R E V I E W S & A N A LY S E S Hospital-Acquired Pressure Ulcers Remain a Top Concern for Hospitals Michelle Feil, MSN, RN, CPPS INTRODUCTION Senior Patient Safety Analyst Pennsylvania Patient Safety Authority Hospital-acquired pressure ulcers (HAPUs) are reportable events under the Pennsylvania Janette Bisbee, MSN, RN-BC, NHA Medical Care Availability and Reduction of Error (MCARE) Act. The MCARE Act Education/Project Manager requires healthcare facilities to report events “involving the clinical care of a patient in Pennsylvania Hospital Engagement Network a medical facility” that either resulted in, or had the potential to result in, “an unantici- The Hospital and Healthsystem Association of Pennsylvania pated injury requiring the delivery of additional health care services to the patient.”1 Pressure ulcers are a frequently reported hospital-acquired condition in Pennsylvania. In 2013, Pennsylvania healthcare facilities reported 33,545 events involving impaired ABSTRACT skin integrity to the Pennsylvania Patient Safety Authority through its Pennsylvania Pennsylvania hospitals reported more Patient Safety Reporting System (PA-PSRS). This represents the fifth most frequently than 19,000 pressure ulcer events reported patient safety event type, following (1) errors related to procedures, treat- to the Pennsylvania Patient Safety ments, or tests, (2) medication errors, (3) complications of procedures, treatments, or Authority in 2013. Hospital-acquired tests, and (4) falls.2 The majority of impaired skin integrity events (n = 19,009, 56.7%) pressure ulcers (HAPUs) are a recog- were hospital-reported pressure ulcers. nized patient safety concern and meet In December 2008, the Authority published “Pressure Ulcers: New Staging, Reporting, the definition of a reportable event and Risk Reduction Strategies”3 following two important changes in pressure ulcer under the Pennsylvania Medical Care staging and reimbursement policies. The first change occurred in 2007 when the Availability and Reduction of Error National Pressure Ulcer Advisory Panel (NPUAP) added two new pressure ulcer stages: Act. Despite changes to the Centers suspected deep-tissue injury (SDTI) and unstageable (see “Pressure Ulcer Staging for Medicare and Medicaid Services’ Guidelines”).4 PA-PSRS added these categories in June 2008. inpatient prospective payment system in 2008 that established regulatory and The second change occurred in October 2008 when the Centers for Medicare and financial incentives for hospitals to pre- Medicaid Services (CMS) modified the inpatient prospective payment system and estab- vent HAPUs, they remain a frequently lished a list of hospital-acquired conditions subject to nonpayment.5 Prior to changes reported hospital-acquired condition. in the inpatient prospective payment system, hospitals received additional reimburse- An analysis of pressure ulcers reported ment from CMS for the care required for patients with pressure ulcers, regardless of through the Pennsylvania Patient Safety whether the pressure ulcer was preexisting or developed in the course of hospitaliza- Reporting System from 2007 through tion. However, effective October 1, 2008, hospitals were no longer reimbursed for stage 2013 suggests the need for improve- III and IV pressure ulcers that were hospital-acquired.6 ment in identification of pressure ulcers While implementation of best practices in HAPU prevention and treatment had present on admission; accurate staging already been established as a priority for hospitals,7 these changes brought heightened of pressure ulcers; and prevention of attention to the need for physicians and nurses to perform thorough skin assess- HAPUs, in particular stage III, suspected ments, to accurately stage and document pressure ulcers at the time of admission and deep-tissue injury, and unstageable throughout the course of hospitalization, and to prevent the development of HAPUs.8 pressure ulcers. Patient safety and The Authority analyzed events of pressure ulcers reported through PA-PSRS in order quality agencies, as well as wound to evaluate the impact these changes may have had on pressure ulcer reporting and to care specialty organizations, have identify trends in pressure ulcer reporting. established evidence-based best prac- tices in pressure ulcer risk assessment METHODS and prevention. Hospitals that have implemented these practices, such as Analysts queried the PA-PSRS database for events of pressure ulcers reported over those participating in the Pennsylvania seven calendar years, from 2007 through 2013; events were categorized both by time of Hospital Engagement Network Pressure acquisition and pressure ulcer stage. Ulcer Prevention project, have reported Three options exist for indicating the time of acquisition when