient, or observing other sanitary precautions,” she adds. “The underlying rationale is that neither Medicare nor the beneficiary should pay a hospital for the higher costs of treating a condition that was acquired during the hospital stay and that was determined to be reasonably preventable through compliance with widely accepted, evidence-based guidelines.”

Industry Reaction

The CMS reimbursement changes might encourage providers to further intensify their efforts, says Janet Corrigan, PhD, president and CEO of the National Quality Forum, a not-for-profit membership organization that develops national strategies to measure healthcare quality.

“Healthcare professionals want the best for their patients,” Corrigan adds. “I have no doubt they will embrace this as an opportunity to refocus and amplify institution-wide efforts to enhance safety.”

There is a renewed urgency and heightened focus on prevention as a result of the CMS changes, according to members of the International Expert Wound Care advisory panel.

“Like any groundbreaking policy, this provides impetus for change,” they wrote in the aforementioned consensus paper. “We view this payment provision as challenging, but one that provides all clinicians and particularly wound care specialists with an opportunity to assume leadership in important preventive healthcare strategies.”

It’s crucial that healthcare facilities take a hard look at their current pressure ulcer prevention strategies to make certain they are optimal, according to the creators of Medline’s Pressure Ulcer Prevention Program. This program was released recently and combines a product bundle, education and training, and program support to assist in reducing healthcare-acquired pressure ulcers.2 It was created by a panel of wound care specialists.

The product bundle includes moisturizers, cleansers, protectants and antifungals, all of which contain amino acids, vitamins and antioxidants. Incontinence products are also part of the product bundle. In a press release, Medline representatives stated that they know the care of incontinent patients is “extremely challenging and time-consuming.”

The Medline bundle program includes training through workbooks (for nurses, nurse assistants, and instructors) that show how to prevent pressure ulcers. The program also offers patient and family education brochures, and a rewards program for staff members who comply with good practices.


Incontinence provides almost endless challenges to patient care, especially when it comes to skin health. However, much better care could be given, according at least to a survey by Sage Products.

According to Sage, in a recent nursing opinion poll 84 percent of the 191 wound ostomy continence nurses who responded said nurses and technicians did not fully comply with incontinence skin care protocols. The poll was conducted in June at the Wound Ostomy Continence Nurse Society’s annual meeting.3

“Incontinence skin care is critical to preventing skin breakdown, which increases the risk for pressure ulcers, a preventable and costly condition,” says clinical nurse specialist Kathleen Vollman, MSN, RN. “Pressure ulcers increase patient’s length of stay in the hospital and can increase morbidity and mortality.”3

Nurses cited several reasons why their staff is not fully compliant with hospital protocol:3

Protective barrier creams are not readily available at the bedside

Variation from effective, established processes

Staff time constraints and employee turnover

Lack of education about basic skin care

According to the survey, skin breakdown occurs most often on the sacrum, perineum, coccyx/buttocks (75 percent) and heels (21 percent). Other areas on the body that also were mentioned include skin folds and hips.3

Patients with fecal incontinence are 22 times more likely to develop pressure ulcers than if they did not have this condition.3

Support Surfaces

A study, “Support surfaces for pressure ulcer prevention” sought to find out to what extent pressure-relieving cushions, beds, mattress overlays and mattress replacements reduce the formation of pressure ulcers compared with standard support surfaces and found that foam alternatives to the standard hospital foam mattress can reduce the incidence of pressure ulcers.4

For patients who are at a high risk of pressure ulcer development, consideration should be given to the use of higher specification foam mattresses rather than standard hospital foam mattresses, the study authors concluded.4

However, the merits of constant low-pressure devices, and of the different alternating pressure devices for pressure ulcer prevention are unclear, the study authors found.4

“Organizations might consider the use of pressure relief for high-risk patients in the operating theatre, as this is associated with a reduction in post-operative incidence of pressure ulcers,” the study authors wrote. “Seat cushions and overlays designed for use in accident and emergency settings have not been adequately evaluated.”

