In a statewide initiative, coordinated by the New Jersey Hospital Association (NJHA) Quality Institute, hospitals together with nursing home and home care agencies were asked to participate in a Pressure Ulcer Prevention Collaborative. The goal of this collaborative was to decrease the incidence and prevalence of pressure ulcers across the state by 25% within a 12-month period. This article discusses the rationale for the Collaborative as well as the requirements and implementation of the initiative within Community Medical Center's Home Health Program.


Article Content

Has the following ever happened to you when admitting a home care patient?


Mr. Smith, an 85-year-old gentleman admitted to home care for management of a gastrostomy tube, is bed-bound, incontinent and needs assistance to move in bed. Mrs. Smith is his primary caregiver. She is 85 years old, frail, and suffering from osteoarthritis. In addition, her memory is poor.


During the initial assessment, the registered nurse (RN) performs a skin assessment and finds a nonblanchable reddened area on the sacrum (stage 1 pressure ulcer). The RN instructs Mrs. Smith to keep the area clean and dry, to reposition the patient every 2 hours, and to use a draw sheet to move him up in the bed.


When the RN returns 3 days later, the area has opened up and is draining serous fluid, with slough covering 75% of the wound. The pressure ulcer has advanced to a stage 3. Daily RN visits are now required to pack the wound.


Could this scenario have been prevented?


With shorter lengths of stay in acute care hospitals, the cases of home care patients are increasingly complex. Home care is also often often with the challenge of untrained, frail elder caregivers who must be taught to manage the care and prevent further complications.


An Overview: The Supporting Numbers

Pressure ulcers are a common, serious, and significant healthcare occurrence among frail elder adults. Ayello (2007) reports a prevalence (the total number of patient's with a pressure ulcer at a point in time) ranging from 10% to 17% in acute care, from 0% to 29% in home care, and from 2.3% to 28% in long-term care (e.g., nursing home sites). The incidence (number of new patients with development of a pressure ulcer in a specified period) ranges from 0.4% to 38% in acute care, from 0% to 17% in home care, and from 2.2% to 23.9% in long-term care.


In addition to causing pain and in some cases disfigurement, pressure ulcers are strongly associated with lengthy stays in acute, postacute, and long-term care settings. According to the U.S. Department of Health and Human Services (DHHS, 1994), the total national cost of pressure ulcer treatment exceeds $1.3 billion. Medical News Today (2006) reports that 1.8 million Americans annually experience pressure ulcers. The same source also reports pressure ulcers as the leading cause of litigation involving nursing homes. More than 17,000 lawsuits are related to pressure ulcers annually, with individual settlements ranging from $50,000 to as much as $4 million. Although home care litigation historically has been a small percentage of overall healthcare litigation, malpractice claims in home care are increasing, and this trend is expected to continue.


The U.S. Health and Human Services Department (2000) in its Healthy People 2010 initiative called for a 50% reduction in pressure ulcers among nursing home residents by 2010. The DHHS Centers for Medicare and Medicaid Services (CMS) (2004) has issued new guidelines for the assessment and treatment of pressure ulcers among nursing home patients. Reporting of nosocomial pressure ulcers stages 3 and 4 became required in acute care in 2005 with the implementation of New Jersey's Patient Safety Act (N.J. Department of Health & Senior Services, 2004). Implementation is expected to extend to all other settings in late 2007, including Home Health (Theresa Edelstein, personal communication, September 2007, NJHA). In home care, the Medicare Adverse Event Outcome Report "Increase in the Number of Pressure Ulcers" is already being reported in outcome-based quality monitoring reports from CMS (U.S. Department of Health and Human Services, 2001).


For home care, the provision of services and supplies to treat wounds is expensive, and Medicare reimbursement rarely covers all the costs. Referral data for home care patients requiring wound care are reportedly 15% to 20% of all referrals, and patients with wounds typically comprise 25% of the active census at any given time (Dailey & Newfield 2005).


The Project Begins

Based on the negative impact of pressure ulcers on patients, the burden of care to the healthcare industry, and state and federal reporting requirements, the NJHA Quality Institute initiated the Pressure Ulcer Collaborative. This project included acute care hospitals, long-term care settings, and home health agencies (HHAs).


A total of 150 organizations participated in this project. The breakdown of participants showed 53 organizations from acute care, 76 from long-term care, 11 HHAs, and 9 "other" (assisted living, rehabilitation facilities, hospices). The goal of the Collaborative was to reduce both the incidence and prevalence of pressure ulcers within a 12-month period. A rate of 25% is considered a good "stretch goal" by the Institute for Healthcare Improvement in Boston, which started "collaborative work" and is used by NJHA as a model in all their work (Aline Holmes, personal communication, January 2007, NJHA).


