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Pressure ulcers arent always simple woundsthat eventually heal with the right treatment.They can have devastating effects on the qual-

ity of life for both patients and their families.

Whats worse, they cause thousands of deaths eachyear, particularly among the elderly. In many morecases, they probably contribute to death even ifthey arent listed as the cause.

An estimated 2.5 million patients in the UnitedStates develop pressure ulcers, and we spend about$11 billion for their treatment. With Medicare nolonger reimbursing healthcare facilities to treat cer-tain types of hospital-acquired pressure ulcers, yournursing care may come under suspicion if your pa-tient develops one.

This article explains how to make pressure ulcer

prevention a part of your everyday nursing prac-tice. By using the bundle approach and practic-ing the Golden Rule, you can develop a preventionprogram on your unit or in your facility.

Getting personal about pressure ulcersImagine that an illness or trauma puts a belovedaunt in the hospital. Although shes getting betterthanks to prescribed drugs and treatments, she devel-ops a pressure ulcer. How do you think youd feel?

Ive heard nurse colleagues justify a patients pres-sure ulcer as a natural part of acute illness and hos-

pitalization. We saved the patients life, they rea-son. A pressure ulcer is the least of his worries. Ican only assume these nurses have never had a fam-ily member develop a pressure ulcer while hospital-ized. If they had, Im sure theyd take a differentview. Far from expecting an ulcer to form because itsa natural part of illness, chances are they wouldtry to ensure that all measures were taken to preventoneand if one developed, theyd consider it com-pletely unacceptable and a sign of poor nursing care.

Even Superman can get them

In 2004, pressure ulcers got a lot of publicity whenChristopher Reeve, the actor who played Superman

in two movies, died from sepsis caused by a pres-sure ulcer. The public found his case compellingbecause of the irony that the ventilator-dependentquadriplegic would die from something so seem-

ingly banal as a pressure ulcer.If Reeve, whose wealth enabled him to receive

state-of-the-art medical care, could succumb to apressure ulcer, how can healthcare providers pre-vent pressure ulcers in those who are much less af-fluentespecially those whose medical coverage islimited after hospital discharge?

Are pressure ulcers preventable?Many clinicians believe all pressure ulcers are pre-ventable, while admitting that some may be hard-er than others to prevent and require more aggres-

sive intervention. But the truth is some pressureulcers may not be preventable. Why? Think back tobasic anatomy and the organ systems: The skin isthe largest organ of the body. If your patient is inmultisystem organ failure with his kidneys, liver,and heart all failing, his skin is likely to fail, too.

Whether or not you view pressure ulcers as pre-ventable, make sure to accurately document thepatients condition and all interventions taken toprevent them.

A never event

As you probably know, the Centers for Medicare &Medicaid Services recently stopped reimbursinghealthcare facilities for the added cost of treatingnever events. Defined as reasonably preventablehospital-acquired conditions, never events includesurgery on the wrong body part, mismatched bloodtransfusions, certain infections, and stage III andstage IV pressure ulcers. Hospitals cant charge pa-tients directly for treating these conditions, either.The idea is that refusing to pay for treatment ofnever events will cause their rates to decline.

Actually, this do-not-pay policy first went into

effect a few years earlier in long-term care facilities.In 2007, a published study reported on the out-

Bundle up to preventpressure ulcersIn this age of increasing accountability, yournursing care may be suspect if your patient developsa pressure ulcer.

By Mary Elizabeth Paciella, MS, RN, CCRN, ANP-C, CNS

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come of a nationwide project that aimed to reducepressure ulcer incidence and prevalence at 52 long-term care facilities. Recommended practices wereimplemented using quality improvement methods;the facilities monitored monthly pressure ulcer in-cidence and prevalence, healing, and adoption ofkey care processes. The results were impressive: Thetotal number of new hospital-acquired stage III to

IV pressure ulcers declined 69%.The Medicare policy has put nursing care underthe microscope. Now is our time to shineto con-tribute to the financial health of our facilities whileproviding the highest-quality care.

The bundle approach to preventionThe Institute for Healthcare Improvement (IHI)promotes the bundle approach to pressure ulcerprevention. A bundle is a set of straightforwardpracticessimple interventions that when com-bined, lead to positive patient outcomes.

The power of the bundle lies in its all-or-nothingnature. To achieve desired results, caregivers mustcomplete all parts of the bundle. Using this conceptalong with the 2003 Guideline for pressure ulcerreduction from the Wound, Ostomy, and Conti-nence Nurses Society, multiple hospitals developedtheir own bundles even before IHI published Pre-vent pressure ulcers: How-to guide as part of its 5Million Lives Campaign. In most facilities, thesebundles were part of a larger pressure ulcer preven-tion program and proved crucial to pushing pres-sure ulcer rates below the national average.

