Incidence Of Hospital-acquired Pressure Ulcers Research Articles

Modelling the cost-effectiveness of subepidermal moisture measurement as part of a process of assessment and intervention to prevent hospital-acquired pressure ulcers.

Skin tissue assessment is traditionally used to identify early signs of pressure damage from changes observed at the skin surface. However, the early onset of tissue damage induced by pressure and shear forces is likely to be on soft tissues beneath the surface of the skin. Subepidermal moisture (SEM) is a biophysical marker for the detection of early and deep pressure-induced tissue damage. Measurement of SEM can detect early pressure ulcers up to 5 days before visible skin changes occur. The aim of this study was to evaluate the cost-effectiveness of SEM measurement compared with visual skin assessment (VSA). A decision-tree model was developed. Outcomes are the incidence of hospital-acquired pressure ulcers, quality-adjusted life-years (QALYs) and costs to the UK National Health Service. Costs are at 2020/21 prices. The effects of parameter uncertainty are tested in univariate and probabilistic sensitivity analysis. In a representative NHS acute hospital, the incremental cost of SEM assessment as an adjunct to VSA is -£8.99 per admission, and SEM assessment is expected to reduce the incidence of hospital-acquired pressure ulcers by 21.1%, reduce NHS costs and lead to a gain of 3.634 QALYs. The probability of cost-effectiveness at a threshold of £30 000 per quality-adjusted life year is 61.84%. Pathways that include SEM assessment make it possible to implement early and anatomy-specific interventions which have the potential to improve the effectiveness of pressure ulcer prevention and reduce healthcare costs.

40 Evaluation of a Multidisciplinary Approach to Pressure Injury Prevention Among Patients in a Burn Center

IntroductionCompromised skin integrity in tandem with the prolonged length of stay necessitated by patients in a burn center has the capacity to result in an increased incidence of hospital acquired pressure ulcers (HAPUs). A HAPU increases the cost of a hospital stay by approximately $43,000. Many interventions exist to reduce their occurrence; however, interventions have been largely compartmentalized by discipline. One burn center’s dramatic increase in HAPUs from 2018 to 2019 led to further evaluation of prevention efforts. Upon detecting a 117% increase of HAPUs and a threefold increase in cost for specialty bed rental, a multidisciplinary approach to pressure injury prevention was employed. The frequency of multidisciplinary patient rounds was increased from once to twice daily, and involved discussions regarding functional status, mobility, and nutrition. The practice of ordering specialty beds was modified to require three-part approval by the Medical Director of Burn Services, Nursing Director, and a burn therapy supervisor. The purpose of this QI project was to examine the implementation of the multidisciplinary approach to pressure injury prevention among patients in a burn center and to identify trends in HAPUs and specialty bed expenses.MethodsThis was a retrospective review of patients admitted to a Burn Center between January 1, 2018 and June 30, 2021. Preexisting pressure ulcers were identified upon admission and were not regarded as HAPUs. Patients were grouped by year of their admission date.ResultsA total of 941 patients were admitted for inpatient care in 2020, six HAPUs (1.35%) were identified for this population. As compared to the prior year, this revealed a 53% decrease in incidence of HAPUs. The specialty bed rental cost from 2019 to 2020 was reduced by $110,181.76 (68%). *Data provided for 2021 is from 01/01/2021 to 06/30/2021ConclusionsFollowing implementation of a multidisciplinary approach to pressure injury prevention, we were able to reduce the incidence of HAPUs and dramatically reduce the expense associated with specialty bed rental. This supports an effort to identify additional practices which may increase quality while decreasing cost.