entering pressure ulcer successful reductions in the incidence reports in PA-PSRS: “admitted from other facility with ulcer,” “new ulcer <24 hours after of HAPUs stage II or greater. (Pa Patient admission,” and “new ulcer >24 hours after admission.” Six options exist for indicating Saf Advis 2015 Mar;12[1]:28-36.) the pressure ulcer stage: I, II, III, IV, SDTI, or unstageable. Of note, time of pressure Corresponding Author ulcer acquisition is a mandatory field in PA-PSRS, while pressure ulcer stage is not. Michelle Feil Additionally, pressure ulcer event reports, as with all event reports, may be submitted through PA-PSRS as Incidents (i.e., events resulting in no harm to the patient) or Page 28 Pennsylvania Patient Safety Advisory Vol. 12, No. 1—March 2015 ©2015 Pennsylvania Patient Safety Authority Serious Events (i.e., events resulting in harm). Those events reported as Incidents PRESSURE ULCER STAGING GUIDELINES may be reported via direct manual entry The National Pressure Ulcer Advisory Panel pressure ulcer staging system is the sys- or via an interface mapped to PA-PSRS tem most frequently used in the United States to classify pressure ulcers. from an event reporting system within a hospital. Serious Events may only be Four original stages were identified in 1989: reported via direct manual entry. ——  Stage I: Localized non-blanchable erythema of intact skin, usually over a bony Analysts reviewed the pressure ulcer event prominence. reports according to (1) time of pressure ——  Stage II: Partial thickness loss of tissue presenting as a fluid-filled blister or a ulcer acquisition reported for all events, shallow crater with a red wound base, free of slough. (2) pressure ulcer stage and level of harm ——  Stage III: Full thickness tissue loss extending to the subcutaneous tissue; slough reported for all events, and (3) stage may be present but does not obscure the wound base. reported for all pressure ulcers identified ——  Stage IV: Full thickness tissue loss extending to muscle or bone; slough or as “new ulcer >24 hours after admission.” necrotic tissue may be present. Two new stages were added in 2007: RESULTS ——  Suspected deep-tissue injury: Localized purple or maroon discoloration of intact Pressure Ulcer Reporting and skin, or a blood blister, caused by damage to the underlying soft tissue. This Time of Acquisition wound may evolve rapidly to a stage III or IV pressure ulcer, even when optimal Figure 1 shows the number of pressure care is provided. ulcers and the time of pressure ulcer ——  Unstageable: Full thickness loss of tissue that cannot be staged because necrotic acquisition reported through PA-PSRS tissue obscures the full depth of the wound. Once necrotic tissue is removed, from 2007 through 2013. The total these ulcers will be staged as either stage III or IV. number of reports increased from 2007 Source: National Pressure Ulcer Advisory Panel. NPUAP pressure ulcer stages/categories [online]. [cited 2014 Jun 9]. http://www.npuap.org/resources/educational-and-clinical-resources/ through 2009, with the largest increase npuap-pressure-ulcer-stagescategories of 39.2% having occurred from 2007 to 2008, concurrent with the addition of 10 reporting hospitals. Total pressure ulcer The increase in pressure ulcers reported Staging and Level of Harm for event reports decreased 10.0% in recent years, from a high of 21,120 in 2009 to as “new ulcer <24 hours after admission” All Reported Pressure Ulcers seen between 2011 and 2012 occurred The number of pressure ulcers reported as 19,009 in 2013. Between 2012 and 2013 at the same time as when large increases stage I has increased in recent years, while alone, there was a 5.9% decrease. were seen in the number of pressure ulcer the number of pressure ulcers reported Analysis revealed that nearly 30% of pres- events reported as Incidents, via interface, as stages II, III, and IV increased between sure ulcers across the seven-year period at less than 10 acute care hospitals in the 2007 and 2009, then decreased through were reported as “new ulcer >24 hours state. Closer examination of report narra- 2013 (see Figure 2, exclusively available in after admission,” a percentage that has tives suggests that this increase may be the the online version of this article). Between remained relatively stable over time. result of reporting pressure ulcers present 2009 and 2013, there was a 30.1% de- An interesting phenomenon occurred on admission (i.e., not hospital-acquired crease in reports of stage II pressure between 2011 and 2012, when there was and therefore not reportable under the ulcers, a 31.1% decrease in reports of stage a decrease in the number and percentage MCARE Act) using the “new ulcer <24 III pressure ulcers, and a 55.3% decrease of pressure ulcers reported as