Cath Lab Digest

P ressure ulcer prevention falls within the domain of nursing practice. Skin assessment and care is taught as a fundamental part of all nursing education curricula. Nurses assess the patient's skin, develop a plan of care to maintain the skin's integrity, and provide the preventative interventions. They are the primary caregivers for inpatients at risk for developing pressure ulcers. At the bedside, nurses note subtle changes in a patient's condition that often lead to prevention interventions.¹ Physicians have only a limited training in the prevention of pressure ulcers.² It follows then that preventing pressure ulcers is a fundamental caring/nursing activity.^3,4

Many surveyors of the healthcare industry believe that the incidence of pressure ulcers can be reduced simpl0y if the primary skin care provider cares enough to deliver quality care.⁵ Surveyors often equate pressure ulcers with neglect. The parameter of pressure ulcer occurrence is included as a national indicator of excellence in nursing and as a significant healthcare value that a facility provides its customers.^{6, 7,8}

Similarly, patient healthcare satisfaction scores are linked to the development of pressure ulcers. Consumers of healthcare hold institutions accountable for quality healthcare at a low cost. The average hospital incurs $400,000 to $700,000 in direct costs to treat pressure ulcers annually. Most of that cost is not reimbursable.^9,10 It is estimated that 20 minutes/day/patient of nursing time is related to services for pressure ulcers.¹¹ Institutions are charged with providing economical skin care. Nurses operationalize that charge.

Prevention Program Development and Implementation

In a 500-bed Midwestern hospital, a quality improvement (QI) monitor demonstrating an increase in pressure ulcers, linked with a review of 10 core indicators for excellence in nursing care that included skin integrity, propelled the development of a pressure ulcer prevention program.^8,12 The interdisciplinary skin team, including unit-based leaders, started the effort during their monthly meetings by implementing the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline Number 3: Pressure Ulcers in Adults: Prediction and Prevention.^6,7,12,13 These evidence-based guidelines limit variability in care and promote quality standards. The guideline provided the research base for risk prediction tools, support surfaces, skin care, ulcer classification, professional, and patient and family or caregiver educational content.

The skin team identified particular areas of concern: pressure ulcer assessment, documentation, and patient and staff education. During inservices for the nursing staff, the team outlined the prevention program, highlighting skin anatomy and function, use of the Braden Scale, the importance of turning and positioning, documentation changes, and the use of skin care products.

Measuring program effectiveness. During the development of the pressure ulcer prevention program, one of the biggest hurdles the team faced was developing goals and measuring outcomes. The literature supports identifying outcomes by collecting prevalence and incidence data.^{3,4,7-10,13,15} Prevalence data reflect patients admitted with ulcers as well as nosocomial pressure ulcers; the figure is calculated by dividing the number of people with an ulcer by the total number of people in the population of interest at that time.