Can We Talk?: Why Are We Still Seeing Pressure Ulcers?

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Janice M. Beitz, PhD, RN, CS, CNOR, CWOCN, CRNP, MAPWCA; Professor of Nursing, School of Nursing-Camden, Rutgers University, Camden, NJ

  Pressure ulcer (PU) prevention has become a great healthcare irony. We know how to prevent PUs, yet according to a 2008 report from the Agency for Healthcare Research and Quality,1 their incidence and prevalence have increased substantially in recent decades in hospitalized patients in the United States. PUs are considered such a serious and complex a healthcare problem, Healthy People 2010 and Healthy People 2020 identify them as a critical target.2,3 The federal government considers Stage III and Stage IV ulcers reasonably preventable and directed the Centers for Medicare and Medicaid Services4 (CMS) to not reimburse hospitals for higher stage levels for hospital-acquired PUs. In 2011, the Joint Commission5 established a national patient safety goal targeting PU prevention through assessment, re-assessment, and prompt interventions. In short, contemporary stakes are high and expectations the most stringent in the history of American healthcare — PUs and their prevention are a measure of healthcare quality.

  What is known about PU prevention? Guidelines and best practices abound.6-11 PU prevention toolkits are available.6,12 The commonalities of evidence among these multidisciplinary approaches are compelling yet remarkably simple.

  Generally, we understand theoretically how to prevent most (not all) PUs — ie, the structural underpinnings are in place. PU prevention is founded on core activities and bundled protocols that include the following components: admission and continuing skin assessments, risk assessment for skin breakdown using a validated instrument (eg, Braden Scale), identification and amelioration of patient etiologic and risk factors (eg, poor nutrition, altered mental status, immobility), support surfaces to redistribute pressure, repositioning as necessary, bowel and bladder management, and documentation of all aspects. Nutritional support and standardized education on all components related to care also are recognized considerations.10,13-16 There is no dearth of evidence-based approaches (structure).

  Structure versus process. Research suggests the problem is not structure as much as process. Several recent studies describe the hindrances in what Ayello17 calls “changing systems, changing cultures” and changing perceptions about what constitutes quality.15 Others suggest organizational culture must enact a zero tolerance for PUs. But how does one get there? Is it just attitudinal or much more complex?

  Various studies support that evidence must be translated into bedside practice.13,18 Vose et al19 described systemwide implementation of a new skin assessment tool that enabled clinicians and managers to track whether needed prevention interventions were implemented. Dahlstrom et al20 tackled an urban academic hospital’s dismal history of PU documentation quality. Jankowski and Nadzam13 studied gaps, barriers, and solutions for implementing PU prevention programs among four hospitals where although a well-designed, evidence-based PU prevention program was in place, physician noninvolvement, faulty communication, and limited education and opportunities for feedback regarding care confounded the processes. Their study yielded the following strategies, later supported and augmented by McElHenny and Hooper21:
    • Involve all levels of nursing staff in PU education
    • Disseminate information about PU prevention to all hospital employees who interact with patients
    • Provide education to all medical staff about PU prevention, targeting their roles in nutrition, hydration, and mobilization interventions
    • Actively seek quality improvement feedback from all levels of unlicensed nursing personnel
    • Include PU risk status in handoff communication (written and verbal)
    • Conduct observation of bedside practices to evaluate the quality of PU prevention
    • Develop hospital support systems so equipment and products are easily accessed to support PU prevention on patient care units
    • Analyze accuracy of risk assessment (eg, Braden Scoring) and offer remediation if inaccurate
    • Collaborate with IT departments to ensure all necessary documentation tools and scales are easily accessed by all staff
    • Provide prompts to staff (digital, visual, flags in the EMR) to remind clinicians to reposition patients
    • Create or utilize available algorithms for skin and wound products with appropriate indications and usage
    • Create gatekeeper systems making specialty beds easily accessible 24-7
    • Conduct unit rounds to verify appropriate supplies at the patient’s bedside, and make extra supplies available on units
    • Clarify “triggers” for nutrition consults for high-risk patients (eg, at what level of albumin or pre-albumin is a dietitian needed).

  Other researchers (Sendelbach et al,16 Tschannen et al,22 Elliott,23 and Ackerman24) describe approaches to improving PU prevention utilize information technology, standardization, awareness campaigns, and communication systems development (eg, physician notification). Some incorporated this comprehensive methodological approach into visual algorithmic guideposts. However, despite some degree of success, challenges in process persist.

  Soban et al25 conducted a systematic review of nurse-focused quality improvement interventions for PU prevention to learn which interventions of the many available PU guidelines can be successfully integrated into routine bedside care. Although the 39 studies analyzed reported common intervention components, many studies did not link interventions with prevention outcomes (ie, staff had little idea if PU prevention techniques worked, despite research from the AAWC9 and Griffin26 that suggests feedback or audit increases compliance). Soban et al also noted that while positive results were obtained (overall PU incidence decreased), the quality of evidence was weak, a big gap in understanding existed as to “how the interventions achieved intended results,” and the role of organizational context was not explained. Bosch et al27 suggest that prevalence of nosocomial PUs and PU prevention go beyond organizational, culture, team climate, and quality management initiatives, and care outcomes may need new and different research approaches.