present on hours after admission” designation in in reports of stage IV pressure ulcers. admission from another facility concurrent PA-PSRS. Other potential contributing with a more than fourfold increase in the The first full year in which SDTI and factors identified from analysis of report number and percentage of pressure ulcers unstageable were included as stages in narratives included failure to identify reported as being “new ulcer <24 hours PA-PSRS was 2009. Although the number pressure ulcers present on admission, after admission.” In 2013 the number of of pressure ulcers reported for each of missing or inadequate pressure ulcer risk pressure ulcers reported as “new ulcer <24 these stages has varied from year to year, assessment, and missing or inadequate hours after admission” decreased some- between 2009 and 2013, there was a implementation of pressure ulcer preven- what, but the reported volume was notably 50.7% increase in the number reported tion measures. greater than in years prior to 2012. Vol. 12, No. 1—March 2015 Pennsylvania Patient Safety Advisory Page 29 ©2015 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Figure 1. Pressure Ulcer Events Reported to the Pennsylvania Patient Safety Authority, by Time of Acquisition, 2007 through 2013 NO. OF EVENT REPORTS NO. OF HOSPITALS 22,000 21,120 21,074 21,079 400 20,063 Admitted from other 18,831 19,009 facility with ulcer 17,600 320 New ulcer <24 hours after admission 13,525 New ulcer >24 hours 13,200 14,352 14,232 14,210 10,867 10,701 240 after admission 12,060 Number of hospitals 8,488 reporting pressure 8,800 160 164 165 167 172 174 ulcer events 151 161 3,228 882 791 744 741 2,600 4,400 703 80 5,889 5,977 6,098 6,126 5,968 5,708 4,334 2* 0 0 2007 2008 2009 2010 2011 2012 2013 MS14677 YEAR *Time of acquisition is a mandatory field in the Pennsylvania Patient Safety Reporting System. In 2011, due to technical difficulties, there were two pressure ulcer event reports missing information on the time of acquisition. as SDTI and a 19.0% decrease in the num- Staging of Pressure Ulcers Similar to reports of all pressure ulcers, ber reported as unstageable. Acquired More Than 24 Hours regardless of time of occurrence, about Of note, each year, approximately one- after Admission one-third of reports of pressure ulcers third of pressure ulcers reports were Because pressure ulcers reported through labeled “new ulcer >24 hours after admis- submitted without staging information, PA-PSRS as “new ulcer <24 hours after sion” did not include staging information. ranging from 29.4% in 2007 (n = 3,980 admission” contained reports of pres- of 13,525 total pressure ulcer reports) to sure ulcers that may have been present DISCUSSION 41.0% in 2011 (n = 8,633 of 21,079 total on admission, analysts undertook a Through analysis of pressure ulcer events pressure ulcer reports). separate analysis of pressure ulcers reported through PA-PSRS from 2007 The majority of pressure ulcer events reported as “new ulcer >24 hours after through 2013, the Authority identified reported through PA-PSRS from 2007 admission” to obtain a more accurate changes in pressure ulcer reporting per- through 2013 were reported as Incidents assessment of HAPUs being acquired haps influenced by the addition of SDTI (see Figure 3). This holds true across within Pennsylvania hospitals. Figure 4, and unstageable as new pressure ulcer all reported pressure ulcer stages. For exclusively available in the online version stages in PA-PSRS as well as modifica- example, in 2013, 97.1% (8,841 of 9,108) of this article, shows a decrease from tions to the CMS payment system, both of all reported stage I and II pressure 2007 through 2013 in the number of of which occurred in 2008. The 10.0% ulcers were labeled as Incidents. In the these HAPUs reported as stages I, II, or decrease in the number of pressure same year, 91.0% (3,270 of 3,592) of all IV, while the number reported as stage ulcer event reports from 2009 to 2013 is reported stage III, IV, SDTI, and unstage- III remained relatively unchanged. Again, encouraging; however, it is too soon to tell able pressure ulcers were labeled as using 2009 as a baseline, the number whether this represents a downward trend Incidents. of these HAPUs reported as SDTI and that will continue. unstageable increased through 2013. Page 30 Pennsylvania Patient Safety Advisory Vol. 12, No. 1—March 2015 ©2015 Pennsylvania Patient Safety Authority Figure 3. Pressure Ulcer Events Reported to the Pennsylvania Patient Safety Authority, by Level of Harm, 2007 through 2013 NO. OF EVENT REPORTS NO. OF HOSPITALS 22,000 21,120 21,074 21,079 600 Incidents 20,063 18,831 19,009 Serious Events 924 577 657 525 17,600 653 Number of 771 622 450 hospitals reporting 13,525 pressure ulcer 13,200 375 events 