Pressure Ulcers (stage III & IV decubitis ulcers)
Strategies for Preventing Pressure Ulcers
Joint Commission Perspectives on Patient Safety, Volume 8, Number 1, January 2008, pp.5-7(3)
Pressure ulcers, also known as decubitus ulcers or bed sores, are suffered by more than 2.5 million patients in U.S. acute-care facilities each year. Approximately 60,000 patients die each year due to pressure ulcer complications. Pressure ulcers can result in increased pain, prolonged infections, amputation, longer lengths of stay, and decreased quality of life. Healthcare providers know how to prevent pressure ulcers - susceptible patients must be frequently repositioned, and their skin must be regularly checked and well-cared for. However, incorporating these tasks into a patient's daily care regimen isn't that simple, particularly when so many health care organizations are facing nursing shortages. This article discusses strategies for prevention.
Pressures Ulcer Monitoring: A Process of Evidence-Based Practice, Quality, and Research
Joint Commission Journal on Quality and Patient Safety, Volume 34, Number 6, June 2008, pp. 355-359(5)
Background: A number of settings in eastern Ontario, Canada, have collaborated on establishing a common pressure ulcer monitoring system. This work was undertaken in a proactive effort to implement practice guideline recommendations related to pressure ulcer prevention. Methods: A work group was formed with clinical, quality, and research expertise. In a prospective (rather than retrospective) chart audit, 12-hour point prevalence surveys are conducted in which risk, occurrence, and interventions are tracked. Trained surveyors conduct a standard risk appraisal, head-to-toe skin assessment, and chart scan. Reporting mechanisms were developed at the organization, program, and unit levels. Results: Between 2001 and 2007, despite an inpatient population of which usually more than 25% were at "high" risk, prevalence decreased from 18% to 14%. Recommendations: Fifteen years' experience in pressure ulcer monitoring suggests the following recommendations: (1) create and enable skin care champions to monitor and develop unit-based solutions in response to survey findings; (2) embed monitoring in the quality and professional practice infrastructure of the organization; (3) use existing structures and processes such as unit councils or quality committees; quality processes and practice panels are ideal venues to situate pressure ulcer monitoring at both organizational and unit levels; and (4) create a data collection process that is as clinically sensible and feasible as possible. Summary and Conclusions: Monitoring is the linchpin that formed the foundation for the long-term, systemwide undertaking of the prevention of pressure ulcers and that created the climate for change and continued momentum.
Preventing Pressure Ulcers: The Goal Is Zero
Joint Commission Journal on Quality and Patient Safety, Volume 33, Number 10, October 2007, pp.605-610(6)
Background: One of the 12 interventions that the Institute for Healthcare Improvement (IHI) recommends for its 5 Million Lives Campaign is "Prevent Pressure Ulcers ... by reliably using science-based guidelines for their prevention." Pressure ulcers cause considerable harm to patients, hindering functional recovery, frequently causing pain, and often serving as vehicles for the development of serious infections. Although the goal for health care facilities to reduce pressure ulcers is admirable, the goal for pressure ulcer incidence should be zero. The Case for Prevention: Pressure ulcer prevention entails two major steps: identifying patients at risk and reliably implementing prevention strategies for all patients identified as at risk. Prevention strategies include six key elements (elements 3-6 address patients at risk): (1) conduct a pressure ulcer admission assessment for all patients, (2) reassess risk for all patients daily, (3) inspect skin daily, (4) manage moisture, (5) optimize nutrition and hydration, and (6) minimize pressure. Facilities may wish to form a multidisciplinary team to develop a pressure ulcer prevention program. Conclusion: The development of pressure ulcers is a painful, expensive, and unnecessary harm event that is all too prevalent in American hospitals. The prevention of pressure ulcers is a key intervention that is not new, not expensive, and has the potential to save thousands of patients from unnecessary harm.
Eliminating Facility-Acquired Pressure Ulcers at Ascension Health
Joint Commission Journal on Quality and Patient Safety, Volume 32, Number 9, September 2006, pp. 488-496(9)
Background: In 2004, as part of Ascension Health's "Healthcare That Is Safe" initiative, St. Vincent's Medical Center, as an alpha site, was charged with defining best practices to eliminate facility-acquired pressure ulcers. A comprehensive plan, including the "SKIN" (Surfaces, Keep the patients turning, Incontinence management, Nutrition) bundle, was developed. Results: The incidence of pressure ulcers decreased from > 2% to < 1% from December 2004 through February 2006. No new Stage III or IV facility-acquired pressure ulcers occurred between August 2004 and February 2006. Weekly SKIN operations meetings and use of the SKIN process tool ensured that all at-risk patients were receiving appropriate interventions. Reporting and Spread: The alpha site work and SKIN bundle were presented to all 67 Ascension Health acute care facilities at a rapid-design-format Pressure Ulcer Summit in mid 2005. All acute care facilities agreed to a single model of care using the SKIN bundle and common measures of quality and performance. Discussion: The St. Vincent's alpha site initiative in pressure ulcer prevention, enabled it to identify at-risk populations, implement appropriate actions, and achieve positive, measurable, meaningful results. Conclusion: The SKIN program was adopted and is being implemented throughout Ascension Health.
Preventing Pressure Ulcers in Connecticut Hospitals by Using the Plan-Do-Study-Act Model of Quality Improvement
Joint Commission Journal on Quality and Patient Safety, Volume 30, Number 4, April 2004, pp. 205-214 (10)
Background: Seventeen hospitals and the Peer Review Organization of Connecticut (Qualidigm) attempted to increase early identification of high-risk patients and utilization of pressure ulcer preventive measures. Methods: A multihospital retrospective cohort study with medical record abstraction was used to obtain a total of 1,955 (baseline) and 891 (follow-up) patients aged 65 years and older discharged after treatment for pneumonia, cerebrovascular disease, or congestive heart failure with a length of stay five days. During a nine-month period, the hospitals conducted four plan-do-study-act improvement cycles and shared their results in conference calls and group meetings. Results: Statistically significant increases were noted from baseline to follow-up in identification of high-risk patients, repositioning of bed-bound or chair-bound patients, nutritional consults in malnourished patients, and staging of acquired Stage II pressure ulcers. Daily skin assessments occurred at a high rate in both periods. There were no statistically significant changes in other processes of care, pressure ulcer incidence, or mortality. Discussion: Performance of four pressure ulcer prevention processes of care increased concurrently with a multifaceted improvement intervention.