Risk factors for newly acquired pressure ulcer and the impact of nurse staffing on pressure ulcer incidence

AimTo analyse patient factors and nurse staffing‐related issues involving hospital‐acquired pressure ulcers in patients at two types of hospital.BackgroundHospital‐acquired pressure ulcers are important for the safety of hospitalized patients. Hospital‐acquired pressure ulcers not only cause health problems, but also pose an economic burden to patients. In addition to patient factors such as mobility and skin integrity, hospital factors such as nurse staffing can also affect the management of such patients.MethodsThis study is a retrospective review of patient data and analysis of factors related to hospital‐acquired pressure ulcers using stratified Cox proportional hazards regression.ResultsA total of 53,923 patients were included. The incidence of hospital‐acquired pressure ulcers was 0.98 per 1,000 days. Hospital‐acquired pressure ulcers were affected by gender, age, previous falls, low oxygen levels, positioning and toilet use. When the levels of nurse staffing were determined as one of the hospital factors, the daily hours of patient care was increased thereby contributing to the reduced incidents of hospital‐acquired pressure ulcers.ConclusionStrategies for preventing hospital‐acquired pressure ulcers should be based on the analysis of risk factors.Implications for Nursing ManagementMost individual risk factors for hospital‐acquired pressure ulcers identified cannot be modified easily in a short time. Nurse staffing should be set at adequate levels to prevent hospital‐acquired pressure ulcers.

Incidence of hospital-acquired pressure ulcers in patients with "minimal risk" according to the "Norton-MI" scale.

IntroductionPressure ulcers (PUs) nowadays are a major health problem in society, associated with increased morbidity and increased health care costs. The incidence of HAPU is an indicator of health care quality.ObjectiveTo describe the profile of patients with minimal risk on the Norton-MI scale who developed PUs during hospitalization, and to identify the incidence of hospital-acquired pressure ulcers (HAPU).MethodsRetrospective cohort study conducted between 2014 and 2017.Study populationPatients over 18 years of age classified as "minimum risk" according to Norton-MI, admitted to acute hospital units of the Severo Ochoa University Hospital—Madrid-Spain. Patients were classified as patients with hospital-acquired pressure ulcers (PWHAPU) if they developed one or more new PU during their hospitalization.VariablesSociodemographic variables, hospitalization units, Morton-MI score and characteristics of the risk factors of HAPU were studied.ResultsThe risk of PU was evaluated in 5530 patients, being 1260 patients classified as "minimum risk", with a median of 16 points in the Norton-MI scale. The average age was 76 years old and 52.5% were women. Principal causes of admission: traumatological pathologies (20.8%) and cardiovascular pathologies (20%). 129 HAPU were diagnosed in 112 patients, implying an incidence of HAPU of 8.89% (CI95%: 7.44–10.59). 106 PWHAPU (94.6%) presented up to 6 risk factors. The excess pressure and altered skin sensibility were identified as statistically significant risk factors as predictive factors of HAPU. In terms of severity, 55% of the HAPU were category I and 42.6% were category II, mainly with anatomical sacro-coxygeal location. In 65.2% of the patients the HAPU appeared in the first week of hospitalization.ConclusionIn our study the incidence of HAPU in patients classified as minimum risk with Norton-MI scale was 8.89%. This elevated risk suggests for future investigations to develop new validity studies of the Norton-MI scale and to maintain a continuo training of professionals in the knowledge of PU risk assessment scales for their safe application in the patients, since it directs the practice of care in the prevention of PUs. It would be advisable to specially control the risk of PUs in care units, mainly in the first week of their hospital stay to minimize the HAPU incidence.

Prediction Model for Hospital-Acquired Pressure Ulcer Development: Retrospective Cohort Study.

