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Pressure ulcers are one of the most costly preventable problems for long-term care patients and an important cause of increased mortality and morbidity, physical disfigurement, extended hospital stays.1,2
An estimated 1.3 million to 3 million adults get hospital-acquired pressure ulcers each year.3 The average cost of pressure ulcer treatment is $40,381, and the aging population ages contributes to a persistent rise in healthcare costs to treat chronic wounds.4 Pressure ulcer incidence varies from 0.4 percent to 38 percent in acute care, 0-17 percent in home health care, and 2.2-23.9 percent in long-term care.5
It is paramount skin care be a top priority at VA facilities. Evidence shows the veteran population demonstrates increased risk due to higher rates of extensive paralysis secondary to spinal cord injury resulting in less functional independence, increased moisture due to neurogenic bowel and bladder, and poor nutrition. In this worst-case scenario, the negative impact to psychosocial and physical wellness contributes to low self-esteem, inadequate nutrition, tobacco use, and drug and alcohol abuse.
In addition, the recent Centers for Medicare and Medicaid Services determination that pressure ulcers are preventable declared facilities would not be reimbursed for increased hospital stay resulting from nosocomial pressure ulcers.6,7 The quality indicator development for pressure ulcers is in response to the Department of Veterans' Affairs Office of Inspector General report "Management of Patients With Pressure Ulcers in Veterans Health Administration Facilities."2
The Bay Pines facility director and chief nursing executive are responsible for establishing procedures to guide care and evaluate pressure ulcer development. VA Nursing Outcome Database indicators provide analysis of data to identify opportunities for improvement.
Taking Action
In 2005, a process action team concluded Bay Pines VA Healthcare System's current skin care system needed restructuring to provide staff with necessary resources to deliver best possible pressure ulcer care and prevention.2 While the facility was well below the national average pressure ulcer incidence of 7 percent for acute care facilities, the cohesive skin care team at the facility set a goal of zero.
When an increase in incidence was noted in the four acute care units, Debra Williams, MSN, RN, the chief nurse of acute care, collaborated with the skin care committee to define deficiencies and implement practice changes. An interdisciplinary team was created to identify the special needs of at-risk patients to prevent nosocomial pressure ulcers and halt progression of existing ones. The skin care team cut the number of hospital-acquired pressure ulcers almost in half.
As safe patient handling coordinator, I performed a methodical review of patient medical records and identified inconsistent use of the Braden Scale on admission and at timely intervals or change in condition, inaccurate staging documentation, and failure to implement interventions on a regular basis for a Braden Score less than 18. The Braden scale provides a structured format for systematic assessment in the dietary intake, activity, friction, mobility, sensory perception and moisture. Failure to provide a complete assessment of the six domains results in an inefficient skin care plan and increased risk for pressure ulcers.
A train-the-trainer program for skin care champions provided the nurses with necessary tools to educate staff about accurate staging techniques such as recognizing similar appearing lesions from bruises, diabetic foot ulcers, radionecrosis, surgical wounds, and stasis ulcers caused by venous and arterial insufficiency.7
Mark Welvaert, BSN, RN, WOCN, skin care specialist, and Gozzard rounded weekly with the skin care champions provide on-the-spot staff education and increase inter-rater reliability.5 Clinical updates such as the classification of "deep tissue injury" are now presented to the staff in a structured format. In addition, pressure ulcer documentation manuals were developed to provide staff education at the main campus, community-based outpatient clinics and outpatient care clinics.
Information is provided monthly to the committee on the latest dietary supplements to assist with adequate hydration and nutrition, and the nutritional resident provides staff with education specific to skin care needs and wound healing.8
Technology experts at the facility maintain integrated templates that automatically generate a nutritional consult for dietary or the certified wound care nurse. An electronic catalog assists staff to make appropriate dressing choices and order supplies. In addition, staff receives trials for up-to-date products.
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