Collaborative requirements were developed by the NJHA Quality Institute Department and the Department of Continuing Care Services under the guidance of Dr. Elizabeth Ayello, a wound care nurse specialist consultant. The required components were


* A comprehensive skin assessment of all patients at admission


* A Braden risk assessment on all patients at admission (Bergstrom, Braden, Laguzza, & Holman, 1987)


* A skin assessment by the RN, physical therapist (PT), or both for "at-risk" patients (Braden score of 18 or less or patients with an existing pressure ulcer) at every subsequent visit throughout the length of care


* A nutrition/dietitian consult and bedside at-home swallowing evaluation by a speech therapist for "at-risk" patients within 7 days of risk determination


* Appropriate pressure redistribution surfaces implemented within 24 hours of risk determination


* Turning of all bed-bound patients every 2 hours and repositioning of all chair-bound patients every hour.



Community Medical Center's HHA Experience

Ocean County, NJ, is one of the fastest growing counties in New Jersey. The county has witnessed a 29% increase in population since the 1970s and had an estimated population of 484,000 in 2000 (U.S. Census Bureau, 2000).


Not only is Ocean County growing; it also is aging. Ocean County is the 3rd most popular retirement location in the United States, just behind Florida and Arizona. The average age of Community Medical Center's HHA patients is 78.67 years.


Participation in the Collaborative was voluntary. Community Medical Center's Home Health Program, one of the larger Medicare/Medicaid-certified HHAs in New Jersey, is an affiliate of the St. Barnabas Health Care system, making participation an even bigger opportunity for improving delivery of care and outcomes across the continuum. Some, but not all, affiliate hospitals and long-term care facilities also were involved in the project.


The HHA's Medicare case mix report identified that approximately 5.1% of the HHA's patient population had pressure ulcers. As a result, the focus was on a proactive approach promoting prevention.


The Pressure Ulcer Collaborative began in September 2005 and to date has provided 10 educational training sessions for participating organizations on preventative strategies, wound treatment protocols, outcome measurement, communications across the continuum, and collaboration among all levels of care. The Collaborative also has provided a Web site with current information and best practice standards as well as a listserv, which has allowed all participants to share ideas, ask questions, and generally brainstorm.


Community Medical Center's HHA selected 2 associates, a process improvement nurse and a wound ostomy and continence nurse (WOCN), to attend the educational sessions and bring back the most current up-to-date knowledge and best practice standards to share with staff. It was up to each member organization to develop a plan to "roll out" their unique program.


At Community Medical Center's HHA, the first action taken was to formulate a steering committee with an interdisciplinary focus. The task of the Steering Committee was to develop the plan, educate all HHA team members, implement the process, collect and analyze the data, design and redesign the process, and report the data back to the Collaborative. The Steering Committee consisted of nurses, PTs, occupational therapists (OTs), speech therapists, a dietitian, home health aides, process improvement nurses, the coordinator of clinical information systems, the HHA administrator, and the 2 directors of patient care services. Buy-in and active participation at all levels was determined to be crucial to the success of the Collaborative.


Because the components required by the Collaborative were structured to reflect care provided primarily in the inpatient setting, modification was needed for several home care requirements. The modifications to the Collaborative requirements were as follows:


* A nutritional consult was ordered only when the patient scored "poor" or "probably inadequate" on the nutrition portion of the Braden scale. The dietitian then assessed the need for a swallowing evaluation and, if appropriate, obtained an order for the speech therapist to perform this evaluation.


* Because home care may face numerous barriers in timely provision of durable medical equipment to the home (e.g., reaching the physician [MD] for the order, awaiting insurance authorization, meeting regulations related to reimbursement, implementing rearrangement of space by the family), the pressure redistribution surface component was modified to read: "MD called to obtain an order for a pressure redistribution surface at time of risk determination."


* Because HHA staff is not always present to turn and position patients, that component was modified to read: "Documented evidence of education to patient and caregiver in turning bed-bound patients every 2 hours and repositioning chair-bound patients every 1 hour."



Once the plan was developed, 1 of the 5 home health teams was selected to be the "test pilot." Individuals who would "champion" the project, embrace it, and bring with it a sense of enthusiasm were sought. The chosen pilot team was interdisciplinary, consisting of nurses, PTs, OTs, speech therapists, home health aides, and a dietitian.


The pilot team was provided with 30 minutes of intense training weekly. Field staff members were selected to provide the education. The pilot team and the staff in general were very enthusiastic about the project. The education of home health aides was structured differently because aide services are provided to patients by both contracted HHAs and agency staff aides. Education in pressure ulcer prevention, skin inspection, and reporting of concerns and changes to the RN case manager was provided to staff aides by the WOCN. For cases serviced by aides from contracted agencies, the RN case manager provided individual education and guidance.


Challenges and Barriers of the Collaborative

Barriers were identified in both the planning and implementation phases. The plan and a required goal was to perform a comprehensive skin assessment at admission together with a Braden Risk Assessment. After the recent purchase of a computer software product for clinical documentation, it was found that the skin assessment was not sufficient to meet the protocol criteria and that the Braden scale was not in the product. The Steering Committee wrote a comprehensive skin assessment based on the CMS and Collaborative guidelines, and the Information Technology team found a way to attach this and the Braden Scale to the clinical documentation.


The Steering Committee also developed a Pressure Ulcer Prevention Care Plan and a patient/caregiver education packet about the prevention of pressure ulcers. Pressure ulcer prevention "Quick Tips" were hung around the office to educate and reinforce the training. These "Quick Tips" were colorful, short, often amusing posters that took very little time to read (Figures 1 to 3).

