1. McInerney, Joan A. MSN, RN, BC, CWOCN


OBJECTIVE: To provide health care organizations with strategies for decreasing the prevalence of hospital-acquired pressure ulcers.


DESIGN: Hospital-acquired pressure ulcer prevalence was measured every 6 months for 4.5 years while multiple strategies were implemented.


SETTING: The study took place in a not-for-profit, 548-bed, 2-hospital system in Southwest Florida.


PATIENTS: All adult patients with the exception of those admitted for obstetric or mental health care.


INTERVENTIONS: An assortment of interventions were implemented, including electronic medical records, risk assessment tied to automatic consults, pressure relief measures including new equipment and personnel augmentation, and an interdisciplinary team to decide on protocols.


MAIN RESULTS: Hospital-acquired prevalence rate for all pressure ulcers was reduced by 81%. The rate for heel ulcers alone was reduced by 90%.


CONCLUSION: A pressure ulcer prevention program has been developed, which has shown a trend toward improved patient outcomes with a resultant cost savings.


Article Content


In 1989, the National Pressure Ulcer Advisory Panel set a goal of 50% reduction in the incidence of pressure ulcers.1 Pressure ulcers continue to be an ongoing concern to health care professionals. In 1992, the guideline, "Pressure Ulcers in Adults: Prediction and Prevention," was published by the Agency for Health Care Policy and Research (now called the Agency for Healthcare Research and Quality). This guideline was followed 2 years later by the guideline, "Pressure Ulcer Treatment."2,3


In the Healthy People 2010 initiative (2000), the US government reported pressure ulcers as a serious quality-of-care issue in all settings.4 In 2000 and 2001, pressure ulcers were cited as 1 of the top 3 in-hospital errors that lead to patient deaths.5 A patient with a pressure ulcer has a mortality risk of 2 to 6 times greater than a patient with intact skin.6 Many health care agencies have adopted prevalence and incidence monitoring surveillance programs and protocols for prevention and intervention for pressure ulcers.1,7-9


This article reports on a program that was effective in reducing the prevalence rate of facility-acquired pressure ulcers by much more than half in 2 acute care facilities.



In one not-for-profit, 2-hospital system with 548 beds in Southwest Florida, hospital-acquired pressure ulcer prevalence was measured every 6 months for 10 years. Incidence data were not collected because of cost and time constraints. This hospital system has relied on prevalence data to gauge the effectiveness of pressure ulcer-reducing initiatives. Measuring prevalence allows one to determine how common a condition is.9 Hospital-acquired prevalence is defined as the percentage of patients, on the day the survey is conducted, who have a pressure ulcer that was not documented within 24 hours of admission.10 In this hospital system's survey, patients who were admitted for obstetric or mental health care are not included, but all other adult patients who were available were included. To determine which ulcers were "hospital-acquired," the admission chart was reviewed to screen out preexisting ulcers. The hospital-acquired pressure ulcer prevalence in January 2002 was 12.8%, compared with 8.5% nationally.11 More than half of the ulcers were located on the heels (Figure 1).

Figure 1 - Click to enlarge in new windowFigure 1. PRESSURE ULCER PREVALENCEThis chart compares the percentage of patients, both nationally and within the Southwest Florida studies, who presented with hospital-acquired pressure ulcers over a time ranging from January 2002 to January 2007. It also charts the percentage of patients presenting pressure ulcers on the heel.


In February 2002, the hospital system implemented the following procedures:


* Electronic Medical RecordsElectronic medical records for nursing charting and order entry were started. The wound ostomy continence (WOC) nurse worked with the information technology department to identify processes and develop electronic forms to assess and document skin care needs.


* Risk AssessmentThe Braden Scale for Predicting Pressure Sore Risk had been used in the paper chart, but was now also included in the nursing admission assessment and in the daily nursing assessment.12 Scores were done for all 6 subscales (sensory perception, moisture, activity, mobility, nutrition, and friction and shear). The computer tallied the score and generated an automatic consult to the WOC nurse when the score falls below 13, indicating that the patient was at a high or very high risk for developing a pressure ulcer.


* Pressure Relief MeasuresFollowing assessment, the WOC nurse entered the appropriate pressure relief orders, which come from evidenced-based guidelines.2 Specifically, the orders used most often was the following: "Turn every 2 hours and elevate heels."Based on experience, a static air overlay was already being ordered for every patient with a Braden Risk Scale score of less than 16. Nurses were also allowed to place patients with risk scores of 16 or more on air overlays if the need arose.


