Improving Incidence & Prevalence of Pressure Ulcers

By: Naia K., Marilyn C., Mary K., Naomi M., Tami W., & Jennifer K.-R.

Etiology & StatisticsA pressure ulcer is tissue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period.

• Also called “bedsore” or “pressure sore”.• It most often develops on skin that covers bony area,

such as the heels, ankles, hips and coccyx area. • Limited mobility, mental status changes and

decreased sensory perception, poor nutrition status, and incontinence status increase the risk of pressure ulcer.

• More prevalent in the elderly, but can affect patients of any age, in any care settings.

Most pressure ulcers are preventable & Stage III or IV are considered never events.

However, complications from hospital-acquired pressure ulcers cause 60,000 deaths and significant morbidity annually in the United States. (Sullivan & Schoelles, 2013)

Hawaii has best nursing homes in the nation according to the U.S. Centers of Medicare and Medicaid Services

• lowest percentage of high-risk, long-stay resident with pressure ulcers or bedsores

According to the Prevention and Treatment of Pressure Ulcers: Clinical Practice Guidelines; “Pressure Ulcers increase hospital costs significantly. In the US, pressure ulcer care is estimated to approach $11 billion (USD) annually, with a cost of between $500 (USD) and $70,000 (USD) per individual pressure ulcer.

Model for ImprovementPICOT

Problem: Someone identified as at risk for developing a pressure ulcer.

Intervention: Provide multiple preventative measures.

Comparison: Compare old and new data.

Outcome: Decreased incidence of pressure ulcers.

Time: Continued improvement weekly and monthly.

What policies and procedures does the facility have in place?

What forms do we use?

How does our physical environment support or hinder this process?

What staff are involved in this process?

What part of this process does not work?

Do we duplicate work unnecessarily?

Current Process Analysis Worksheet

Assessing Pressure Ulcer Policies Worksheet

Does the facility’s policy include a statement regarding the facility’s commitment to prevention and management?

Does the policy include screening, assessment and monitoring?If the patient isn’t immediately at risk is there policy to screen at regular intervals?Is there a policy to be screened upon admission? change of condition? Is there policy in place for high risk patients be assessed daily?Is there a policy to monitor and evaluate effectiveness?Is there policy for protocol when communicating concerns, interventions, results?

Assessing Staff Education and TrainingDoes the facility have the initial and ongoing education for prevention and management for both nursing and non-nursing staff?

If so does it include the following components?

Are new staff members assessed for their need for education?

Are current staff provided with ongoing education?

Does education model provide discipline specific education?

Is there a designated clinical expert available to assist staff?

Does training include documentation methods?Location, size, depth, appearance, treatment, devices, etc.

Goal Setting and Implementation

GoalsWhat does the facility want to accomplish?Be measurable. Be short.The goal does not include how the goal will be achieved.Post goal where it is visible to team.

Implementation

What is the change? Why?

Who will be involved?

When and where will change occur?

When and how will change be evaluated?

Risk Assessment

Copyright. Barbara Braden and Nancy Bergstrom, 1988

Preventive Measures: Staff Education• Risk assessment using appropriate tools• Proper skin & tissue assessment• Repositioning

– Frequency: Q2hr– Prevent friction, shearing, or bunched up skin– Use of pillows or padding devices to keep pressure-free

One study conducted by Kwong, Lau, Lee, & Kwan (2011) in Hong Kong revealed that a pressure ulcer prevention programme at long term care facilities over 12 weeks decreased the incident rate from 9-2.5% to 2-0.8%. Prevention programme covered knowledge of pressure ulcers and skills about positioning and transferring.

Another study conducted by Woodhouse and Graham (2014) found a reduction in stage 3 & 4 pressure ulcers, more appropriate use of mattresses, increased awareness of skin checking (evident from nursing notes/wound care plans), increased awareness of continence associated problems and appropriate management, and clearer, more accurate patient safety incident reports occurred as a direct result of education and training.

