Pressure Ulcers

This guide outlines the steps that managers can follow to prevent pressure ulcers:

Use this checklist as a guide to determine whether current evidence-based guidelines are being followed in your organization:

Provide ongoing education.

1. Provide pressure ulcer-specific ongoing education and include pressure ulcer education in other related education (e.g., education around ventilator management, mobility, medical device use, etc.).
2. Ensure all tools, images, and educational materials include pressure ulcer presentation across multiple skin tones.
3. Include actionable steps that patients and family members can take to prevent pressure ulcers in patient-facing educational materials.

Engage those on the frontline in quality-improvement initiatives.

1. Identify a pressure ulcer champion to visibly lead prevention efforts and engage frontline staff.
2. Identify and publicize what all roles can do to prevent pressure ulcers.
3. Ensure that pressure ulcer prophylaxis and treatment protocols are embedded into clinical workflows, whether electronic or paper.
4. Ensure there are enough staff to effectively manage necessary preventive care.
5. Evaluate the clinical workflow to embed pressure ulcer surveillance into pre-existing processes to optimize efficiency. Bundle pressure ulcer prevention with other related activities.
6. Encourage documentation of both assessment findings and prevention strategies employed.

Standardize processes and measure trends.

1. Make sure patients are repositioned every two hours.
2. Set clear, unambiguous aim statements.
3. Standardize risk and skin assessment tools across the system to optimize data integrity.
4. Measure and report pressure ulcer process and outcome metrics monthly. Note trends in areas with low compliance and high pressure ulcer incidence. Routinely reassess outcomes.
5. Debrief on a regular basis to solicit team feedback about barriers to sustained compliance. Adjust the plan quickly and nimbly as needed.
6. Ensure that leaders have a simple process to oversee pressure ulcer improvement work while also considering how it aligns with other initiatives across the organization.
7. Consider incorporating pressure sensors that will alert the caregiver if the patient needs to be moved.

PRESSURE ULCER PROCESSES TO CONSIDER ASSESSING

1. Pressure ulcer assessment upon admission
2. Pressure ulcer reassessment during routine care
3. Diet and fluid intake assessment and how this is linked with pressure ulcer assessments in the EHR or other documentation
4. Documentation of pressure ulcer assessment
5. Use of pressure redistribution devices
6. Measures taken when a patient is at risk for pressure ulcers and when these measures are implemented (e.g., immediately or upon worsening)
7. Mobility decision-making discussions
8. Discharge planning
9. Patient and family member education

TYPICAL GAPS IDENTIFIED IN PRESSURE ULCER PREVENTION

1. It is difficult to assess which patients arrived with a pressure ulcer.
2. Clinicians may prioritize patient comfort over skin assessment.
3. Skin assessment is competing with other higher priorities.
4. There’s differential interpretation of the skin assessment among clinicians.
5. The assessment is not conducted multiple times while the patient is in the hospital.
6. Different scales are used across the organization.
7. Policies are not reinforced by workflows/task lists.
8. There’s no prompt for the nurse to document the assessment.
9. Assessment documentation may not be pulled into the patient chart for ongoing comparison with other assessments.
10. The documentation data integrity is compromised between units/facilities.
11. The standardized rounding is not consistent or tailored to the patient’s needs (e.g., if the patient is incontinent, hourly may not be enough).
12. Workers may not know what interventions are available to prevent pressure ulcers.
13. In the assessment of pressure ulcers specifically, there’s no assessment of factors that may contribute to pressure ulcers (e.g., mobility, nutrition, medications, restraints, etc.).
14. Staff are rushed during ongoing assessment and face competing priorities.
15. Pressure ulcers may not be detected as readily for those with darker skin tones.
16. Patient is transported or discharged before the wound care nurse can see the patient.
17. There is a shortage of wound care nurses.
18. The receiving facility does not have data from previous risk assessments.
19. Wound interventions are not communicated to the receiving facility.
20. Pressure ulcer prevention is not incorporated into patient education at discharge.
21. Only previous wounds are documented in the EHR. If the patient is at risk, but did not have a previous wound, this is often not documented.
22. Case managers may not know to order any equipment/services for pressure ulcer prevention if the risk or previous wound is not documented.
23. Patients and family members interpret mobility status differently than the clinician. Equipment to facilitate early mobility is not readily accessible.
24. Clinicians do not acknowledge the patient’s fear of falling when working to implement early mobility interventions.
25. The responsibility of early mobility management is placed on one discipline.
26. It is assumed that the initial mobility assessment is sufficient throughout care despite changes.
27. Fall risks are not recognized.
28. Mobility processes are not audited or reviewed routinely.
29. The family does not know their role in continuing mobility in the home setting.
30. Patients do not have help in picking up and transporting durable medical equipment.
31. There’s no follow-up post-hospitalization.
32. Processes for accountability are lacking.