Reducing Harm to Patients from Pressure Sores
Once considered an occasional and unfortunate by-product of hospital care, pressure ulcers are now seen as a preventable source of unnecessary harm. In 2006, SVMC worked with the Centers for Living & Rehabilitation to recognize and reduce pressure sores in the hospital.
The basic definition of pressure ulcers - damage to the skin or underlying tissue caused by unrelieved pressure - has remained constant, but the tools and techniques of skin care have changed in recent years. The products to prevent ulcers has changed, too. So has the overall approach to maintaining skin integrity.
Pressure ulcers are most common on bony prominences with little protective fat or muscle (such as heels, hips, shoulders, and tail bones). They develop when patients stay in one position for too long without shifting their weight. Any patient who is bedridden or wheelchair-bound is especially vulnerable. But even patients who sit in a regular chair without moving much are susceptible. The constant pressure against the skin reduces blood flow to contact areas. The skin begins to break down, and the tissue dies, often in a matter of hours. Friction and shear — caused by sliding down in the bed, for example, or being moved improperly from a stretcher to a bed — can make the problem worse.
The prevalence of pressure ulcers in hospitals across the nation typically ranges from 0.4 percent to 38 percent. Before conducting the project, SVMC had an average prevalence of hospital acquired pressure ulcers of 6.3 percent — slightly above the national mean of 5.1 percent for hospitals of 100 beds or less who report to the National Database of Nursing Quality Indicators.
What got the hospital's attention, however, was the fact that some 20% of its patients transferred to the Centers for Living & Rehabilitation, long-term care facility, had pressure ulcers upon admission. When the long-term care facility launched a project in conjunction with the hospital to reduce the incidence of pressure ulcers in the facility, it found that many of the patients they admitted from SVMC had no documentation in the hospital record indicating they had pressure ulcers during their hospital stay.
Experts say there are two main tasks in preventing pressure ulcers: identifying patients who are particularly at risk, and using a combination of equipment and vigilance to relieve pressure on vulnerable parts of the body. When the team analyzed both the hospital and long-term care practices relative to these tasks, they found that mattresses used in both facilities were not state-of-the-art for pressure ulcer prevention. In addition, a well-known risk assessment tool was not utilized fully to predict risk and aid in development of care plans, and that the nursing skill set for pressure ulcer identification was inconsistent.
Through collaboration between the two facilities, best practice standards were implemented for wound care and prevention followed by mandatory staff education about wound care, skin assessment, and documentation; the hospital developed new skin assessment documentation screens, and both facilities purchased state-of-the-art pressure relief mattresses and standardized all chair cushions and seating.
As a result of this work, the percentage of patients transferred from the hospital to a long-term care facility with pressure ulcers has dropped significantly, from an average of nearly 20 percent to just over 8 percent. Documentation of evidence of pressure ulcers upon discharge from the hospital has improved to nearly 100%, enabling caregivers at the long-term care facility the opportunity to identify and treat patients with pressure ulcers as soon as they are admitted. This has significantly reduced the percentage of high-risk patients with pressure ulcers from 19.7% to 11.8%; and the percentage of low-risk patients with pressure ulcers from 5.75% to 3.2%.