Figure 1 - Click to enlarge in new windowFigure 1. Pressure ulcer prevention quick tips: support surface.
Figure 2 - Click to enlarge in new windowFigure 2. Pressure ulcer prevention quick tips: avoiding friction and shear.
Figure 3 - Click to enlarge in new windowFigure 3. Pressure ulcer prevention quick tips: deep tissue injury.

Another barrier was that skin assessments were required at every RN and PT visit of "at-risk" patients. The HHA therapists during their education and training never had to perform a "comprehensive" skin assessment. The WOCN was instrumental in raising the bar on everyone's skill in performing comprehensive skin assessments.


One of the areas for which the staff reported feeling the least competence was pressure redistribution surfaces. This included indications for use and Medicare guidelines for coverage of these products at home. Vendors were called, and actual surfaces were brought in to provide hands-on training to all RNs, PTs, and OTs. In fact, this interactive "station" is now a part of the HHA's annual Equipment Competency Fair. The Braden scale and related preventative strategies were added to the annual skills competency. The Steering Committee participated in monthly conference calls offered through the Collaborative, including a conference call with Dr. Barbara Braden herself.


After the bugs had been worked out, the program was rolled out agency-wide in April 2006. The "champion" pilot team provided the education to the remainder of the staff. The agency currently has its own internal success story of having clinicians educate their peers. Due to the enthusiasm of participating organizations the Collaborative continued for a second year. The goals were to sustain the gains, keep the momentum going, and improve outcomes even further. Data were submitted monthly to the Collaborative, and the staff was provided with monthly voice mail or e-mail messages about progress and outcomes.


The Results

Using the Medicare Adverse Event Outcome Report "Increase in the Number of Pressure Ulcers," the agency started at 0.84% in September 2005, and by August 2006 was at 0.63%, a 25 % decrease!! The stated threshold "stretch" goal was reached. At the end of year 2, the HHA's percentage had decreased to 0.2%, a 78% decrease since the start of the project.


How did the Collaborative perform? In a presentation at the NJHA Collaborative to Decrease Pressure Ulcers learning session on March 7, 2007, Dr. Elizabeth Ayello reported that from October 2005 to October 2006, the NJHA Quality Institute was able to demonstrate a 30% reduction in pressure ulcer incidence across the reporting organizations. At the end of year 2 (May 2007), the Collaborative demonstrated a 70% reduction in pressure ulcer incidence.


What Has Changed?

The Pressure Ulcer Collaborative has given the staff a more comprehensive focus on improving patient care, gaining access to protocols, and ensuring standardization and consistency in practice. In addition, there is increased knowledge about data analysis, benchmarking, and outcome analysis. This heightened awareness has allowed staff to conduct more sophisticated evidenced-based quality improvement activities and preventive strategies across the organization.


Another challenge emerged. Since January 2006, 12 new RN associates have been hired who have not had the extensive training that was part of the Collaborative project. Pressure ulcer prevention and the Collaborative-required goals are now a part of the HHA's orientation program. The organization is committed to improving patient care and outcomes. This Pressure Ulcer Collaborative (and those to come) has opened the door to cost containment, has standardized best practices for care and treatment, and has provided tools for effective care, prevention, and awareness not only to healthcare workers, but also to the communities that are served.




Ayello, E. A. (2007). Predicting pressure ulcer risk. The Hartford Institute for Geriatric Nursing, New York University College of Nursing. Retrieved March 15, 2007 from [Context Link]


Bergstrom N, Braden BJ, Laguzza A, Holman V. (1987). The Braden scale for predicting pressure sore risk. Nursing Research, 36, 205-210. [Context Link]


Dailey, M., & Newfield, J. (2005). Legal issues in home care: Current trends, risk-reduction strategies, and opportunities for improvement. Home Health Care Management Practice, 34, 93-100. [Context Link]


Medical News Today. (2006). Clinical trial shows 96% improvement on pressure ulcer healing among nursing home residents. Retrieved March 15, 2007 from [Context Link]


N.J. Department of Health & Senior Services. (2004). New Jersey Patient Safety Act. P.L. 2004. Retrieved March 22, 2007 from [Context Link]


U.S. Census Bureau. (2000). Ocean County New Jersey fact sheet. Census 2000, Demographic Profile Highlights. [Context Link]


U.S. Department of Health and Human Services. (2000). Healthy People 2010. National Nursing Home Survey, Objective 1-16.


U.S. Department of Health & Human Services. Centers for Medicare & Medicaid Services. (2004). Guidance to surveyors for long-term care facilities. Transmittal #4. Retrieved March 22, 2007 from [Context Link]


U.S. Department of Health & Human Services. (1994). Treatment of pressure ulcers, clinical practice guidelines. AHCPR publication no. 95-0652. p 19. [Context Link]


U.S. Department of Health & Human Services, Health Care Financing Administration. (2001). Quality monitoring using case mix and adverse event outcome reports. Section 1-5. [Context Link]