  Focus for the future. The clinical implications of these research studies are compelling given the stance of the federal government and private insurers to not reimburse hospital-acquired PU costs. Structural issues such as staff knowledge may be good, support surfaces on hospital beds may be of superior quality, and skin protection principles may be well understood, but PUs may still develop. My personal experiences from decades of wound care practice support that these authors are revealing critical deficiencies in the delivery of safe patient care. Process issues such as easily available resources, standardized interventions, quickly available guidelines built into information and documentation systems, feedback of results to staff, education and involvement of multiple levels of staff, and care triggers that alert staff to requisite consults are what really matter more than some structural aspects. Future research is needed to ascertain which aspects are more important.

This article was not subject to the Ostomy Wound Management peer-review process.

References: 

1. Agency for Healthcare Research and Quality. PUs increasing among hospital patients. Available at: www.ahrq.gov/news/nn/nn120308.htm. Accessed April 1, 2011.

2. United States Department of Health and Human Services. Healthy People 2010. Available at: www.healthypeople.gov/2010. Accessed July 1, 2011.

3. United States Department of Health and Human Services. Healthy People 2020. Available at: www.healthypeople.gov/2020/default.aspx. Accessed July 1, 2011.

4. Centers for Medicare and Medicaid Services. Hospital-acquired conditions (present on admission indicator). Available at: www.cms.gov/hospitalacqCond/. Accessed April 1, 2011.

5. Joint Commission. 2011–2012 National Patient Safety Goals. Available at: www.jointcommission.org/assets/1/18/2011-2012.npsg_presentation.final.8-.... Accessed March 22, 2012.

6. Agency for Healthcare Research and Quality. Preventing PUs in hospitals: A toolkit for improving quality of care. Available at: www.ahrq.gov. Accessed February 28, 2012.

7. European Pressure Ulcer Advisory Panel/National Pressure Ulcer Advisory Panel. Clinical practice guidelines for PU prevention and treatment. Available at: www.guidelines.gov. Accessed March 1, 2012.

8. European Pressure Ulcer Advisory Panel/National Pressure Ulcer Advisory Panel. Clinical practice guidelines for PU prevention and treatment. Available at: www.guidelines.gov. Accessed March 1, 2012.

9. Association for the Advancement of Wound Care. AAWC Pressure Ulcer Guidelines. Available at: www.guidelines.gov. Accessed March 15, 2012.

10. Jankowski IM. Matching patient safety goals to the nursing specialty: using wound, ostomy, continence nursing services. J Nurs Administr. 2010;40(11):26–31.

11. Pressure Ulcer Management Guidelines. National Guidelines Clearinghouse. Available at: www.guidelines.gov. Accessed August 22, 2011.

12. Institute for Healthcare Improvement. Prevent pressure ulcers. 5 million lives campaign, getting started kit. Available at: www.ihi.org/ihi/programs/campaign/pressureulcers.htm. Accessed January 30, 2012.

13. Jankowski I, Nadzam D. Identifying gaps, barriers, and solutions in implementing PU prevention programs. Joint Commission Journal of Quality and Patient Safety. 2011;37(6):253–264.

14. Pressure ulcers: the importance of nutrition in prevention and treatment. The Joint Commission Perspectives on Patient Safety. 2011;11(1):1–5.

15. Yap TL, Kennerly S. A nurse-led approach to preventing pressure ulcers. Rehabil Nurs. 2011;36(3):106–110.

16. Sendelbach S, Zink M, Peterson J. Decreasing pressure ulcers across a healthcare system — moving beneath the tip of the iceberg. JONA. 2011;41(2):84–89.

17. Ayello E. Changing systems, changing cultures: reducing pressure ulcers in hospitals. Joint Commission Journal on Quality and Patient Safety. 2011;37(3):120–122.

18. Beitz J. The continuing challenge of pressure ulcers. Joint Commission Journal on Quality and Patient Safety. 2011;37(6):243–244.

19. Vose C, Murphy RX, Burmeister DB. Buckenmyer C, Davidson C, Meltsch TJ, et al. Establishing a comprehensive network wide pressure ulcer identification process. Joint Commission Journal on Quality and Patient Safety. 2011;37(3):131–137.

20. Dahlstrom M, Best T, Baker C, Dueing D, Davis A, Doty J, Arora V. Improving identification and documentation of pressure ulcers at an urban academic hospital. Joint Commission Journal of Quality and Patient Safety. 2011;37(3):123–130.

21. McElhinny ML, Hooper C. Reducing hospital-acquired heel ulcer rates in an acute care facility: an evaluation of a nurse driven performance improvement project. JWOCN. 2008;35:79–83.

22. Tschannen D, Talsma A, Gombert J, Mowry J. Using the TRIP model to disseminate an IT-based pressure ulcer intervention. Western J Nurs Res. 2010;33(3):427–442.

23. Elliott J. Applying pressure ulcer prevention theory to practice. Nurs Res Care. 2011;13(6):276–279.

24. Ackerman CL. “Not on my watch”: treating and preventing pressure ulcers. Med Surg Nurs. 2011;20(2):86–93.

25. Soban LM, Hempe S, Munjas BA, Miles J, Rubinstein L. Preventing pressure ulcers in hospitals: a systematic review of nurse-focused quality improvement interventions. Joint Commission Journal on Quality and Patient Safety. 2011;37(6):245–251.

26. Griffin B, Cooper H, Horack C, Klyber M, Schimmeldfenning D. Best-practice protocols: reducing harm from pressure ulcers. Nurs Manage. 2007;107(9):29–32.

27. Bosch M, Halfens R, Van Der Weijden T, Wensing M, Akkermans R, Grol R. Organizational culture, team climate, and quality management in an important patient safety issue. Worldviews on Evidence-Based Nurs. 2011;8(1):4–14.