571 300 12,954 18,060 20,196 20,497 20,422 19,410 18,387 8,800 225 161 164 165 167 172 174 151 150 4,400 75 0 0 2007 2008 2009 2010 2011 2012 2013 MS14679 YEAR HAPUs acquired less than 24 hours after PA-PSRS, either manually or via elec- preventable, some pressure ulcers may be admission. The increase seen in the tronic interface, and to ensure that only unavoidable, particularly in the critically number and percentage of pressure ulcers HAPUs are being reported. ill11-13 or patients who are dying.14 reported as “new ulcer <24 hours after HAPUs acquired more than 24 hours Pressure ulcer staging. Staging informa- admission” (see Figure 1) suggests that hospitals need to closely examine proto- after admission. It is encouraging that the tion is missing in approximately one out cols for skin inspection and pressure ulcer number of pressure ulcers reported of three PA-PSRS pressure ulcer event prevention that are part of the admis- as “new ulcer >24 hours after admission” reports (see Figures 2 and 4, exclusively sion process. Because pressure ulcers has decreased in recent years. However, available in the online version of this can develop within as few as two to six more information is needed to know article). It is not clear whether this cor- hours,9,10 especially in critically ill patients, whether this is a true decrease in the relates with missing documentation of it is vital that nurses and other healthcare incidence of HAPUs in Pennsylvania pressure ulcer staging in the medical professionals assess risk and implement hospitals. Despite this apparent improve- record. Appropriate staging information preventive measures as quickly as possible ment, these pressure ulcers continue may help clinicians provide patients upon admission. to represent approximately 30% of all with appropriate wound care and take pressure ulcer events reported to the action when progression to deeper stages Additionally, it appears that some hospi- Authority, and the number of these of tissue damage is recognized. Missing tals may utilize their internal reporting HAPUs being reported at deeper stages of documentation of staging may also systems to capture reports of pressure tissue damage (i.e., unstageable and SDTI) negatively impact reimbursement. Several ulcers that are community-acquired and has increased (see Figure 4, exclusively organizations offer resources that address present on admission. Some of these re- available in the online version of this clinician education and pressure ulcer ports may have been mapped via the inter- article). Hospitals are encouraged to exam- staging competency, including the Agency face, and submitted through PA-PSRS, ine this issue more closely and to gather for Healthcare Research and Quality as “new ulcer <24 hours after admission” more information on possible causes and (AHRQ),15 ConvaTec,16 the National when in fact these are not HAPUs and opportunities for process improvements. Database of Nursing Quality Indicators,17 do not need to be reported under the Increased patient acuity and illness sever- and NPUAP.4 MCARE Act.1 Hospitals are encouraged ity may also be considerations; while Incidents versus Serious Events. By to look more closely at what pressure ulcer the majority of HAPUs are considered event reports are being submitted through definition, pressure ulcers are the result Vol. 12, No. 1—March 2015 Pennsylvania Patient Safety Advisory Page 31 ©2015 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S PENNSYLVANIA HOSPITAL ENGAGEMENT NETWORK PRESSURE ULCER PREVENTION PROJECT* The Pennsylvania Hospital Engagement Network (PA-HEN) PA-HEN/HAP patient and family guidebook (available Pressure Ulcer Prevention (PUP) project is a collaborative project at https://www.haponline.org/Portals/0/docs/Quality/ led by the Hospital and Healthsystem Association of Pennsylvania Patient_Family_Centered_Care/HAP_Patient_and_Family_ (HAP) targeted at reducing the incidence of hospital-acquired Centered_Care_Guidebook_July2013.pdf) pressure ulcers (HAPU) by 40% by the end of calendar year ——  Provided opportunities for hospital skin care teams and 2014. Twenty-four hospitals joined the collaboration in 2012, project leaders to share information and receive feedback and as of June 2014, 18 continued to participate. Members of through the following: the collaboration seek to decrease rates of HAPUs by increasing * Networking calls open to all project participants implementation of best practices in pressure ulcer prevention. * One-on-one coaching calls, conducted by the project Project Interventions manager, with individual hospital skin care teams Interventions implemented by the HAP project leadership team * Utilization of the Pennsylvania Patient Safety Knowledge and hospitals participating in the collaboration