BackgroundA pressure ulcer is injury to the skin or underlying tissue, caused by pressure, friction, and moisture. Hospital-acquired pressure ulcers (HAPUs) may not only result in additional length of hospital stay and associated care costs but also lead to undesirable patient outcomes. Intensive care unit (ICU) patients show higher risk for HAPU development than general patients. We hypothesize that the care team’s decisions relative to HAPU risk assessment and prevention may be better supported by a data-driven, ICU-specific prediction model.ObjectiveThe aim of this study was to determine whether multiple logistic regression with ICU-specific predictor variables was suitable for ICU HAPU prediction and to compare the performance of the model with the Braden scale on this specific population.MethodsWe conducted a retrospective cohort study by using the data retrieved from the enterprise data warehouse of an academic medical center. Bivariate analyses were performed to compare the HAPU and non-HAPU groups. Multiple logistic regression was used to develop a prediction model with significant predictor variables from the bivariate analyses. Sensitivity, specificity, positive predictive values, negative predictive values, area under the receiver operating characteristic curve (AUC), and Youden index were used to compare with the Braden scale.ResultsThe total number of patient encounters studied was 12,654. The number of patients who developed an HAPU during their ICU stay was 735 (5.81% of the incidence rate). Age, gender, weight, diabetes, vasopressor, isolation, endotracheal tube, ventilator episode, Braden score, and ventilator days were significantly associated with HAPU. The overall accuracy of the model was 91.7%, and the AUC was .737. The sensitivity, specificity, positive predictive value, negative predictive value, and Youden index were .650, .693, .211, 956, and .342, respectively. Male patients were 1.5 times more, patients with diabetes were 1.5 times more, and patients under isolation were 3.1 times more likely to have an HAPU than female patients, patients without diabetes, and patients not under isolation, respectively.ConclusionsUsing an extremely large, electronic health record–derived dataset enabled us to compare characteristics of patients who develop an HAPU during their ICU stay with those who did not, and it also enabled us to develop a prediction model from the empirical data. The model showed acceptable performance compared with the Braden scale. The model may assist with clinicians’ decision on risk assessment, in addition to the Braden scale, as it is not difficult to interpret and apply to clinical practice. This approach may support avoidable reductions in HAPU incidence in intensive care.

Significance of Friction and Shear in the Prevention of Contemporary Hospital-acquired Pressure Ulcers.

Hospital-acquired pressure ulcers (HAPUs) are largely preventable yet still common occurrences in hospitals. The purpose of the current study is to determine how data from the electronic medical record can be used to better understand and predict HAPU formation over the course of a hospital admission. A case-control study on HAPUs was performed over an 8-month period at Yale New Haven Hospital. A Cox regression analysis model analyzed the impact of multiple factors on HAPU development including friction and shear, among other Braden score components. A receiver operating characteristic curve was calculated to determine the sensitivity and specificity of changes in these factors in predicting HAPU development. On a sample of 8,790 admissions, HAPU incidence was 4.2% over the study period (6.3% per annum). The average hospital day for HAPU development was day 15.6 (± 19.3). The Cox regression analysis demonstrated that the volatility of the friction and shear component of Braden scores had a risk ratio of 28.6 (P < 0.01; CI, 14.5-56.4). Volatility in the friction and shear component was the most predictive factor with a high receiver operating characteristic curve area of 0.865 (CI, 0.847-0.882). Volatility of the friction and shear component of Braden scores appears to be the most significant factor preceding HAPU development at Yale New Haven Hospital. Efforts to place more focus on identifying and reducing volatility of this factor may help decrease HAPU risk for future patients.

Success In Hospital-Acquired Pressure Ulcer Prevention: A Tale In Two Data Sets.

Chart-based surveillance reviews indicate that the incidence of hospital-acquired pressure ulcers (HAPUs) declined 23percent during 2010-14, equating to an estimated savings of $1billion during that period. Yet it remains unclear whether the administrative data used to implement three Medicare value-based purchasing programs that target HAPUs indicate similar improvements, and how success varied by HAPU severity. These programs measure and penalize only for more severe ulcers (stage3 or 4 or unstageable), which are much more costly than less severe cases (stage1 or 2). We assessed HAPU incidence, severity, and trends using administrative data for 2009-14 from three states. The HAPU incidence we found was approximately one-twentieth of that found in chart-based surveillance review data. HAPU incidence in administrative data declined, but 96percent of the change was due to a decline in the incidence of less severe HAPUs. Transitioning from administrative data to chart-based surveillance review to measure HAPUs (mirroring changes that have already been made in reporting hospital-acquired infections) and accounting for HAPU severity could improve the validity of HAPU measures for assessing the clinical and financial impact of value-based purchasing interventions.

Five-Layered Soft Silicone Foam Dressing to Prevent Pressure Ulcers in the Intensive Care Unit.

