Improving Incidence &

Prevalence of Pressure Ulcers

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

Etiology & Statistics

A 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 Improvement

PICOT

Current Process Analysis

Worksheet

Problem: Someone identified as at risk for

developing a pressure ulcer.

What policies and procedures does the facility have in

place?

Intervention: Provide multiple preventative

measures.

What forms do we use?

How does our physical environment support or hinder
this process?

Comparison: Compare old and new data.

What staff are involved in this process?

Outcome: Decreased incidence of pressure

ulcers.

What part of this process does not work?

Time: Continued improvement weekly and

monthly.

Do we duplicate work unnecessarily?

Assessing Pressure Ulcer Policies Worksheet

Does the facilitys policy include a statement regarding the facilitys commitment to
prevention and management?
Does the policy include screening, assessment and monitoring?
If the patient isnt 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 Training

Does 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

Goals
What 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 patients 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 patients 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
Patients 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 Worksheet

Has 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 Chart
Example 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.

Algorithm
Algorithms 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.

Conclusion
Communication 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 patients 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 treatment
After 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

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

References

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., Ortuo Soriano, I., Zaragoza-Garcia, I., & Martinez-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