were varied Exchange (PassKey) website, a secure, collaborative and multifaceted. workspace for sharing project information and tools such as an education calendar, shared documents, HAP Project Leadership Team Interventions links to applicable skin care sites, educational materi- ——  Formed an advisory group of skin care experts to offer als, and a library of past webinars and networking calls guidance in program design, provide ongoing support, ——  Collected, analyzed, and distributed actionable data as a and ensure adherence to evidence-based best practices in means to drive improvement pressure ulcer prevention ——  Identified and paired mentor with mentee hospitals, and ——  Established a team of “skin care safety advisors,” trained utilized peer-to-peer learning to close gaps on perfor- in analysis of strengths, weaknesses, opportunities, and mance and foster improvements threats (i.e., SWOT analysis) and tracer methodology, Hospital Interventions who conducted on-site hospital visits and worked collab- oratively with the hospital staff to analyze current pressure ——  Developed individual hospital multidisciplinary skin care ulcer prevention initiatives and develop action plans for teams who implemented project tools, education, and improvement training ——  Designed robust webinars and in-person educational pro- ——  Designated hospital “skin care champions” who advocated grams provided by expert faculty for the project at the unit level and mobilized and moti- ——  Developed and distributed the Pressure Ulcer Prevention vated staff Resource Guide (available at https://www.haponline.org/ ——  Completed a comprehensive self-assessment survey, Portals/0/docs/Quality/Pressure_Ulcer/PA_HEN_PUP_ which was utilized to create action plans and tailor edu- Resource_Guide_June2014.pdf) cational content ——  Encouraged hospitals to incorporate patient and family ——  Participated in networking and coaching calls, in-person engagement best practices in their work, and provided educational events, and on-site visits from skin care access to tools, documents, educational events, and the safety advisors *The analyses upon which this publication is based were in part funded and performed under contract number HHSM-500-2012-00022C, entitled “Hospital Engagement Contractor for Partnership for Patients Initiative.” of damage to the skin and its underly- involving the clinical care of a patient in a delivery of additional healthcare services, ing structures; however, the majority of medical facility which could have injured it is suggested that hospitals reconsider HAPUs are reported through PA-PSRS the patient but did not either cause an the level of harm assigned to these event as Incidents. The reasons for this are not unanticipated injury or require the deliv- reports. Further investigation and estab- clear from the reports. As outlined in ery of additional health care services to lishment of criteria to delineate HAPUs the MCARE Act, an Incident is defined the patient.”1 In light of this definition, reportable as Serious Events is warranted. as “an event, occurrence or situation and because HAPUs typically require the Page 32 Pennsylvania Patient Safety Advisory Vol. 12, No. 1—March 2015 ©2015 Pennsylvania Patient Safety Authority ——  Shared tools and best practices with other collaboration a lonely dinghy in the sea. It’s nice to be part of a network! project members This is so exciting! Thanks for everything! ——  Collected and submitted monthly data on process and — Charissa Carfrey, team leader for Roxborough Hospital, outcome measures which joined the PA-HEN PUP project in 2014 ——  Served as mentor or mentee hospitals Data and Results Of note, an important tenet of the PA-HEN PUP project has been the involvement of the bedside nurse and other direct care All PA-HEN hospitals, regardless of PUP program participation, are providers. On two separate instances, webinars directed to unli- evaluated using Medicare PSI-03 data to calculate the incidence censed direct care providers resulted in the highest attendance rate of stage III and IV HAPUs per 1,000 Medicare patient numbers for any PUP project webinars. Many hospitals provide discharges. PA-HEN hospitals, as a group, achieved a 62.7% “lunch and learn” educational events for their direct care pro- reduction in this rate, from a baseline of 0.51 in 2011 to 0.19 viders during PA-HEN PUP webinars or use archived webinars in the fourth quarter of 2013. for orientation and ongoing educational purposes. In addition, hospitals participating in the PUP project are Hospitals participating in the project work together in a spirit required to self-report incidence rates of pressure ulcers, stage II of collaboration by sharing pressure ulcer prevention practices or greater, per 1,000 