In critically ill patients, prevention of pressure ulcers is a challenge because of the high risk for multiple comorbid conditions, immobility, hemodynamic instability, and increased use of medical devices. To compare the difference in incidence rates of hospital-acquired pressure ulcers (HAPUs) in critically ill patients between those treated with usual preventive care and a 5-layered soft silicone foam dressing versus a control group receiving usual care. Secondary goals were to examine risk factors for HAPUs in critically ill patients and to explicate cost savings related to prevention of pressure ulcers. A prospective, randomized controlled trial in the intensive care units at a 569-bed, level II trauma hospital. All 366 participants received standard pressure ulcer prevention; 184 were randomized to have a 5-layered soft silicone foam dressing applied to the sacrum (intervention group) and 182 to receive usual care (control group). The incidence rate of HAPUs was significantly less in patients treated with the foam dressing than in the control group (0.7% vs 5.9%, P = .01). Time to injury survival analysis (Cox proportional hazard models) revealed the intervention group had 88% reduced risk of HAPU development (hazard ratio, 0.12 [95% CI, 0.02-0.98], P = .048). Use of a soft silicone foam dressing combined with preventive care yielded a statistically and clinically significant benefit in reducing the incidence rate and severity of HAPUs in intensive care patients. This novel, cost-effective method can reduce HAPU incidence in critically ill patients.

ISQUA16-2368THE EFFECT OF A PATIENT CENTRED CARE BUNDLE INTERVENTION ON PRESSURE ULCER INCIDENCES (INTACT)

Hospital acquired pressure ulcers (HAPU) are a serious patient safety concern, resulting in poor patient outcomes and high healthcare costs. We developed a patient-centred pressure ulcer prevention care bundle (PUPCB) with input from patients, nurses and other health professionals. The objective of this study was to test the effectiveness of this PUPCB on incidence of HAPU in at-risk hospitalised patients. This cluster randomised trial recruited tertiary hospitals with >200 beds in three Australian states. Patients were eligible if they were: …

The effect of a patient centred care bundle intervention on pressure ulcer incidence (INTACT): A cluster randomised trial

BackgroundHospital-acquired pressure ulcers are a serious patient safety concern, associated with poor patient outcomes and high healthcare costs. They are also viewed as an indicator of nursing care quality. ObjectiveTo evaluate the effectiveness of a pressure ulcer prevention care bundle in preventing hospital-acquired pressure ulcers among at risk patients. DesignPragmatic cluster randomised trial. SettingEight tertiary referral hospitals with >200 beds each in three Australian states. Participants1600 patients (200/hospital) were recruited. Patients were eligible if they were: ≥18 years old; at risk of pressure ulcer because of limited mobility; expected to stay in hospital ≥48h and able to read English. MethodsHospitals (clusters) were stratified in two groups by recent pressure ulcer rates and randomised within strata to either a pressure ulcer prevention care bundle or standard care. The care bundle was theoretically and empirically based on patient participation and clinical practice guidelines. It was multi-component, with three messages for patients’ participation in pressure ulcer prevention care: keep moving; look after your skin; and eat a healthy diet. Training aids for patients included a DVD, brochure and poster. Nurses in intervention hospitals were trained in partnering with patients in their pressure ulcer prevention care. The statistician, recruiters, and outcome assessors were blinded to group allocation and interventionists blinded to the study hypotheses, tested at both the cluster and patient level. The primary outcome, incidence of hospital-acquired pressure ulcers, which applied to both the cluster and individual participant level, was measured by daily skin inspection. ResultsFour clusters were randomised to each group and 799 patients per group analysed. The intraclass correlation coefficient was 0.035. After adjusting for clustering and pre-specified covariates (age, pressure ulcer present at baseline, body mass index, reason for admission, residence and number of comorbidities on admission), the hazard ratio for new pressure ulcers developed (pressure ulcer prevention care bundle relative to standard care) was 0.58 (95% CI: 0.25, 1.33; p=0.198). No adverse events or harms were reported. ConclusionsAlthough the pressure ulcer prevention care bundle was associated with a large reduction in the hazard of ulceration, there was a high degree of uncertainty around this estimate and the difference was not statistically significant. Possible explanations for this non-significant finding include that the pressure ulcer prevention care bundle was effective but the sample size too small to detect this.

Using clinical data to predict high-cost performance coding issues associated with pressure ulcers: a multilevel cohort model.