Preventive Measures: Support Surfaces• Pressure redistribution is created by immersion and envelopment

– Immersion = measure of how deep one sinks into the support surface– Envelopment = capability of a support surface to deform around and encompass the contours of the

human body• Wide variety of support surfaces available classified as either static (constant low pressure) or

dynamic (alternating)– Static systems work by increasing the contact area between the loaded point of the body and the surface

the person is lying or seated on– Dynamic systems are composed of air filled cells that are timed to inflate and deflate and, in so doing,

redistribute pressure• The pressure redistribution device cover plays an important role in the capability of the device to

operate effectively– Should be non-slip, should have a low coefficient of friction, should be moisture vapour permeable, and

should be able to keep the skin relatively cool because an increase in skin temperature also increases pressure ulcer risk

Preventative Measures: Microclimate Control● Microclimate (external environment) refers to skin temperature and skin moisture between a patient’s skin and support

surface○ Skin temperature is a quantitative measurement○ Skin temperature has been shown to increase by 1-2 degrees Celsius in 24-96 hours before pressure ulcers

develop (SEM scanner)○ Skin moisture has been known as the subjective indicator of pressure ulcer development as it is used as a

subscale of the Braden scale and a quantitative measurement to predict pressure ulcers■ Increased skin moisture contributes to skin breakdown and maceration

● Any surface that has contact with the skin has the potential to alter the microclimate, including the contact between textiles and skin

● A study published by the International Wound Journal in 2015 found that the development of pressure ulcers and superficial skin changes were related to increasing microclimate status (skin temperature) and hospital bed sheets have the potential to reduce the incidence of pressure ulcers and superficial skin changes by creating a physiological microclimate environment

○ Fabrics/textiles of hospital bed sheets play at least three roles in maintaining a favorable microclimate between the patient’s skin and support surface

■ Wicking away perspiration■ Reducing heat insulation■ Reducing the coefficient of friction

Preventative Measures: Nutrition● Prevention and healing of pressure ulcers can be challenging due to various factors

○ Patient’s burden of illness○ Degree of physiological compromise

● Adequate nutrition is essential in the prevention and healing of pressure ulcers○ Screen for nutritional status and assess risk for pressure ulcers○ Collaborate with a registered dietician ○ Administer appropriate feeding formulations and micronutrient/macronutrient supplements to promote wound healing

Collection Data Evaluation WorksheetHas the change had an impact?Example: 5 out of 5 new admissions have completed assessment forms within 24 hours. Example: 5 out of 5 call lights received response within X minutes.Goal: To have all admissions assessed within 24 hours.Goal: To answer call lights within X minutes.Data source (prevalence and incidence, medical records, staff survey, patient survey)Results:

Did the team reach their goal?Does the team need to change or revise process or make changes?

Evaluation Worksheet

Evaluating allows the team to organize observations. Evaluation also includes data the assess whether the changes have helped to reach projected goals.

Do we need to reevaluate our initial goal?What is working well? Why?What is not working? Why?What can be done differently?Do we need to revise or add materials?How does staff feel about the change in process?Are patients positively affected by the change in protocol?

Run ChartExample of a run chart. Run charts measure data over a period of time. Run charts can be used to track the amount of healthcare acquired pressure ulcers versus community acquired pressure ulcers. They can also be used to track newly acquired versus ongoing pressure ulcers. A run chart can be adjusted depending on the specific needs of the facility. If new procedures, improvements, education, or other preventative measures are implemented during a time specific frame the quality improvement and effectiveness could be determined with a run chart.

AlgorithmAlgorithms are created by professionals using best evidenced based practice. An algorithm can be used as a proactive approach towards preventing pressure ulcers as well as a guide for treatment, or a guide for predicting pressure ulcers. Algorithms standardize care within a facility which makes all care providers aware and able to take action promptly.

ConclusionCommunication and education is key to preventing pressure ulcers. Emphasis on relieving pressure to pressure points by frequent repositioning and minimizing shear and friction can eliminate pressure ulcers from forming. Utilizing the Braden scale can alert staff to monitor patients who are considered high risk. Other preventive measures such as providing appropriate support surfaces, microclimate control, and proper nutrition can decrease the development of pressure ulcers.

Pressure ulcers are complex wounds with various degrees of severity in relation to depth, inflammation, and granulation. Due to the different pressure ulcer stages, different methods of treatment, healing times, and a patient’s response to treatment varies greatly.Prognosis for early stage pressure ulcer is excellent with proper treatment in a timely manner

● Typically requires weeks of routine treatmentAfter 6 months of treatment >70% of stage II pressure ulcers resolve

● 50% of stage III● 30% of stage IV

Monitoring ulcers progression is essential.● Pressure Ulcer Scale for Healing (PUSH) is a tool that can be used to monitor progression of pressure ulcers

http://www.npuap.org/wp-content/uploads/2012/02/push3.pdf

ReferencesAgency for Healthcare Research & Quality. (n.d.) Retrieved March 27, 2016 from http://www.ahrq.gov/

Beldon, P. (2014). How to accurately identify and record pressure ulceration. Journal of Community Nursing, 28(5), 33-40 8p.

