Tuesday, April 16, 2024

Hospital Acquired Pressure Ulcers Prevention

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What Is A Pressure Injury

Medical Device-Related Pressure Injury: AHRQ Preventing Pressure Ulcers in Hospitals Toolkit

A pressure injury is an area of injured skin. A pressure injury happens when force is applied on the surface of the skin. This force can be a constant pressure on an area of skin or a dragging force between the skin and another surface. These injuries usually happen over bony parts of the body . A pressure injury can become life-threatening if it advances to a deep wound or becomes infected.

What Are The Causes Of Pressure Injuries

Pressure injuries are caused when a force is applied to the skin, causing damage to the tissue. Several types of force include:

  • Pressure: Constant pressure on the skin results from remaining in the same position for a prolonged period of time.
  • Shear: Shear damage or a dragging force can occur when the head of the bed is raised and the body slides down. The skin sticks to the sheets, but internal structures are damaged.
  • Moisture: Fluids that remains on the skin can cause the skin to become overly wet, which increases the risk for pressure injury development.

Preventive Interventions: Nutrition Support Heel And Head

Assessment for nutritional deficits is strongly recommended in current guidelines.1 A nutritional support consultation or plan was present for 82.7% of patients with severe HAPIs and 71.4% for patients with Stage 1 or 2 HAPIs .6). Nutritional support was not provided for 10.7% of those with the most severe HAPIs .

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Biography Of Dean Whitehead

Dean Whitehead is a Senior Lecturer in the School of Nursing and Midwifery since January 2015 arriving after 10-years in New Zealand and the UK prior to that. He sit on several international Executive Editorial / Advisory Journal Boards, including the Journal of Clinical Nursing, Nurse Education Today, International Journal of Orthopaedic and Trauma Nursing and ISRN Nursing. His research interests in health promotion and health education theory and practice, health policy, public health and primary health care. He has over 150 theoretical/research publications in these fields and received the Emerald LiteratiNetwork Highly Commended Award for Excellence 2006

What Measures Are Included In The Hac Reduction Program

Preventing Pressure Ulcers in Hospitals

The following measures are included in the HAC Reduction Program, grouped here by category:

Patient Safety and Adverse Events Composite

We calculate the CMS PSI 90 using Medicare Fee-for-service claims. The CMS PSI 90 measure includes:

  • PSI 03 Pressure Ulcer Rate
  • PSI 06 Iatrogenic Pneumothorax Rate
  • PSI 08 In Hospital Fall with Hip Fracture Rate
  • PSI 09 Perioperative Hemorrhage or Hematoma Rate
  • PSI 10 Postoperative Acute Kidney Injury Requiring Dialysis Rate
  • PSI 11 Postoperative Respiratory Failure Rate
  • PSI 12 Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate
  • PSI 13 Postoperative Sepsis Rate
  • PSI 14 Postoperative Wound Dehiscence Rate
  • PSI 15 Abdominopelvic Accidental Puncture/Laceration Rate

Centers for Disease Control and Preventions National Healthcare Safety Network healthcare-associated infection measures

We calculate the following HAI measures using data on infections taken from charts, reports, and other sources and reported to the National Healthcare Safety Network:

  • Central Line-Associated Bloodstream Infection

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Staff Education With Audit Feedback

From a systematic review of interventions, Sullivan & Schoelles reported successful quality improvement programs with care bundles reporting reduced HAPU risk almost always included staff education and frequently included staff feedback from audits . In addition, Swafford et al. assessed the effectiveness of a year-long HAPU prevention program in an adult ICU, including the Braden scale, revised skin-care protocol, fluidized repositioners, silicone adhesive dressings, and face-to-face staff education.There was a 69% reduction in HAPUs at the end of the program . The authors reported staff education with performance feedback positively contributed to the program outcomes. Similarly, Armour-Burton et al. reported a multidisciplinary healthy skin project eliminated HAPUs in a surgical progressive care unit . The key intervention strategies were staff education, unit based WOC nurse, risk assessment with the normal care . Finally, Kelleher et al. attributed the elimination of HAPU to enhanced education and feedback provided by a WOC nurse. Overall, quality improvement programs with multidisciplinary participation, structured education, and adherence to evidence-based protocols resulted in significant HAPU reductions .