Hospital-acquired pressure ulcers (HAPUs) have a mortality rate of 11.6%, are costly to treat, and result in Medicare reimbursement penalties. Medicare codes HAPUs according to Agency for Healthcare Research and Quality Patient-Safety Indicator 3 (PSI-03), but they are sometimes inappropriately coded. The objective is to use electronic health records to predict pressure ulcers and to identify coding issues leading to penalties. We evaluated all hospitalized patient electronic medical records at an academic medical center data repository between 2011 and 2014. These data contained patient encounter level demographic variables, diagnoses, prescription drugs, and provider orders. HAPUs were defined by PSI-03: stages III, IV, or unstageable pressure ulcers not present on admission as a secondary diagnosis, excluding cases of paralysis. Random forests reduced data dimensionality. Multilevel logistic regression of patient encounters evaluated associations between covariates and HAPU incidence. The approach produced a sample population of 21 153 patients with 1549 PSI-03 cases. The greatest odds ratio (OR) of HAPU incidence was among patients diagnosed with spinal cord injury (ICD-9 907.2: OR = 14.3; P  < .001), and 71% of spinal cord injuries were not properly coded for paralysis, leading to a PSI-03 flag. Other high ORs included bed confinement (ICD-9 V49.84: OR = 3.1, P  < .001) and provider-ordered pre-albumin lab (OR = 2.5, P  < .001). This analysis identifies spinal cord injuries as high risk for HAPUs and as being often inappropriately coded without paralysis, leading to PSI-03 flags. The resulting statistical model can be tested to predict HAPUs during hospitalization. Inappropriate coding of conditions leads to poor hospital performance measures and Medicare reimbursement penalties.

Staffing and the incidence of pressure ulcers in German hospitals: A multicenter cross-sectional study.

In this study, we investigated the association between nurse and physician staffing and the incidence of hospital-acquired pressure ulcers in acute care hospitals in Germany. The study population, derived from the Quality Reports of German Hospitals and the Hospital Directory, consisted of 710 hospitals covering 716,281 cases in the first quarter of 2010, and 672 hospitals covering 757,665 cases in the first quarter of 2012. The relationship between staffing variables and the standardized incidence ratios of pressure ulcers was examined using bivariate and multivariable linear regression models. Estimates were controlled for several patient and hospital characteristics. The total number of nurses and physicians per 100 beds did not show significant associations with outcome variables. However, the proportion of nurses with at least 3 years of training to total nursing staff was inversely associated with the incidence of pressure ulcers at hospital level, indicating a higher efficacy of pressure ulcer-prevention measures.

Are Evidence-based Practices Associated With Effective Prevention of Hospital-acquired Pressure Ulcers in US Academic Medical Centers?

In 2008, the Centers for Medicare and Medicaid Services (CMS) established nonpayment policies resulting from costliness of hospital-acquired pressure ulcers (HAPUs) to hospitals. This prompted hospitals to adopt quality improvement (QI) interventions that increase use of evidence-based practices (EBPs) for HAPU prevention. To evaluate the longitudinal impact of CMS policy and QI adoption on HAPU rates. We characterized longitudinal adoption of 25 QI interventions that support EBPs through hospital leadership, staff, information technology, and performance and improvement. Quarterly counts of HAPU incidence and inpatient characteristics were collected from 55 University HealthSystem Consortium hospitals between 2007 and 2012. Mixed-effects regression models tested the longitudinal association of CMS policy, HAPU coding, and QI on HAPU rates. The models assumed level-2 random intercepts and random effects for CMS policy and EBP implementation to account for between-hospital variability in HAPU incidence. Controlling for all 25 QI interventions, specific updates to EBPs for HAPU prevention had a significant, though modest reduction on HAPU rates (-1.86 cases/quarter; P=0.002) and the effect of CMS nonpayment policy on HAPU prevention was much greater (-11.32 cases/quarter; P<0.001). HAPU rates were significantly lower after changes in CMS reimbursement. Reductions are associated with hospital-wide implementation of EBPs for HAPU prevention. Given that administrative data were used, it remains unknown whether these improvements were due to changes in coding or improved quality of care.

Use of a Comprehensive Program to Reduce the Incidence of Hospital-Acquired Pressure Ulcers in an Intensive Care Unit.

