Hospital Acquired Pressure Ulcers

Background – Harm

• Incidence of Stage II or greater > Hospital-Acquired Pressure Ulcers ranges from 5% - 9%

• 60, 000 die from pressure ulcer complications each year

Background – Harm

• Decrease quality of life and functionality

• Increase risk of other complications

• Increase hospital mortality

• Increase need for skilled care and rehab after discharge

Who get’s pressure ulcers?

• Spinal cord injuries & elderly

• Higher incidence in hospitals (38%) not nursing homes (23.9%)

• Pressure ulcers do not always signify poor care

Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: A systematic review. JAMA. 2006;296:974-984.

Co-Morbidities

Diabetes Heart disease

Renal disease

Dementia Malnutrition

Age 70 or greater

Impaired mobility

Physical restraints

Pathogenesis for HAPU

Friction Shear Force

Moisture Temperature elevation

Sensory impairment

Oxygen deprivation

Friction

AIM

• Reduce the prevalence of hospital acquired Stage II or greater pressure ulcers from 2010 baseline rate by 50% by December 31, 2013

Suggested Measures

Outcome• Patients with at least one

Stage III or greater hospital acquired pressure ulcer

Process• Skin assessment

documented within 24 hours of admission

• HAPU risk assessment completed within 24 hours of admission

Reduce HAPU by 50%

Conduct Skin/Risk AssessmentHead-to-toe skin & risk assessment

Assess on admission & reassess daily

Manage MoistureKeep skin dry & protected

Optimize Hydration & NutritionAssess weight

Assess nutrition & hydration status

Minimize Pressure, Shear, & FrictionTurn & reposition patients every 2 hours

Early mobility/ambulation

AIM Primary Driver Secondary Driver

Primary Driver: Conduct Skin & Risk Assessment

Head to Toe Risk Assessment

• Within 4 hours of admission

• At least every day• Check skin during

routine care, i.e. turning, bathing

Take Action!

• Plan of care & interventions based on skin & risk assessment

Include Skin Risk in Handoffs

Primary Driver: Manage Moisture

Balance Need for Dry but Moisturized Skin

Use Under Pads to Keep Skin Dry

Will hold up to 1 liter

& Keep skin dry!

Use ‘Reminders”

P = PainP = PottyP = Position or Pressure

3 P’s

Primary Driver: Optimize Hydration & Nutrition

Monitor…

• Weight• Hydration status

Offer Appetizing Food & Drink Choices

• Tempt patient with food & drink they like

• Consider cultural food preferences

Additional Interventions:

• Consult a registered dietician

• Consider nutritional supplements

Primary Driver: Minimize Pressure, Shear, & Friction

Turn! Turn! Turn!

• Turn & reposition at least every 2 hours

Pressure Relieving Special Surfaces & Tools

• Foam wedges to position patients

• Special pressure redistributing/relieving mattresses

• Use pillows only for limbs

• Heel boots

Early Mobility & Ambulation

Staff driven protocol Get patients moving!• Includes assessment of

patient strength & weaknesses

• Includes ‘opt out’ for contraindications

• Triggers referral to physical therapy based on criteria

Minimizing Shear & Force

• Use lifts to reposition• Breathable glide sheets• Limit linen layers to no

more than 3• Foam sacral dressing

Key Resources

• AHRQ Toolkit: Preventing Pressure Ulcers in Hospitals• AHRQ Guideline Synthesis on Preventing Pressure Ulcers• National Pressure Ulcer Advisory Panel• IHI: How to Guide on Reducing Pressure Ulcers• Hughes RG (ed). Patient Safety and quality: An evidence-

based handbook for nurses. AHRQ Publication No. 08-0043, Rockville, MC: Agency for Healthcare Research and Quality; April 2008

• Gibbons W, Shanks HT, Kleinhelter P, Jones P. Eliminating facility-acquired pressure ulcers at ascension health. JC J Qual Pt Safety. 2006;32(9).488-496.