patient-days. PUP project hospitals and tools (e.g., policies and procedures, documents, forms, achieved a 41.7% decrease in this rate, from a baseline of 2.04 toolkits) and recounting experiences in working to prevent in the third quarter of 2012 to 1.19 in the third quarter of 2014. HAPUs, presenting success stories as well as challenges and While quarterly data reveals fluctuation and variability with opportunities for improvement. Hospitals report great benefit the rate over time, hospitals report being able to move the from this networking opportunity and celebrate the camaraderie needle steadily toward achievement in reduction of HAPUs that arises from working together toward a common goal. by the prompt implementation of pressure ulcer prevention interventions for patients deemed at highest risk for ulcer We have implemented some great things with the PA-HEN development. Improvements noted are largely felt to be attrib- and are focusing on how we can maintain our improved rate uted to heightened awareness and the leveraging, sharing, decrease in HAPUs. Our current focus is considering the and implementation of interventions and strategies from purchase of new pressure-reduction surfaces and looking the project. at ways to educate and engage patients and their families. It is my hope that we continue to make strides in preventing Looking Ahead pressure ulcers! The PA-HEN PUP project has evolved from a unit-level, nurse- — Barbara Gregory, team leader for Wayne Memorial driven initiative to a statewide, hospital-based, multidisciplinary Hospital initiative to prevent HAPUs. In addition, HAP has offered PA- HEN hospitals that are not members of the PUP project access I am eagerly putting together my wound care team with a to educational events and other project resources such as the diverse group of passionate individuals which include per- Pressure Ulcer Prevention Resource Guide and the PA-HEN/HAP formance improvement professionals, the patient experience patient and family guidebook (see HAP Project Leadership Team director, nutritionist, registered nurses, nonlicensed profes- Interventions above), as well as on-site visits by the skin care safety sionals, and a physical therapist. I hope to have as many advisors. Looking ahead, the PA-HEN PUP project continues to people as possible attend educational events, although I focus on spread and sustainability, with a goal of decreased rates am aware that a few will be working and I am grateful that of HAPUs for patients in all Pennsylvania hospitals. they can access it afterwards. WOCNs [wound ostomy continence nurses] in our hospital often feel like we float on Hospitals interested in learning more about the PA-HEN PUP project can contact HAP at (717) 564-9200. Pennsylvania Hospitals Hospital and Healthsystem Association See “Pennsylvania Hospital Engagement Collaborating to Reduce HAPUs of Pennsylvania (HAP), these hospitals Network Pressure Ulcer Prevention The Pennsylvania Hospital Engagement have been working collaboratively since Project” for more details and for links to Network (PA-HEN) Pressure Ulcer 2012 to increase implementation of best free resources developed by HAP to assist Prevention (PUP) project has reported practices in pressure ulcer prevention hospitals in implementing best practices success in reducing HAPUs. Led by the and decrease the incidence of HAPUs. in pressure ulcer prevention. Vol. 12, No. 1—March 2015 Pennsylvania Patient Safety Advisory Page 33 ©2015 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S RISK REDUCTION STRATEGIES color, temperature, texture, turgor, the pressure ulcer prevention plan Evidence-based pressure ulcer preven- consistency, or moisture.15,18-22 to all members of the healthcare tion guidelines have been developed by —— Repeat a head-to-toe skin assessment team.15,18-20,22 several patient safety and quality agencies, every 8 to 24 hours, depending on —— Provide ongoing education to the such as AHRQ,15 the Hartford Institute the clinical condition of the patient. patient, family, and all members for Geriatric Nursing,18 the Institute for Patients at high risk for pressure of the healthcare team regarding Clinical Systems Improvement,19 and ulcer formation and those who are pressure ulcer prevention and the National Quality Forum,20 as well as critically ill may require more fre- treatment.15,18-20,22 wound care specialty organizations, such quent assessments.15,18-22 —— Establish a protocol for clearly as the Wound, Ostomy and Continence —— Establish a pressure ulcer prevention and consistently documenting and Nurses Society21 and NPUAP.22 See plan, targeted to the patient’s identi- reporting pressure ulcers present “Evidence-Based Pressure Ulcer Prevention fied risk factors, that aims to on admission and those