* Personnel AugmentationA second WOC nurse was hired, which allowed for additional time to be dedicated to staff education and monitoring patients.




Eighteen months later in July 2003, the overall hospital-acquired prevalence rate had decreased to 5.1%, compared with 8.2% nationally. Heel ulcers still accounted for more than half of the ulcers.11



An overall decrease in hospital-acquired prevalence was achieved, but there was concern that greater than 50% of ulcers were located on the heel. Usually, the heel is the second most common site for pressure ulcers.1,13 Previously, nurses had intervened with a rigid, pressure-relieving boot. Over time, it was noted that the rigid boot placed undue pressure on the dorsum of the foot and over the Achilles tendon. As a result, physicians and nurses were reluctant to use the rigid boot. A new initiative focusing on hospital-acquired heel ulcers was begun in September 2003.13-15



A team consisting of a critical care physician, a podiatrist, the risk manager, and the 2 WOC nurses reviewed literature and inspected several heel pressure-relieving devices available on the market. Ultimately, the Heelift (DM Systems, Evanston, IL), a lightweight-foam, 1-size-fits-all boot, was selected for use on patients. A task force was formed, consisting of the original small group as well as the chief medical and nursing officers, a clinical informatics analyst, and the managers of central distribution, education, operating room, and critical care. The task force made the unanimous decision that all patients with end-stage renal disease and all patients on ventilators would routinely have their heels protected with Heelift boots. These patients were selected because of their vulnerability and because the computer system was able to link automatic orders to these conditions. As soon as the initial order for a ventilator or hemodialysis is placed, an automatic consult now appears on the WOC nurses' list, and central distribution is notified to send the boots to the patient's location.


In the spring of 2004, powered air beds with continuous lateral rotation therapy capability were purchased for most critical care rooms, and new pressure-reducing mattresses were purchased for most of the other beds in the 2 hospitals, which then eliminated the need for the static air overlays. In the fall of 2004, the use of Heelift boots was expanded to include all patients with a Braden Risk Scale score of less than 13.



By July 2005, the hospital-acquired prevalence rate was decreased to 2.0%. The national rate had decreased to 7.5%.11 No patient had a hospital-acquired heel pressure ulcer. One year later, in July 2006, the hospital-acquired prevalence rate was 2.4%, with 0.7% being patients with a heel ulcer.



The average hospital-acquired pressure ulcer prevalence rate over the past 2 years was 3% compared with the rate 4.5 years ago of 12.8%. One way of estimating the annual cost savings for the next year based on a projected 39,000 discharges is to calculate the number of patients who will presumably be spared the development of a pressure ulcer compared with what could have been expected 4.5 years ago, before all of the aforementioned changes were implemented. The difference between the previous rate and the average rate over the past 2 years is 9.8% (3822 patients). A report from another multisite, not-for-profit hospital system presented in 2006 estimated that the additional cost per case of a pressure ulcer was $3,000.16 Using that factor, the cost savings for the next year are estimated to be $11,466,000.



Computerized charting and order entry, along with evidence-based guidelines, have made it possible to identify specific groups of patients who are vulnerable to developing pressure ulcers. With early identification, automatic orders for preventive interventions can be implemented quickly. With the assistance of the automated consults and orders, the addition of another WOC nurse, the appropriate equipment, the interdisciplinary task force, continuing education, and monitoring, the hospital system was able to reduce the hospital-acquired pressure ulcer prevalence rate by 81%, and the rate for heel ulcers alone was reduced by 90%.


Although pressure ulcers as a concern will never disappear, this study adds to previous reports that the hospital-acquired prevalence rate can be reduced considerably.10,17,18 The resultant cost savings to the clinical agency, as well as the elimination of pain and suffering from a pressure ulcer for the patient, can significantly impact the cost and quality of care.



The author thanks Barbara Bixby, ARNP, Risk Manager, NCH Healthcare System, Naples, FL; Jill V. Hickey, DPM, Naples, FL; David H. Lindner, DO, Director of Critical Care, NCH Healthcare System, Naples, FL; and Sandra K. Wheeler, BSN RN CWOCN, NCH Healthcare System, Naples, FL. Submitted June 7, 2006; accepted in revised form on November 14, 2007.




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