Hospital-acquired pressure ulcers (HAPUs) are a costly and largely preventable complication occurring in a variety of acute care settings. Because they are considered preventable, stage III and IV HAPUs are not reimbursed by Medicare. To assess the effectiveness of a formal, year-long HAPU prevention program in an adult intensive care unit, with a goal of achieving at least a 50% reduction in 2013, compared with 2011. Planning for the prevention program began in 2012, and the program was rolled out in the first quarter of 2013. Program components included use of Braden scores, a revised skin care protocol, fluidized repositioners, and silicone gel adhesive dressings. Efforts were made to educate and motivate staff and encourage them to be more proactive in detecting patients at risk of HAPUs. Incidence of HAPUs in the unit was reduced by 69% (n = 17; 3% of patients in 2013 vs n = 45, 10% of patients in 2011), despite a 22% increase in patient load. The potential cost saving as a result of this decrease was approximately $1 million. A comprehensive, proactive, collaborative ulcer prevention program based on staff education and a focus on adherence to protocols for patient care can be an effective way to reduce the incidence of HAPUs in intensive care units.

Improving Outcomes by Implementing a Pressure Ulcer Prevention Program (PUPP): Going beyond the Basics.

A multidisciplinary process improvement program was initiated at the University of Miami Hospital (UMH) in 2009 to identify the prevalence of hospital-acquired pressure ulcers (HAPU) at the institution and to implement interventions to reduce the incidence of HAPU. This deliberate and thoughtful committee-driven process evaluated care, monitored results, and designed evidence-based strategic initiatives to manage and reduce the rate of HAPU. As a result all inpatient beds were replaced with support surfaces, updated care delivery protocols were created, and monitored, turning schedules were addressed, and a wound, ostomy, and continence (WOC) nurse and support staff were hired. These initial interventions resulted in a decrease in the prevalence of HAPU at UMH from 11.7% of stage II to IV ulcers in the second quarter, 2009 to 2.1% the third quarter. The rate remained at or near the 2009 UMH benchmark of 3.1% until the first quarter of 2012 when the rate rose to 4.1%. At that time new skin products were introduced into practice and continuing re-education was provided. The rate of HAPU dropped to 2.76% by the second quarter of 2012 and has remained steadily low at 1%–2% for nine consecutive quarters.

Hospital-Acquired Pressure Ulcers at Academic Medical Centers in the United States, 2008–2012: Tracking Changes Since the CMS Nonpayment Policy

In 2007, the Centers for Medicare & Medicaid Services (CMS) announced its intention to no longer reimburse hospitals for costs associated with hospital-acquired pressure ulcers (HAPUs) and a list of other hospital-acquired conditions (HACs), which was followed by enactment of the nonpayment policy in October 2008. This study was conducted to define changes in HAPU incidence and variance since 2008. In a retrospective observational study, HAPU cases were identified at 210 University HealthSystem Consortium (UHC) academic medical centers in the United States. HAPU incidence rates were calculated as a ratio of HAPU cases to the total number of UHC inpatients between the first quarter of 2008 and the second quarter of 2012. HAPU cases were defined by multiple criteria: not present on admission (POA); coded for stage III or IV pressure ulcers; and a length of stay greater than four days. Among the UHC hospitals between 2008 and June 2012, 10,386 HAPU cases were identified among 4.08 million inpatients. The HAPU incidence rate decreased significantly from 11.8 cases per 1,000 inpatients in 2008 to 0.8 cases per 1,000 in 2012 (p < .001; 95% confidence interval: 8.39-8.56). Among HAPU cases were trends of more elderly patients, greater case-mix index, and more surgical cases. The analysis of covariance model identified CMS non-payment policy as a significant covariate of changing trends in HAPU incidence rates. HAPU incidence rates decreased significantly among 210 UHC AMCs after the enactment of the CMS nonpayment policy. The hospitals appeared to be reacting efficiently to economic policy incentives by improving prevention efforts.

