Pressure Ulcer Prevention

Pressure ulcers have been recognized as a disease entity through the ages – even some mummies from 5,000 years ago were found to have them.1 Today, our understanding of pressure ulcers, or bed sores, focuses on the fact that they are potentially preventable complications of hospitalization. As such, pressure ulcers have been a patient safety indicator (PSI) since 2003. Despite the best efforts of hospital staffs, however, pressure ulcers still occur. VHHA’s Research Department recently assisted the American Hospital Association’s Hospital Research and Education Trust (HRET) in demonstrating how administrative data can describe common principle diagnoses among pressure ulcer patients, age distribution, location on the body, and how to separate ulcers present on a patient at the time of admission from hospital-acquired sores. To perform this analysis, Agency for Health Research and Quality’s (AHRQ) 2015 data specifications for PSI #03 (pressure ulcer rate) were reviewed and then applied to the 2016 Virginia inpatient database. While this process provided insight about patients with pressure ulcers, it was ultimately determined that the algorithm used provided little guidance for preventing ulcers. Of the 170,350 records that met AHRQ’s criteria for 2016, there were 143 patients with pressure ulcers. This equates to one patient per 1,000 discharges. The average patient with a pressure ulcer is a 61-year-old who has a primary diagnosis of sepsis and a 63-day length of stay. The chart below gives the list of diagnoses associated with the presence of a pressure ulcer, grouped by the service line to which the patients were assigned. The programming does not give clinicians a list of co-morbidities found in each patient, or the contribution each makes to the probability that a decubitus ulcer forms. This is not the case with the readmission algorithms used in prevention activity that identify common pairing of co-morbidities to predict a readmission. Examples are fluid imbalance and renal failure for heart failure readmissions, or diabetes and arrhythmias for acute myocardial infarction readmissions. A constellation of co-morbidities cannot be derived from the PSI #03. From the list of diagnoses, we know 40 patients required a tracheotomy. However, we don’t know how many of the 40 had diabetes or hypertension that would impact their ability to stave off a decubitus ulcer. As such, the utility of the information for prevention work is limited. Despite the shortcomings in the programming, clinicians can use the information to develop effective strategies to uncover a hospital’s pressure ulcer patterns. For example, knowing that patients with sepsis may be at higher risk for pressure ulcers means they should be included, when appropriate and safe, in a pressure ulcer prevention bundle for high-risk patients. Such a bundle would include choosing the appropriate surface for sleeping or sitting, off-loading pressure frequently (turning/repositioning), offering a protein-rich diet, and managing moisture on the patient’s skin and bedclothes. Identifying these patient populations allows for the design of population, or disease specific, interventions to prevent bed sores. To assist hospitals with prevention efforts to reduce pressure ulcer incidences, HRET has a Hospital-Acquired Pressure Ulcer Change Package available without charge. It includes the top 10 evidence-based best practices, a comprehensive literature review, and resources for clinicians on preventing pressure ulcers. All content is publicly available, and can be accessed here. Just as our understanding of pressure ulcers has moved from what happens and when it occurs to diagnoses associated with pressure ulcer formation, the patient safety algorithms need to be expanded to include additional data to assist clinicians. To assist with prevention efforts, the algorithm needs to identify co-morbidities and groups of disease entities to more thoroughly predict pressure ulcer occurrence. In the meantime, clinicians can use the current data to identify populations at risk for bed sores in their facilities and develop their own strategies for preventing pressure sores. The HRET guide is an excellent resource for this endeavor. (6/9)

1 Eltorai IM. History of spinal cord medicine. In: Lin VW, Cardenas DD, Cutter NC, Frost FS, Hammond MC, Lindblom LB, et al., editors. Spinal cord medicine: Principles and Practice. New York: Demos Medical Publishing; 2003.

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