The importance of the surface in preventing and treating pressure ulcers is dependant upon the circumstances, says Samantha Baron, a new product development engineer for Allen Medical Systems.

A good surface will help distribute pressure over a larger area, which results in lower overall pressures. The best method, however, is to periodically turn the patient, Baron says. That method works fine in most arenas, but not in the operating room (OR), where a patient is on a narrow table, is confined by sterile drapes, and is surrounded by materials that can’t or shouldn’t be moved.

“Turning a patient to relieve pressure would entail the staff blindly grasping at undefined features under the drape and trying not to roll the patient off of the OR table all together,” Baron says. “Aside from this, there is the possibility of tangling the many tubes protruding from the patient and compromising the sterile field. This all makes turning a patient during surgery an impossibility.”

In the OR, surface is the most important factor, but there are limitations to the available options.

“Low air loss, alternating pressure, and fluidized surfaces all show clinical advantage over static, non-powered foam surfaces, however they are not stable,” Baron says. “The surgical surface must be stable to ensure that the location the surgeon intends to cut is indeed the location that his cut is made. Multi-layered foam pads are currently the only technology that aids in preventing pressure ulcers while also meeting the requirements for stability, durability, and disinfection.”

Preventive Strategies

Since Medicare’s hospital inpatient prospective payment system will no longer pay for facility-acquired pressure ulcers, it is crucial that healthcare providers copiously document any potential signs of bed sores that are present upon admission.1 Otherwise, hospital staffs will be paying for illnesses they did not create.

This will require some new approaches in how healthcare professionals in the acute-care setting manage patients who have pressure ulcers upon admission, and who are at abnormal risk for pressure ulcers.1

The onus is partially on physicians since their documentation is required, but the expertise of wound assessment in hospitals is predominantly with nurses, according to members of the International Expert Wound Care advisory panel.

The CMS reimbursement provision gives clinicians the opportunity to treat preventive care with the importance it deserves, the panel members wrote. These strategies include educating patients and their families about skin care, training and empowering clinicians, and developing toolkits and specific protocols that can be used in facilities nationwide.1

The bundling of prevention resources is essential.

For instance, a program called Pressure Ulcer Prevention Protocol Interventions (PUPPI) found that assessing risk and nutritional status, providing skin care and offering referrals (if appropriate) decreased the amount of pressure ulcers patients received by more than 50 percent.1

The “NO ULCERS© bundle” developed by the New Jersey Hospital Association reduced pressure ulcer incidents by 70 percent and pressure ulcer prevalence by 30 percent in 20 months.1

The NO ULCERS© bundle stands 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

Support surfaces for pressure redistribution

Another program is called the SKIN©® bundle and was released in 2004 by Ascension Health, the nation’s largest not-for-profit healthcare system. It reduced pressure ulcer incidents to about 1.4 per 1,000 patient days.1 At many Ascension hospitals, no new stage three or four pressure ulcers were acquired from August 2004 to February 2006.1

The SKIN©® bundle stands for:

Surface selection

Keep turning

Incontinence management


A successful pressure ulcer prevention program includes the establishment of protocol, says Tina Meyers, BSN, RN, CWOCN, ACHRN, manager of wound, ostomy and continence nursing services at Harris County Hospital District in Houston.

“Frequent use of a standard data collection tool to ensure appropriate evaluation is essential,” Meyers says. “To promote caregiver compliance with pressure ulcer protocols, standardize care and make it easy. Regarding patient care, nutritional status plays a key role in prevention and minimizing pressure and friction helps to eliminate risk of development.” 


1. Armstrong DG, et al. New opportunities to improve pressure ulcer prevention and treatment: implications of the CMS inpatient hospital care present on Admission (POA) indicators/hospital-acquired conditions (HAC) policy. A consensus paper from the International Expert Wound Care Advisory Panel. May 2008.

2. Medline press release. Medline’s Pressure Ulcer Prevention Program addresses new CMS deadline of October 1, 2008. PR Newswire Association. May 2008.