Benchmarking and auditingTo develop a successful pressure ulcer preventionprogram, you must know how your facilitys pres-sure ulcer prevalence rate compares to that of oth-er facilities with similar patient populations. To dothis, you can use benchmarking. You can alsocompare different units in your facility.

However, dont simply rely on reported ratesbased on cases involving consultation with woundspecialists. Such data can be inaccurate because ofunderreportingor in some cases overreporting, as

staff sometimes include conditions that arent trulypressure ulcers.

A formalized skin study or prevalence studyshould be conducted by a team trained to assess allinpatients. Before the study begins, the staff mustreceive formal education on pressure ulcer stagingand on where to find specific elements of the audittheyll be performing (either in the paper chart orthe electronic record). The audit monitors the levelof compliance in your facility, and usually consistsof a list of things one would expect to seefor in-stance, a units or facilitys compliance with preven-

tive measures or its pressure ulcer prevalence rates.For quality-control purposes, staff shouldnt au-

dit their own unit. (For information on how to setup a prevalence study, visit the website of the Na-tional Database of Nursing Quality Indicators atwww.nursingquality.org.) Both the overall pressureulcer prevalence rate and the hospital-acquired

pressure ulcer prevalence rate for your unit or facil-ity should be determined. (See How to calculate pres-sure ulcer prevalence.)

Bundle elementsOnce you know your facilitys or units pressure ul-cer prevalence rates, you can put the bundle con-cept to work. A successful bundle consists of key el-ements, starting with a thorough head-to-toe skinassessment on admission and then at least everyshift for all patients. Risk assessment should bedone at least daily. Using the Braden Scale as a risk

assessment tool enables you to quantify the pa-tients risk: the lower the score, the higher the pa-tients risk of pressure ulcers.

Other typical elements of a bundle include turn-ing and repositioning, nutritional assessment, bedelevation, incontinence care, and pressure relief.(See One hospitals pressure ulcer prevention bundle.)

The gold standard in prevention is patient turn-ing and repositioning every 2 hours. (Some pa-tients may require a more frequent schedule to en-sure adequate blood flow to compromised areas.)Patients unable to turn on their own must be

turned and repositioned by staff at least every 2hours while in bed and every hour while sitting in

How to calculate pressure-ulcerprevalence

The prevalence rate provides a snapshot of pressure

ulcers on the particular day in which all patients in a unit

or facility are assessed. This value can be used to track

and trend pressure ulcer prevention. Be sure to

determine hospital-acquiredulcer prevalence, which can

reflect the quality of care provided.

How to Calculate Pressure Ulcer (PU) Prevalence:

# of patients with a PU__________________________

100 = % prevalenceTotal # of patients assessed

How to Calculate Hospital Acquired PressureUlcer (HAPU) Prevalence:

# of patients with a HAPU_________________________ 100 = % HAPU prevalence

Total # of patients assessed

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a chair. To prevent heel pressure ulcers, use pillowsor heel-lift devices to keep the patients heels fromtouching the bed. Elevate the head of the bed lessthan 30 degrees, unless contraindicated for othermedical reasons. (For example, if the patient is atrisk for aspiration or ventilator-associated pneumo-nia, raise the knees of the bed to prevent slidingand subsequent sheering injuries.)

Optimizing nutritional statusUsing all available resources, evaluate the patientsnutritional status and then maintain it at an opti-mal level. If possible, consult with a nutritionist assoon as possible. If you believe your patients nutri-tional status is compromised, urge the physician toorder testing of C-reactive protein and prealbuminlevels together, as this gives a better idea of currentnutritional status than the albumin level alone. Al-so, ensure that patients arent kept NPO withoutnutrition for more than 72 hours.

Special beds and moisture managementA pressure-relief surface or special-care bed is rec-

ommended to help prevent pressure ulcers. Man-age incontinence and moisture with a skin-careregimen, such as frequent cleansing and use of amoisture-barrier ointment. Clean the incontinentpatient immediately and apply A&D Zinc Oxideafter every incontinence episode. Together, thesesimple interventions can yield great results.

Education, auditsand education and moreauditsFor the bundle concept to work, the educationalrollout, reinforcement, and culture change aremandatory. All nursing staff, including nursingassistants, should be included in the educationaleffort. Points to cover include Medicares do-not-pay policy for hospital-acquired pressure ulcers,your facilitys current pressure ulcer rates, andthe expectation that these rates will decrease.Get the staff excited about pressure ulcer preven-tion. As nurses, this is our opportunity to make

an impact and show the quality of the care weprovide.

