Problem Addressed

• A common condition: On any given day, more than 15 percent of hospitalized patients have a pressure ulcer.¹ In 2006, more than 500,000 admitted patients across the nation had a pressure ulcer documented at some point during their stay.²
• Failure to identify and treat in timely manner: Early identification and treatment of pressure ulcers—whether present on admission or developed during the inpatient stay—is critical to minimizing their impact. Yet many hospitals fail to consistently identify and document the existence of pressure ulcers on admission.
• Leading to profound human impact and significant (unreimbursed) costs: Without timely treatment, pressure ulcers often lead to severe complications, including blood and bone infections, infectious arthritis, holes below the wound that burrow into bone or deeper tissues, and scar carcinoma, a form of cancer that develops in scar tissue.³ The cost of treating a pressure ulcer ranges from $2,000 to $70,000 per wound, with total costs for the average hospital being $400,000 to $700,000 annually.¹ For any Stage III or IV pressure ulcer not documented on admission, the Centers for Medicare & Medicaid Services (CMS) will not reimburse hospitals for treatment, as these are classified as "never events."^2,4

Description of the Innovative Activity

• Baseline skin assessment for all admitted patients: Nurses at all points of hospital admission—including the emergency department (ED), operating room (OR), the postanesthesia care unit, and express admissions unit (which allows physicians to bypass the ED and directly admit patients to the hospital)—complete a baseline skin assessment as part of the patient intake and admission process. The assessment involves evaluation of bony prominences, gluteal folds, and behind the ears to determine risk and/or presence of pressure ulcers at each site. Protocols require the nurse to complete the assessment within 2 hours of the admission order being written and before the patient’s departure from the unit.
• Documenting those with existing pressure ulcers, high risk: The nurse documents the presence of any identified pressure ulcers in the patient’s chart. The nurse also makes a note in the chart of any patient at high risk of developing a pressure ulcer. Whenever a pressure ulcer is identified, the nurse completes a patient safety report that documents its presence on admission.
• Wound team consult: For those with or at risk of a pressure ulcer, the nurse uses the computerized order entry system to order a consult from the hospital’s wound healing team, specifying the reason for the request, such as a pressure ulcer identified or concern about skin integrity. The team includes certified wound nurse specialists, enterostomal therapists, and physical therapists drawn from the hospital’s Wound Healing Center. The team performs a very thorough assessment of the pressure ulcer and/or pressure ulcer risk, documents findings in the patient’s medical record, photographs any pressure ulcers present on admission to improve documentation, makes treatment recommendations to the physician, and initiates treatment (e.g., pressure relieving devices, wound products, debridement).
• Flagging other caregivers about at-risk patients: When a patient's pressure ulcer requires time-sensitive care, the team highlights its care recommendations in the patient's chart on the “green sheet” (a communication tool used throughout the hospital to highlight particularly pertinent or time-sensitive information). This easily visible sheet, which is displayed outside the patients' rooms, also contains information about pressure ulcers that were present on admission and serves as a visual cue for the physician to evaluate the patient's skin and document their assessment appropriately (such as documenting that a pressure ulcer was present on admission).
• Daily wound team assessment: The team rounds on inpatients daily to assess their wound healing and evaluate changes in pressure ulcer risk.
• Performance reporting to simulate improvement: Along with performance on other quality indicators, raw data on hospital acquired pressure ulcers are presented through monthly reporting via an electronic program and on a large white board in a public area on every nursing unit.

References/Related Articles

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Innovator Disclosures

Results

• High adherence to skin assessments: During the first 5 months after implementation, 83.8 percent of ED patients and 91.9 percent of patients at other admission entry points had their skin assessment completed within the required 2-hour window.
• Better identification, documentation of existing pressure ulcers: The annual number of pressure ulcers identified and documented in the hospital increased by 36.3 percent (from 809 to 1,103) in the year after implementation of the program. Of these, the proportion documented on admission rose from 80 to 85 percent. The percentage of pressure ulcers identified on admission in patients transferring from another facility increased by 52 percent, while those identified in patients admitted from home increased by 36 percent. The percentage identified within 24 hours of admission increased by 81 percent. Finally, between July 2008 and February 2010, the hospital identified nearly every severe (Stage III/IV) pressure ulcer present on admission.
• Lower incidence of hospital-acquired pressure ulcers: Between July 2009 and June 2011, the incidence of hospital-acquired pressure ulcers decreased by 26 percent; Stage I pressure ulcers decreased by 30.5 percent, Stage II pressure ulcers decreased by 15.6 percent, and hospital-acquired suspected deep tissue injury decreased by 38.8 percent. Between July 2010 and June 2011, there were no Stage III ulcers and only one Stage IV hospital-acquired pressure ulcer.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Creating wound team: With the support of other senior leaders, the director of the Wound Healing Center (also the hospital’s assistant chief medical officer) chartered the "pressure ulcer present on admission" or PU POA team. Led by an administrator in patient care services, the team included representatives from senior leadership, patient care services, the medical staff, the Wound Healing Center, health care research, infection control and prevention, and the quality department.
• Reviewing literature: The PU POA team conducted a literature review to identify strategies for early identification of pressure ulcers, including those present on admission.
• Identifying patient entry points: Using Toyota lean methods, the team reviewed all points of entry for hospital admission, identified “fail points," and designed an improved process for ensuring that all admitted patients received a baseline skin assessment.
• Developing process algorithm: The team designed a process algorithm for each point of entry for admitted patients to help clinicians understand process steps related to wound assessment, documentation, and wound healing team consult orders.
• Introducing program to staff: Over several months, the director of the Wound Healing Center met with various groups of physicians and staff to communicate the new process for wound identification and emphasize its ability to improve quality. He also led a meeting of the Medical Advisory Council (comprising physician leaders from all disciplines) to ensure its support for the new processes. During these sessions, he tailored his message to the audience, conveying to allied health professionals the critical role they play in ensuring quality, and emphasizing with physicians the program's ability to improve patient outcomes.

Resources Used and Skills Needed

• Staffing: The program requires no new staff, as existing staff incorporate it into their daily routines.
• Costs: Program development did not require any financial outlay. Potential adopters that do not have a wound care team would have to hire appropriate staff to fill this role.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Create multidisciplinary quality improvement team: To ensure the program is supported throughout the hospital, involve staff from different disciplines at the earliest stage of development and ask them to discuss issues surrounding pressure ulcers with their colleagues.
• Focus on quality when courting physicians: Physicians may express concerns about allowing nurses to order a wound healing team consult. Once they understand that direct orders can expedite care and improve quality, they will likely be more accepting of this change in culture.
• Emphasize patient in promoting collegiality between nurses, wound team: To minimize "turf issues" between floor nurses and the wound healing team, emphasize that the program represents the right thing to do for patients and to improve the quality of care. Introduce the wound healing team as a nonthreatening group of professionals available to assist in patient care.
• Be sensitive to culture change in ED: ED personnel generally focus on specific urgent needs rather than “whole-body” health. However, this program requires ED nurses to perform comprehensive skin assessments on every high-risk admitted patient. To sell them on the merits of this, reiterate the potential benefit to patients, which should convince them of the value of changing their perspective.

Sustaining This Innovation

• Measure and report on performance: Regularly reporting assessment adherence rates, pressure ulcer rates, and other key statistics helps to keep hospital leaders and clinicians engaged in and supportive of the program.
• Consider financial incentives: Financial incentives can help to maintain high performance over time. Lehigh Valley Hospital-Muhlenberg has found that use of financial incentives tied to specific goals helps to motivate staff to adhere to best practices.