3. Nursing opinion poll reveals pressure ulcer prevention not seen as a top priority. Sage survey. July 2004.

4. Cullum N, McInnes E, Bell-Syer SEM, Legood R. Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews. Issue 2. May 2004.

Risk Assessment

1. Any patient who is bed-bound, chair-bound persons, or has an impaired ability to reposition is at risk for pressure ulcers.

2. Use a valid, reliable and age appropriate method of risk assessment that ensures systematic evaluation of individual risk factors.

3. Assess all at-risk patients/residents at the time of admission to healthcare facilities, at regular intervals thereafter and with a change in condition. A schedule is helpful.

Acute care: assess on admission and reassess at least every 24 hours or sooner if the patient’s condition changes.

Long-term care: assess on admission and weekly for four weeks, then quarterly and whenever the resident’s condition changes.

Home care: assess on admission and at every nurse visit.

4. Identify all individual risk factors (decreased mental status, exposure to moisture, incontinence, device related pressure, friction, shear, immobility, inactivity, nutritional deficits) to guide specific preventive treatments. Modify care according to the individual factors.

5. Document risk assessment subscale scores and total scores and implement a risk-based prevention plan.

Skin Care

1. Perform a head-to-toe skin assessment at least daily. Pay special attention to pressure points such as the sacrum, ischium, trochanters, heels, elbows, and the back of the head.

2. Individualize bathing frequency. Use a mild cleansing agent. Avoid hot water and excessive rubbing. Use lotion after bathing. For neonates and infants follow evidence-based institutional protocols.

3. Establish a bowel and bladder program for incontinent patients. If incontinence is unavoidable, cleanse the skin when it becomes soiled, and use a topical barrier to protect it. Select under pads or briefs that are absorbent and provide a quick drying surface. Consider a pouching system or collection device to contain stool and protect the skin.

4. Use moisturizers for dry skin. Minimize environmental factors that lead to dry skin such as low humidity and cold air. For neonates and infants follow evidence-based institutional protocols.

5. Avoid massaging bony prominences.

Mechanical Loading and Support Surfaces

1. Reposition bed-bound patients at least every two hours and chair-bound patients every hour.

2. Consider postural alignment, distribution of weight, balance and stability, and pressure redistribution when positioning people who are chair bound.

3. Teach chair-bound persons (who are able) to shift weight every 15 minutes.

4. Follow a written repositioning schedule.

5. Place at-risk persons on pressure-redistributing mattress and cushion surfaces.

6. Avoid using donut-type devices and sheepskin for pressure redistribution.

7. Use pressure-redistributing devices in the operating room for people who are at a high risk for pressure ulcer development.

8. Use lifting devices (a trapeze or a bed linen) to move patients rather than dragging them.

9. Use pillows or foam wedges to keep bony prominences (such as knees and ankles) from direct contact with each other. Pad the skin that is subjected to device-related pressure and inspect those sections regularly.

10. Use devices that eliminate pressure on the heels. For short-term use with cooperative patients, place pillows under the calves to raise the heels off the bed. Use heel suspension boots for long-term use.

11. Do not position directly on the trochanter when using the side-lying position. Instead, use the 30-degree-lateral-inclined position.

12. Maintain the head of the bed at or below 30 degrees or at the lowest degree of elevation that is consistent with the patient’s medical condition.

13. Institute a rehabilitation program to maintain or improve the patient’s mobility status.


1. Implement pressure ulcer prevention educational programs that are structured, organized, comprehensive, and directed at patients, family, and all levels of healthcare providers.

2. Include information on:

etiology of and risk factors for pressure ulcers

risk assessment tools and their application

skin assessment

selection and use of support surfaces

nutritional support

program for bowel and bladder management

development and implement individualized programs of skin care

demonstration of positioning to decrease risk of tissue breakdown

accurate documentation of pertinent data


1. Identify and correct factors that compromise the patient’s protein/calorie intake.

2. Consider nutritional supplementation for nutritionally compromised persons.

3. Keep the patient hydrated.

4. With a physician’s approval, administer multivitamins with minerals. ICT