Once everyone has been educated about thebundle concept and elements, compliance withthese elements must be audited. Develop a checklistfor themwhat you expect to see or not to see.Identify who will be involved in the audit. The moredirect-care staff members that can be involved, thebetter the final results are likely to be. Ideally, nurs-ing staff should go from patient to patient to seewhich bundle elements are being completed andwhich ones may require staff reeducation.

Staff auditors can help your unit or facility makea positive change. This form of peer review givesdirect caregivers a clearer understanding of thequality improvement process as well as their unitspractices and how these measure up to expecta-tions. Then staff can educate peers on the findings.Audit results also may show areas where improve-ments should be made and may identify other edu-cational deficiencies that must be corrected toachieve positive outcomes.

Performing frequent prevalence studies will helpyour facility detect any increase in pressure ulcer

rates that may relate to a particular systems issue,such as lack of available equipment or decreasedpersonnel in a certain area or unit. These studiesalso may suggest where to focus your efforts if aparticular unit in your facility has a higher pres-sure ulcer rate than others; conversely, if one unithas a lower rate, it can be studied to determinewhats being done right.

The results of prevalence studies should be com-municated to all staff. Physicians, nurses, andnursing assistants in particular need to be aware ofpressure ulcer rates; if they dont know a problem

exists, they cant fix it. Likewise, if they dont knowtheir actions are improving patient care outcomes,

One hospitals pressure ulcerprevention bundle

Stony Brook University Medical Center in upstate New

York uses the eight-element bundle shown below to

prevent pressure ulcers.

Used with permission.

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theyre unlikely to keep making that extra effort.

Practice the Golden RuleIn many cases, nurses are being held accountableif their patients develop pressure ulcers while undertheir care. And with the new Medicare rules linkingquality of care to a facilitys financial health, it willbe obvious to all when preventing pressure ulcers

isnt a priority.As nurses, we need to be aware of the financialaspects of health care while not allowing them tobecome the primary driver of our care. What shoulddrive us is the expectation that every patient re-ceives the same care wed want and expect our ownfamily members to get. The Golden Rule tells us todo unto others as we want others to do unto us. Inessence, it steers us back to the basics of nursing,the basics of life. Imagine what health care wouldbe like if we allfollowed the Golden Rule. I

Selected referencesAyello E, Lyder C. Protecting patients from harm: preventing pressureulcers in hospital patients. Nursing2007. 2007;37(10):36-40.

Baldelli P, Paciella M. Creation and implementation of a pressure ul-cer prevention bundle improves patient outcomes. Am J Med Qual.2008;23(2):136-142.

Christopher Reeve dies at 52. http://news.bbc.co.uk/1/hi/entertainment/film/3732310.stm. Accessed February 27, 2009.

Eliminating serious, preventable, and costly medical errorneverevents. Centers for Medicare & Medicaid Services. May 18, 2008.

www.cms.hhs.gov/apps/media/press/release.asp?Counter=1863.Accessed February 27, 2009.

Institute for Healthcare Improvement. Prevent pressure ulcers. 5 Mil-

lion Lives Campaign. Getting Started Kit. Cambridge, MA; 2008.www.ihi.org/IHI/Programs/Campaign/PressureUlcers.htm. AccessedFebruary 27, 2009.

Krasner DL. Never. Never say Always. Never Say Zero. 2008.Healthy Skin. 2008;5(3):34-35.

Lyder C. Pressure ulcer prevention and management. JAMA.

2003;289(2):223-226.Lynn J, West J, Hausmann MS, et al. Collaborative clinical quality im-provement for pressure ulcers in nursing homes. J Am Geriatr Soc.2007;55(10):1663-1669. www.ncbi.nlm.nih.gov/pubmed/17714457.

Accessed February 27, 2009.

Medicare project proves pressure ulcers can be stopped in nursinghomes. Senior Journal.com. http://seniorjournal.com/NEWS/Medicare/2007/7-10-24-MedicareProject.htm. Accessed February 27, 2009.

National Database of Nursing Quality Indicators. http://www.nursing

quality.org. Accessed February 27, 2009.

Ratliff C, Bryant D. Guideline for Prevention and Management ofPressure Ulcers. Glenview, IL: Wound, Ostomy, and Continence Nurs-

es Society; 2003.

Reddy M, Gill S, Rochon P. Preventing pressure ulcers: a systematicreview. JAMA. 2006;296(8):974-984.

Redelings M, Nolan L, Sorvillo F. Pressure ulcers: more lethal than we

thought? Adv Skin Wound Care. 2005;18(7):367-372.

Whittington K, Briones R. National Prevalence and Incidence Study:6 year sequential acute care data. Adv Skin Wound Care. 2004;17:490-494.

Mary Elizabeth Paciella is a clinical nurse specialist at Stony Brook University

Medical Center in Stony Brook, New York.