Comparative Effectiveness of Quality Improvement Interventions for Pressure Ulcer Prevention in Academic Medical Centers in the United States

Prevention of pressure ulcers, one of the hospital-acquired conditions (HACs) targeted by the 2008 nonpayment policy of the Centers for Medicare & Medicaid Services (CMS), is a critical issue. This study was conducted to determine the comparative effectiveness of quality improvement (QI) interventions associated with reduced hospital-acquired pressure ulcer (HAPU) rates. In an quasi-experimental design, interrupted time series analyses were conducted to determine the correlation between HAPU incidence rates and adoption of QI interventions. Among University HealthSystem Consortium hospitals, 55 academic medical centers were surveyed from September 2007 through February 2012 for adoption patterns of QI interventions for pressure ulcer prevention, and hospital-level data for 5,208 pressure ulcer cases were analyzed. Between- and within-hospital reduction significance was tested with t-tests post-CMS policy intervention. Fifty-three (96%) of the 55 hospitals used QI interventions for pressure ulcer prevention. The effect size analysis identified five effective interventions that each reduced pressure ulcer rates by greater than 1 case per 1,000 patient discharges per quarter: leadership initiatives, visual tools, pressure ulcer staging, skin care, and patient nutrition. The greatest reductions in rates occurred earlier in the adoption process (p<.05). Five QI interventions had clinically meaningful associations with reduced stage III and IV HAPU incidence rates in 55 academic medical centers. These QI interventions can be used in support of an evidence-based prevention protocol for pressure ulcers. Hospitals can not only use these findings from this study as part of a QI bundle for preventing HAPUs.

Pressure-ulcer reduction using low-friction fabric bootees.

At St Helens and Knowsley Teaching Hospitals NHS Trust, implementation of pressure management measures has reduced the incidence of hospital-acquired pressure ulcers. There is now a focus on those pressure ulcers still occurring despite these measures, particularly grade 2 ulcers on the heel, which are often attributed to friction and shear. During 2012 and 2013 low friction fabric bootees (Parafricta®) were used on at-risk patients (where possible) to attempt to address this issue. The bootees were first introduced in 2012. There was a decline in heel ulcers of 78% in the 2 years, which accounted for a sizeable portion of the overall decline in all grade 2 pressure ulcers. There was also a substantial change in the ratio of heel to all other grade 2 pressure ulcers, which fell from 0.67 to 0.24. On the basis of heel pressure ulcers avoided, there is an implied net saving to the NHS. The trust concluded that routine use of low-friction fabric bootees made a significant further contribution towards achieving zero harm targets and had done so while providing substantial cost benefits.

Preventing pressure ulcers in patients in intensive care

This article discusses the prevention and management of pressure ulcers in intensive care. It outlines a service improvement project conducted in the intensive care units at Imperial College Healthcare NHS Trust with the aim of reducing the incidence of hospital-acquired pressure ulcers. The project introduced a set of 'essential standards' and an audit tool to monitor compliance. Implementation of the essential standards resulted in a reduction in the total number of pressure ulcers acquired in the four intensive care units, with an absence of any category 3 or 4 pressure ulcers (the most severe categories of pressure ulcer). The article describes the measures taken to ensure the sustainability and spread of the initiative within the NHS trust.

Incidence of hospital-acquired pressure ulcers - a population-based cohort study.

Our study sought to estimate the association between race, gender, comorbidity and body mass index (BMI) on the incidence of hospital-acquired pressure ulcer (PU) from a population-based retrospective cohort comprising 242 745 unique patient hospital discharges in two fiscal years from July 2009 to June 2010 from 15 general and tertiary care hospitals. Cases were patients with a single inpatient encounter that led to an incident PU. Controls were patients without a PU at any encounter during the two fiscal years with the earliest admission retained for analysis. Logistic regression models quantified the association of potential risk factors for PU incidence. Spline functions captured the non-linear effects of age and comorbidity. Overall 2·68% of patients experienced an incident PU during their inpatient stay. Unadjusted analyses revealed statistically significant associations by age, gender, race, comorbidity, BMI, admitted for a surgical procedure, source of admission and fiscal year, but differences by gender and race did not persist in adjusted analyses. Interactions between age, comorbidity and BMI contributed significantly to the likelihood of PU incidence. Patients who were older, with multiple comorbidities and admitted for a surgical diagnosis-related groups (DRG) were at greater risk of experiencing a PU during their stay.