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Selection Criteria For Subjects

This study included only the first patient admission during the study period, assuming that prior hospitalization might contribute to pressure ulcer development. In addition, patients were selected if they stayed longer than four days and had both health history and physical assessment records, including admission route activities of daily living prior to admission endocrine history as well as genitourinary, cardiovascular, musculoskeletal, neurological, and gastrointestinal histories/ assessments. Since this study used the Braden scale as a reference standard of predictive modeling results, patients also needed to have Braden scores documented on admission in order to be eligible for the study. Among the patients who met the selection criteria, patients with pressure ulcers were excluded if it was unclear whether or not the pressure ulcers developed during their stay. As a result, 84 subjects with hospital-acquired pressure ulcers and 2,263 non-HPU subjects were available for the analysis .

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How Pressure Ulcers Develop

Pressure ulcers can develop when a large amount of pressure is applied to an area of skin over a short period of time. They can also occur when less pressure is applied over a longer period of time.

The extra pressure disrupts the flow of blood through the skin. Without a blood supply, the affected skin becomes starved of oxygen and nutrients, and begins to break down, leading to an ulcer forming.

Pressure ulcers tend to affect people with health conditions that make it difficult to move, especially those confined to lying in a bed or sitting for prolonged periods of time.

Conditions that affect the flow of blood through the body, such as type 2 diabetes, can also make a person more vulnerable to pressure ulcers.

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The Repose Foot/heel Protector

Pressure Ulcer Prevention Program [Overview]

Repose foot protectors are designed specifically to minimise the risk of pressure damage to heels. They come in the form of splints made of Platilon, a polyurethane material with unique stretch, thermal and vapour-permeable properties. They are most effective when the patient is recumbent, semirecumbent or upright while on bed-rest, as the heels are supported above a void and therefore close to zero pressure, while the malleoli are protected by air-filled compartments.

The foot protectors are inflated using a hand-help pump. A valve ensures they are inflated to the correct pressure with no chance of over-inflation. This provides a pressure-reducing splint where the weight of the lower leg is redistributed over a wider area.

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Why Pressure Ulcer/injury Prevention Is Critical

Pressure injuries are very common in hospitals and long-term care facilities. In one recent survey, it was found that 26.7% of patients in a hospital had pressure injuries.2 The high rate of pressure injuries equates to significant time and resources spent on care and treatment. Some estimates place the cost of pressure injury treatment in the United States as high as $11.6 billion each year. This makes pressure injuries one of the most costly medical conditions.3 To reduce these costs and improve patient outcomes, it is important for nurses and other health care professionals to take a proactive approach focused on pressure injury prevention.

Interested in more information on pressure injury prevention?

  • Take initiative The first step to making a facility-wide impact on pressure injury prevention is to work with key staff and stakeholders to develop a prevention initiative. It is important to make sure that all relevant stakeholders, including senior administration and all health care clinicians providing hands-on care, understand the importance of reducing the incidence of pressure injuries and the steps they need to take to prevent them. Circulating risk assessment and best practice literature can help ensure that the staff is well educated and prepared to move forward with the initiative.
  • About the Sponsor:For over 155 years, Smith & Nephew has provided innovative solutions that help reduce the human and economic costs of wounds and help people regain their lives.

    C: Current Process Analysis

    Background: Before beginning a quality improvement initiative, you need to understand your current methods. This tool can be used to describe key processes in your organization where pressure ulcer prevention activities could or should happen.

    Reference: Adapted from: Quality Partners of Rhode Island. QI Worksheet E, Current Process Analysis. Available at: .


    • Have the implementation team identify and define every step in the current process for pressure ulcer prevention.
    • When defining a process, think about staff roles in the process, the tools or materials staff use, and the flow of activities.
    • Everything is a process, whether it is admitting a resident, serving meals, assessing pain, or managing a nursing unit. The ultimate goal of defining a process is identifying problems in the current process.

