Pressure Ulcers are Serious Reportable Events
Did You Know…?
A Stage 3 or 4 (full skin thickness injury) pressure ulcer acquired after hospital admission is considered a serious reportable event (SRE). The Massachusetts Department of Public Health (DPH) mandates that hospitals report SREs within seven days of discovery and conduct a root cause analysis within 30 days. At BWH, root cause analyses are confidential reviews, coordinated by Risk Management, that examine the contributing factors to a SRE. The purpose is to identify correctable system-level solutions to prevent future occurrences.
As of June 12, hospitals must also notify the patient and third party payers of SREs, including hospital-acquired Stage 3 or 4 pressure ulcers. Failure to comply could result in daily fines and/or suspension or revocation of the hospital’s license. Risk Management staff submit these reports, relying on both nursing and medical documentation in the medical record.
Although estimates vary, there’s no doubt that hospital-acquired pressure ulcers are widespread, costly and harmful to patients. Pressure ulcers affect at least 2.5 million patients in this country per year, at a cost of $11-13 billion. A single Stage 3 or 4 pressure ulcer can cost $70,000 or more to treat. Pressure ulcers cause pain, suffering and functional impairment, and they contribute to at least 60,000 deaths in the U.S. annually.
What’s Coming….
The Department of Nursing is developing a comprehensive pressure ulcer program that will address resources, infrastructure, staff education, equipment/supplies and ongoing monitoring/evaluation. In the meantime, a hospital-wide review of pressure ulcer prevention strategies is underway. Similar in content to “bundles” that have been successfully implemented at hospitals throughout the country, this review focuses on a set of interventions proven to lower the prevalence of hospital-acquired pressure ulcers (see table). Other key components include
Assessment: Daily head-to-toe skin assessment on all admitted patients, and daily pressure ulcer risk assessment using the Braden scale. This includes documentation of the six Braden subscores (sensory/perception, moisture, activity, mobility, nutrition and friction/shear) on the flow sheets. Low subscores should direct preventive nursing interventions (refer to the table on p. 3 of INT-04 in the Nursing Clinical Practice Manual or Bedside Books).
Communication of pressure ulcer risk or presence: During hand-offs to RNs and PCAs, during interdisciplinary rounds and through filing Safety Reports on all pressure ulcers, noted either on or during admission.
Documentation: In addition to documentation on flow sheets, synthesis notes and transfer notes, listing pressure ulcer risk (or presence) on the plan of care with a related goal and interventions helps to ensure consistent, individualized care.
Education: Krames on Demand has several excellent resources that describe what pressure sores are, how they form, and what patients can do to help prevent them.
Be A SKIN Saver
Surface
AtmosAir 9000 pressure redistribution mattress is standard.
Low air loss surface for severe excess moisture only – check for air leaks and “bottoming out” (should not feel bony prominences when hand placed under inflated surface).
Float the Heels if limited mobility (e.g., with pillows or multipodus boots) – heels must be completely off the bed surface!
Limit linen layers – Less is Best!
Smooth surface – avoid wrinkles, wires, tubes under patient.
Obtain chair cushion (PS# 37310) if unable to shift in chair.
Avoid donuts – they reduce circulation to damaged area.
Avoid massaging reddened areas and bony prominences!
Decrease friction injuries over bony prominences with gentle application of lubricants, protective films (e.g., Tegaderm), protective dressing (e.g., Duoderm extra thin), skin sealants (e.g., skin protective barrier film, protective padding).
Keep Turning
Use a written turning schedule (e.g., with Comfort Rounds).
Bed-bound: turn/reposition at least every 2 hr.
Chair-bound: reposition at least every 1 hr. (every 15 min. shifts, if able).
Lift, don’t drag (use ceiling lift), to avoid friction/shear injuries.
Side-lying positioning: Use 30° or less lateral position to avoid trochanter pressure, and pillows between bony prominences.
Avoid positioning directly on a pressure ulcer or suspected deep tissue injury (DTI).
Keep HOB elevated less than 30°, unless contraindicated (e.g., VAP protocol, aspiration precautions).
Incontinence
Establish a toileting schedule (e.g., with Comfort Rounds), or a bowel/bladder program.
Apply topical agents to cleanse and protect skin from excessive moisture/drainage every 2-4 hours and prn (i.e. Comfort Shield, pH balanced cleansers [Carrington CarraFoam® PS # 36424], and protective barrier ointments [Carrington Moisture Barrier Cream® PS # 36423 and Critic Aid Clear PS # 147437].
Use underpads that wick wetness away from skin.
Use containment devices, such as external urinary collection devices and fecal incontinence collectors, when appropriate
Nutrition
Identify individualized nutrition goals.
Request a Nutrition consult for at-risk patients.
Monitor/encourage protein/calorie & fluid intake, as indicated.