The Pressure is On

By | 2022-02-03T17:27:12-05:00 January 14th, 2008|0 Comments

Pour on the Maalox. Sprinkle in a little sugar. Turn on the heat lamp. The former “tried and true” remedies for pressure ulcers are enough to make any nurse cringe.

Now in the evidence-based practice era, nurses use a problem-solving approach to the longstanding challenge of pressure ulcer prevention. The result is treatments that combine the best available current, valid, and reliable evidence; clinical expertise; and individual patient values.

A grave problem

Each year nearly 1 million people develop pressure ulcers, reports the Institute of Healthcare Improvement (IHI). Resulting costs exceed $1.3 billion, and the human suffering is inestimable. Pressure ulcers escalate patients’ decline and cause an estimated 60,000 acute care patient deaths from related complications. “Pressure ulcers are high on the list of ‘never events’ developed by the Centers for Medicare and Medicaid (CMS) and the National Quality Forum — serious, reportable errors that should not happen, but when they do cause serious injury or death and result in increased cost to treat,” says Kay Elliott, RN, wound resource nurse/surgical services educator at Laurel Regional Hospital in Laurel, Md.

Given that CMS no longer reimburses healthcare facilities for treatment of pressure ulcers that occur during hospitalization, the assessment and recognition of pressure ulcers on patient admission is crucial to the financial stability of the organization. “If we don’t assess for and identify pressure ulcers on admission, we own them,” says Elliott. “This adds to the burden of hospitals already in financial crisis.”

Nurses have no control over how many patients with pressure ulcers are admitted to acute care facilities, but they often can reduce the number of patients who acquire them in the hospital.

Nursing challenge

Patients with comorbidities — the elderly with diabetes, for example — who are at higher risk for developing pressure ulcers present greater prevention and treatment challenges. On certain hospital units, such as the OR, there is greater risk for ulcers when skin breakdown occurs from surface contact, Elliott says.

As a quality nursing indicator, pressure ulcers fall under nurses’ responsibilities, Elliott says. A significant part of the best practice nursing initiatives at Laurel Regional Hospital includes the assessment of patients for skin breakdown, measurement, and documentation (including photography) of existing pressure ulcers. This process occurs upon admission to the facility or the OR and again when the patient is transferred to the recovery room, says Elliott.

Patients with pressure ulcers are referred to nutrition services for high-protein diets to encourage wound healing, and they are provided special beds designed for preventing and treating pressure ulcers.

The pressure ulcer prevention culture at Laurel Regional Hospital involves daily use of the Norton Scale for risk assessment, turning patients every two hours as needed, and preventive skin-care products. “Our goal is to identify existing pressure ulcers and prevent wounds from getting worse,” Elliott says.

Collaboration counts

Thanks to an initiative sponsored by the New Jersey Hospital Association (NJHA) in Princeton, a group of 150 hospitals, nursing homes and healthcare agencies across the state reduced pressure ulcers among patients at their facilities.

“We were able to achieve measurable, significant improvement in the quality of care provided to patients, with respect to pressure ulcer prevention across care settings,” says Aline Holmes, RN, senior vice president of clinical affairs for NJHA, whose two-year pilot program, the NJHA Pressure Ulcer Collaborative, began in September 2005.

Forty-eight organizations reported no new pressure ulcers for three months or more. In addition, the prevalence of existing pressure ulcers as patients moved from one care setting to another was reduced by 30%. Before the collaborative, an average of 16% of patients in the various centers had a pressure ulcer.

Award-winning success

Chilton Memorial Hospital (CMH) in Pompton Plains, N.J., had 95% or greater compliance in implementing the NJHA Pressure Ulcer Collaborative’s preventive strategies.

As a result, the hospital reduced the overall incidence of pressure ulcers by 25% during the two-year pilot program and won an award from the NJHA. (See “NJHA Recognizes Success.”)

“Pressure ulcer statistics at CMH went from 3% on the intermediate care unit and 5% in ICU in 2005 to zero housewide by 2007,” says Linda Thoden, RN, MS, CNAA, director of critical care services and senior leader of the CMH Pressure Ulcer Collaborative. “It’s rewarding when staff see patients healing.”

Kathleen Shala, RN, MS, CCRN, APN, critical care clinical nurse specialist, says the educational programs developed by CMH to support the initiative were key to its success. (See “Pressure Ulcer Staging Update.”)

Strategies for success

In addition to evidence-based educational programs in the classroom and frequent bedside rounds, Shala and former nurse manager Julie Dumpert, RN, BSN, developed and implemented the following protocol for identifying at-risk patients on the IMCU and then expanded its use hospitalwide.

  • Using a turning clock in patient rooms to remind nurses to turn and reposition patients every two hours
  • Elevating patients’ heels
  • Substituting soap-and-water baths with bath in a bag — a prepackaged, disposable, patient bathing system
  • Using laminated quick-reference grids when administering skin care
  • Adding Braden Scale and pressure ulcer information to the charge nurse shift report for follow-up and rounds
  • Using preprinted physician order forms for pressure ulcer care
  • Using physician order sets in the computer order-entry program
  • Substituting thinner, absorbent pads for the quilted-cotton, rubber-backed underpads for patients
  • Using a laminated quick-reference card provided by a skin care product vendor for pressure ulcer identification
  • Revising the extended-care facility transfer form to include a more thorough description of pressure ulcers and current treatment
  • Support throughout the ranks

    An important component of the CMH collaborative was the support of administration, namely Mary Rich, RN, vice president and chief nurse executive, for the purchase of additional skin- and wound-care products; a capital expenditure of $1.3 million to buy 152 beds designed for preventing and treating pressure ulcers; and the involvement of all levels of nursing staff in decision-making.

    Shala and Thoden say teamwork encourages their continued accomplishments in preventing pressure ulcers. Staff nurses, patient care technicians, nutrition specialists and physical therapists have unique roles in ensuring patient well-being.

    As part of the NJHA Pressure Ulcer Collaborative, the CMH team collaborated with extended-care facilities to which CMH patients are often discharged. Collaborative team members rotated sites and compared pressure ulcer products and protocols for consistency. “We aimed for continuity of care, a smooth transition for patients and long-term success,” says Shala.

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