    Use: Determine if there are any gaps and problems in your current processes, and use the results of this analysis to systematically change these processes.


    Example: Process for Making Buttered Toast

    Step Define

  • Wait for bread to toast.
  • When toast is ready, remove from toaster and put on plate.
  • Use knife to cut pat of butter.
  • Use knife to spread butter on toast.
  • Identify the steps of your defined process.

    Team discussion

    Evaluate your current process as you define it:

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    Goal 1 Objective : Expand Safe High

    Strengthening the nations health care system is not achievable without improving health care quality and safety for all Americans. The immediate consequences of poor quality and safety include health care-associated infections, adverse drug events, and antibiotic resistance.

    Health care safety is a national priority. HHS investments in prevention have yielded both human and economic benefits. From 2010 to 2014, efforts to reduce hospital-acquired conditions and infections resulted in a decrease of 17 percent nationally, which translates to 87,000 lives saved, $19.8 billion in unnecessary health costs averted, and 2.1 million instances of harm avoided.2

    In the previous administration, the Office of the Secretary led this objective. The following divisions are responsible for implementing programs under this strategic objective: ACL, AHRQ, CDC, CMS, HRSA, OCR, ONC, and SAMHSA. HHS has determined that performance toward this objective is progressing. The narrative below provides a brief summary of progress made and achievements or challenges, as well as plans to improve or maintain performance.

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    Identification Of Unavoidable Hapis


    To achieve the first study aim, eligible patients were identified by using monthly pressure injury prevalence surveys, medical record reporting mechanisms, medical coding procedures, and/or quality reporting processes. Patients were divided into 2 groups using the PUPI tool.

    The PUPI contains 13 items . If all items in the PUPI are answered âyesâ , the HAPI was identified as unavoidable.

    The Braden Inventory Worksheet, an investigator-developed data collection tool specific to our electronic medical record documentation, was used to collect Braden Scale subscale and total scores for the 3 days before the first documentation of the HAPI and the interventions documented that correspond to each Braden Scale subscale . These data were then used to complete the PUPI.

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    Essentials Of A Bariatric Patient Handling Program

    • Email:

      Gail Archer-Heese is an Occupational Therapist who graduated from the University of Manitoba with an undergraduate degree in Medical Rehabilitation. She has been involved in the area of work-related injury and rehabilitation since 1992. Currently she is a Musculoskeletal Specialist in Ergonomics at the Health Sciences Centre Site, which is part of the Winnipeg Regional Health Authority in Manitoba, Canada. She has been responsible in the past for the development of a musculoskeletal injury prevention program at a regional facility and instrumental over the past few years in developing the Patient Handling and Movement Guidelines and the Bariatric Care Guidelines for the Regional Authority. Ms. Archer-Heese has co-authored several journal articles on the topic of bariatric patient handling she continues to provide clinical care on the wards and serve as a consultant in the community.

    Keywords: bariatric patients injury prevention safe patient handling protocols and guidelines risk to healthcare workers

    Bariatric Definitions

    Health Concerns of Bariatric Patients

    Risks for Healthcare Providers

    Components of a Bariatric Patient Handling Program

    • Operational Procedure and Policy

    Each of these components will be discussed in turn below.

    Operational Procedure and Policy

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    If You Use A Wheelchair

    Make sure your wheelchair is the right size for you.

    • Have your doctor or physical therapist check the fit once or twice a year.
    • If you gain weight, ask your doctor or physical therapist to check how you fit your wheelchair.
    • If you feel pressure anywhere, have your doctor or physical therapist check your wheelchair.

    Sit on a foam or gel seat cushion that fits your wheelchair. Natural sheepskin pads are also helpful to reduce pressure on the skin. DO NOT sit on a donut-shaped cushions.

    You or your caregiver should shift your weight in your wheelchair every 15 to 20 minutes. This will take pressure off certain areas and maintain blood flow:

    • Lean to one side, then lean to the other side

    If you transfer yourself , lift your body up with your arms. DO NOT drag yourself. If you are having trouble transferring into your wheelchair, ask a physical therapist to teach you the proper technique.