Cherry, B. (2014). Contemporary nursing - issues, trends & management (6th ed.). St Louis: Elsevier Mosby.

Cox, J., & Rasmussen, L. (2014). Enteral Nutrition in the Prevention and Treatment of Pressure Ulcers in Adult Critical Care Patients. Critical Care Nurse, 34(6), 15-27 13p. doi:10.4037/ccn2014950

Ignagtavicius, D. D. & Workman, L. M., (2013). Medical-Surgical Nursing (7th ed.). St. Louis: Elsevier.

Kroshinsky, D, Strazulla, L.(2016). Pressure ulcers ( pressure sore; bedsores;decubitus ulcers; decubiti). http://www.merckmanuals.com/professional/dermatologic-disorders/pressure-ulcers/pressure-ulcers . Retrieved March 25, 2016.

Kwong, E. W., Lau, A. T., Lee, R. L., & Kwan, R. Y. (2011). A pressure ulcer prevention programme specially designed for nursing homes: does it work?. Journal Of Clinical Nursing, 20(19/20), 2777-2786 10p. doi:10.1111/j.1365-

2702.2011.03827.x

Lyder, C.H., Wang, Y., Metersky, M., Curry, M., Kliman, R., Verzier, N.R., & Hunt, D.R. (2012). Hospital acquired pressure ulcers. Journal of the American Geriatrics Society, 60(9), 1603-1608.

Moore, Z., Haynes, J. S., & Callaghan, R. (2014). Prevention and management of pressure ulcers: support surfaces. British Journal of Nursing, 23(6 Supp), S36-42 1p.

The National Pressure Ulcer Advisory Panel - NPUAP. (2015, September 18). Retrieved March 30, 2016, from http://www.npuap.org/news/

Ohura, T., Nakajo, T., Okada, S., Omura, K., & Adachi, K. (2011). Evaluation of effects of nutrition intervention on healing of pressure ulcers and nutritional states (randomized controlled trial). Wound Repair & Regeneration, 19(3), 330-336 7p.

doi:10.1111/j.1524-475X.2011.00691.x

The Pew Charitable Trusts. (2014). Tracking key health indicators: Providing context for state health care spending. Retrieved from http://www.pewtrusts.org/~/media/data-visualizations/interactives/2014/health_indicators/index.html?la=en.

Posada-Moreno, P., Losa Iglesias, M. E., Becerro De Bengoa Vallejo, R., Ortuño Soriano, I., Zaragoza-Garci a, I., & Marti nez-Rincon, C. (2011). Influence of different bed support surface covers on skin temperature. Contemporary Nurse: A Journal

For The Australian Nursing Profession, 39(2), 206-220 15p.

State of Hawaii Department of Health. (2015, March 9). Hawaii: Best nursing homes in the nation. Rerieved from http://health.hawaii.gov/news/olalokahi/hawaii-best-nursing-homes-in-the-nation/.

Sullivan, N., & Schoelles, K. M. (2013). Preventing In-Facility Pressure Ulcers as a Patient Safety Strategy. Annals of Internal Medicine, 158410-416.

Van Rijswijk, L. & Beitz, J. (2013). Creating a pressure ulcer prevention algorithm: systematic review and face. Ostomy wound management, 59(11), 28-40. Retrieved from

http://www.o-wm.com/article/creating-pressure-ulcer-prevention-algorithm-systematic-review-and-face-validation

Woodhouse, L., & Graham, K. (2014). Meeting targets in pressure ulcer prevention in the community by collaborating with industry. British Journal Of Community Nursing, 19(Sup12), S14-20 1p.

Yusuf, S., Okuwa, M., Shigeta, Y., Dai, M., Iuchi, T., Rahman, S., & ... Sanada, H. (2015). Microclimate and development of pressure ulcers and superficial skin changes. International Wound Journal, 12(1), 40-46. doi:10.1111/iwj.12048