that are Guidelines” for a list of these guidelines minimize or eliminate friction hospital-acquired.15,19 along with links for accessing them. and shear, —— Monitor compliance with pressure The following are strategies based upon minimize pressure with off-load- ulcer prevention practices through these guidelines that hospitals can use ing and support surfaces, auditing of process measures to improve identification and reporting manage moisture, and (e.g., percentage of patients with of HAPUs, as well as to prevent their documentation of a risk assessment maintain adequate nutrition occurrence: and skin inspection within six hours and hydration.15,18,19,21,22 of admission, percentage of at-risk —— Consult evidence-based guidelines —— Document and communicate the patients with an appropriate pressure in developing a pressure ulcer results of the pressure ulcer risk reduction surface in place).15,19,20 prevention program (see “Evidence- assessment, skin assessments, and Based Pressure Ulcer Prevention Guidelines”). —— Establish an interdisciplinary team EVIDENCE-BASED PRESSURE ULCER PREVENTION GUIDELINES with defined roles and responsibili- ties to develop and oversee a pressure The following guidelines are available to assist hospitals in developing pressure ulcer ulcer prevention program.15,19 prevention programs: —— Identify clinicians with pressure ulcer ——  Agency for Healthcare Research and Quality—Preventing Pressure Ulcers in prevention and wound care expertise Hospitals: A Toolkit for Improving Quality of Care, available at http://www.ahrq. to serve as a resource for staff and gov/professionals/systems/long-term-care/resources/pressure-ulcers/ to provide ongoing pressure ulcer pressureulcertoolkit/index.html prevention education, including ——  Hartford Institute for Geriatric Nursing—Nursing Standard of Practice Protocol: with regard to accurate pressure ulcer Pressure Ulcer Prevention & Skin Tear Prevention, available at http:// staging.15 consultgerirn.org/topics/pressure_ulcers_and_skin_tears/want_to_know_more —— Consider developing a team of unit- ——  Institute for Clinical Systems Improvement—Pressure Ulcer Prevention and based champions to engage staff and Treatment Protocol, available at https://www.icsi.org/guidelines__more/ support ongoing pressure ulcer pre- catalog_guidelines_and_more/catalog_guidelines/catalog_patient_ safetyreliability_guidelines/pressure_ulcer vention efforts.16 ——  National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory —— Perform a pressure ulcer risk assess- Panel—Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, ment for all patients upon admission available at http://www.guideline.gov/content.aspx?id=24492 using a validated risk assessment tool ——  National Quality Forum—“Safe Practice 27: Pressure Ulcer Prevention” in Safe such as the Braden scale.15,18-22 Practices for Better Healthcare—2010 Update: A Consensus Report, available —— Reevaluate pressure ulcer risk daily at http://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_ and with changes in level of care or Better_Healthcare_–_2010_Update.aspx changes in condition.15,18-22 ——  Wound, Ostomy and Continence Nurses Society—Guideline for Prevention and —— Perform a head-to-toe skin inspec- Management of Pressure Ulcers, available at http://www.guideline.gov/content. tion for all patients upon admission, aspx?id=23868 and document any alteration in skin Page 34 Pennsylvania Patient Safety Advisory Vol. 12, No. 1—March 2015 ©2015 Pennsylvania Patient Safety Authority —— Evaluate the effectiveness of the information reported through PA-PSRS, the MCARE Act. Analysis suggests that pressure ulcer prevention program which, by itself, cannot be used to cal- Pennsylvania hospitals have room for through ongoing monitoring of culate prevalence or incidence rates improvement in identification of pressure outcome measures. Recommended for HAPUs. Analysis of event report ulcers present on admission; accurate stag- measures include prevalence rates data reveals variation in pressure ulcer ing of pressure ulcers; and prevention of (i.e., the number of patients with reporting practices among hospitals in HAPUs, in particular stage III, SDTI, and pressure ulcers at a certain point or Pennsylvania. Because of these limita- unstageable HAPUs. period in time) and incidence rates tions, decreases in the number of HAPUs Accurate staging and reporting of pres- (i.e., the number of patients devel- reported through PA-PSRS or changes in sure ulcers provides data that can be oping HAPUs during a period in the number of HAPUs reported at vari- trended over time to help hospitals assess time).15,19,20 ous times of acquisition or pressure ulcer the effectiveness of their current pressure —— Investigate every occurrence of stage stages