    If your caregiver transfers you, make sure they know the proper way to move you.

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    Strength And Limitation Of Study

    The main strength of the study is the size of the sample obtained during the 4 consecutive years of the study period, we believe this gives it the necessary validity, and will be useful in future comparisons. A limitation of this study the was retrospective data collection, although hospital protocols normalize nursing activity on prevention, communication and follow-up of PUs, there may be undocumented or incomplete or even underestimated information in the HAPU.

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    How Should A Comprehensive Skin Assessment Be Conducted

    Pressure Ulcers – prevention and treatment at The Pennine Acute Hospitals NHS Trust (2013)

    The first step in our clinical pathway is the performance of a comprehensive skin assessment. Prevention should start with this seemingly easy task. However, as with most aspects of pressure ulcer prevention, the consistent correct performance of this task may prove quite difficult.

    3.2.1 What is a comprehensive skin assessment?

    Comprehensive skin assessment is a process by which the entire skin of every individual is examined for any abnormalities. It requires looking and touching the skin from head to toe, with a particular emphasis over bony prominences.

    As the first step in pressure ulcer prevention, comprehensive skin assessment has a number of important goals and functions. These include:

    • Identify any pressure ulcers that may be present.
    • Assist in risk stratification any patient with an existing pressure ulcer is at risk for additional ulcers.
    • Determine whether there are other lesions and skin-related factors predisposing to pressure ulcer development, such as excessively dry skin or moisture-associated skin damage .
    • Identify other important skin conditions.
    • Provide the data necessary for calculating pressure ulcer incidence and prevalence.

    Additional Information

    It is important to differentiate MASD from pressure ulcers. The following articles provide useful insights on how to do this:

    3.2.2 How is a comprehensive skin assessment performed?

    • Skin integrity .

    Detailed instructions for assessing each of these areas are found in Tools and Resources .

    Action Steps

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    B: Quality Improvement Process

    Background: This tool will help you and your team identify the extent to which you have the resources for quality improvement in your organization. The form was developed by the Turning Point Initiative to assess if an organization has the needed systems in place to improve quality and performance.

    Reference: Turning Point Performance Management National Excellence Collaborative. Performance Management Self-Assessment Tool. Available at: .

    Instructions: This tool should be filled out by the implementation team leader in consultation with the QI department. The “you” refers to your organization as a whole. Check the box that most accurately describes your organization’s current resources.

    Use: If you find that your organization has fully operationalized QI processes, connect the pressure ulcer prevention initiative with these existing processes. If some processes are missing, advocate for them to be put into place in the context of the pressure ulcer initiative.

    Quality Improvement Process

    The Nurses Role In Pressure Ulcer Prevention

    Nurses have more touchpoints with patients than any other member of the care team. As a result, the nurses role in pressure ulcer prevention is greater than most. To prevent pressure ulcers from forming, nurses should:

    • Check patients for factors that increase their risk of developing an ulcer
    • Turn the patients every 2 – 6 hours, depending on their risk factors
    • Use barrier creams to manage moisture
    • Keep patients well-hydrated
    • Ensure patients have good nutrition

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    The Administrative Teams Role In Pressure Ulcer Prevention

    The administrative team may not have many touchpoints with the average patient, but they still play a role in care. Since part of their job is to analyze and reduce the cost of care, an administrative team is in the perfect position to lower the cost of hospital-acquired pressure ulcers.

    Specifically, theyre perfectly positioned to provide access to equipment that lessens the risk of pressure ulcers. This equipment may include:

    • Beds with better ventilation
    • Devices that help move a patient more quickly and safely
    • Props to help patients rest in less stressful positions

    Admin teams can also work with doctors to ensure that patients have access to better nutrition during their stay.

    Many administrative teams are reluctant to provide room in the budget for these devices. However, stage 3 and 4 HAPIs account for 58% of annual costs, despite being considered a rare outcome.

    Even if better equipment and nutrition reduce the instances of these late stage ulcers, the return on investment is significant.

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