may or may not represent improve- ulcer prevention protocols and design and III and stage IV pressure ulcers to ments in pressure ulcer prevention monitor the progress of quality improve- (1) identify systems failures and other practices or patient care results. ment efforts. Hospitals, such as those factors contributing to the occur- participating in the PA-HEN PUP project, rence of these pressure ulcers and CONCLUSION have demonstrated that the incidence (2) identify opportunities for Pressure ulcer prevention remains a prior- of HAPUs can be successfully reduced improvement. Root-cause analysis ity for hospitals because of identification through collaboration and implementa- may be a useful technique to accom- of HAPUs as a measure of patient safety tion of evidence-based best practices in plish this task.15 and quality of care, the establishment of pressure ulcer prevention. regulatory and financial incentives for LIMITATIONS Acknowledgments HAPU prevention, and the impact of Edward Finley, BS, data analyst, Pennsylvania Detailed analysis of HAPUs occurring in HAPUs on patients. HAPUs meet the Patient Safety Authority, contributed to data Pennsylvania hospitals is limited by the definition of a reportable event under acquisition and analysis for this article. NOTES 1. 2002 Pa. Laws 154, No. 13. Medical 5. Centers for Medicare and Medicaid 8. Wound, Ostomy and Continence Care Availability and Reduction of Error Services. Hospital-acquired conditions Nurses Society. Inpatient prospec- (MCARE) Act. Also available at https:// [online]. [cited 2014 Jun 6]. http://www. tive payment changes: a guide for the www.portal.state.pa.us/portal/server.pt/ cms.gov/Medicare/Medicare-Fee-for- WOC nurse [press release online]. document/495911/hb1802_pdf Service-Payment/HospitalAcqCond/ 2009 Mar 13 [cited 2014 Jun 9]. 2. Pennsylvania Patient Safety Authority. Hospital-Acquired_Conditions.html http://www.wocn.org/news/67092/ Pennsylvania Patient Safety Authority 2013 6. Centers for Medicare and Medicaid Inpatient-Prospective-Payment-Changes-A- annual report [online]. 2014 Apr 30 [cited Services. Final changes to the hospital Guide-for-the-WOC-Nurse.htm 2014 Jun 6]. http://patientsafe tyauthority. inpatient prospective payment systems 9. Kosiak M, Kubicek WG, Olson M, et al. org/PatientSafetyAuthority/Documents/ and fiscal year 2009 rates. Fed Regist Evaluation of pressure as a factor in the Annual%20Report%202013.pdf 2008 Aug 19;73(161):48474-9083. Also production of ischial ulcers. Arch Phys Med 3. Pressure ulcers: new staging, reporting, available at http://www.cms.gov/Medi Rehabil 1958 Oct;39(10):623-9. and risk reduction strategies. Pa Patient care/Medicare-Fee-for-Service-Payment/ 10. Kosiak M. Etiology and pathology of isch- Saf Advis [online] 2008 Dec [cited 2014 HospitalAcqCond/HAC-Regulations-and- emic ulcers. Arch Phys Med Rehabil 1959 Jun 9]. http://patientsafetyauthority.org/ Notices-Items/CMS1252755.html?DLPag Feb;40(2):62-9. ADVISORIES/AdvisoryLibrary/2008/ e=1&DLSort=3&DLSortDir=ascending 11. Edsberg LE, Langemo D, Baharestani Dec5(4)/Pages/118.aspx 7. Agency for Health Care Policy and MM, et al. Unavoidable pressure injury: 4. National Pressure Ulcer Advisory Research. Pressure ulcers in adults: prediction state of the science and consensus out- Panel. NPUAP pressure ulcer stages/ and prevention. Clinical Practice Guideline comes. J Wound Ostomy Continence Nurs categories [online]. [cited 2014 Jun 9]. no. 3. AHCPR Publication No. 92-0047. 2014 Jul-Aug;41(4):313-34. http://www.npuap.org/resources/ Rockville (MD): US Department of educational-and-clinical-resources/npuap- Health and Human Services; 1992 May. pressure-ulcer-stagescategories Vol. 12, No. 1—March 2015 Pennsylvania Patient Safety Advisory Page 35 ©2015 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S 12. Black JM, Edsberg LE, Baharestani 16. ConvaTec Academy. Pressure ulcer 20. 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Perry D, Borchert K, Burke S, et al. pressure ulcers: clinical practice guide- 19]. http://www.ahrq.gov/professionals/ Institute for Clinical Systems Improve- line [online]. 2009 [cited 2014 Aug 22]. systems/long-term-care/resources/ ment. Pressure ulcer prevention and http://www.guideline.gov/content. pressure-ulcers/pressureulcertoolkit/ treatment protocol [online]. 2012 Jan aspx?id=24492 index.html [cited 2014 Aug 21]. https://www.icsi. org/guidelines__more/catalog_guide lines_and_more/catalog_guidelines/cata log_patient_safetyreliability_guidelines/ pressure_ulcer Page 36 Pennsylvania Patient Safety Advisory Vol. 12, No. 1—March 2015 ©2015 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 12, No. 1—March 2015. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. 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