Quality Rounds
Under Pressure
By Scott D. Smith
Minnesota’s Adverse Health Events Reporting law has prompted hospitals to make the lowly pressure ulcer a top patient safety concern.
Pressure ulcers—more commonly known as bedsores—are often thought to be a problem of the elderly. Andrew Kiragu, M.D., director of Hennepin County Medical Center’s (HCMC) pediatric intensive care unit, can tell you from experience that they’re not for adults only.
In 2005, an infant in Kiragu’s ICU developed a stage III pressure ulcer. The child had an underlying skin condition and severe lung disease. She breathed with the assistance of a high-frequency oscillating ventilator. At one point, moving her risked worsening her respiratory status.
For this patient, it was virtually impossible to prevent a pressure ulcer. But the experience opened Kiragu’s eyes to the problem. Although research on pressure ulcers in children is scant, a Harvard study published in Pediatric Critical Care Medicine in July 2003 found that 27 percent of children who spent more than one day in the ICU had some form of pressure ulcer.
Children in pediatric ICUs are at increased risk of developing pressure ulcers because they tend to be relatively immobile and have equipment pressing on or rubbing their skin. In addition, some may have low blood pressure, which can lead to compromised circulation. Vasopressors, which are used to raise blood pressure, can further compromise circulation to the skin and leave patients vulnerable to pressure ulcers.
Pressure Ulcer Prevention
Minimize or eliminate friction and shear
- Use transfer or assistive devices to reduce friction and/or shear
- Use lift sheets or devices to turn, reposition, or transfer patients
- Maintain head of bed at or below 30 degrees; match knee angle with angle of head of bed
- Keep skin clean and dry
- Use trapeze when not contraindicated
Minimize pressure
- Make frequent, small position changes
- Use pillows or wedges to reduce pressure on bony prominences
- At a minimum, turn every two hours
- Do not position directly on the hip
- Encourage patients to shift weight every 15 minutes (ie, do chair push ups, stand and reseat, elevate legs)
- Reposition every hour if patient is unable to reposition self
- Use pressure support surfaces to reduce or relieve pressure
- Consider patient’s weight when selecting a bed. Use a bariatric body mattress for patients weighing more than 300 pounds.
- Free-float heels by elevating calves on pillows
- Minimize or eliminate pressure from medical devices
Manage moisture
- Implement toileting schedule as appropriate
- Cleanse skin gently with pH-balanced cleansers and apply moisture barrier
- Contain urine and stool
- Contain wound drainage
- Keep skin folds dry
Maintain adequate nutrition/hydration
- Provide nutrition compatible with patient’s condition
- Encourage intake of supplements
Source: Institute for Clinical Systems Improvement Pressure Ulcer Protocol (www.icsi.org)
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With new appreciation for the problem, Kiragu became a member of HCMC’s recently formed skin team, which is grappling with the one of the most common adverse events in Minnesota hospitals: the development of stage III and IV pressure ulcers.
The possibility of patients developing pressure ulcers often falls off physicians’ radar screen because they are so focused on treating acute illnesses, Kiragu says. But allowing stage I and II pressure ulcers to progress to stages III and IV can be costly in terms of both money and suffering. If an early-stage ulcer festers, it eventually may result in the need for skin and muscle grafts as well as infections that can lead to sepsis and even death. Treating such conditions can cost tens of thousands of dollars, compared with several hundred for treating a pressure ulcer in its early stages.
The Most Common Error
The fact that Kiragu has become one of the hospital’s champions for preventing pressure ulcers is evidence that Minnesota’s Adverse Health Events Reporting Law is having an effect.
In 2003, Minnesota passed the law, which requires hospitals to report 27 preventable medical errors such as leaving an object in a patient during surgery, doing a procedure on the wrong patient, or allowing a patient to develop a stage III or IV pressure ulcer.
Between October 2004 and October 2005, pressure ulcers were the most frequently reported adverse event in Minnesota hospitals. They accounted for 31 of 106 errors reported in the second annual Adverse Health Events in Minnesota report, which was released in February. In the first report, pressure ulcers ranked second and accounted for 24 out of 99 errors.
Soon after the problem of pressure ulcers came to light, Minnesota hospitals and quality advocacy groups began responding. In April 2005, the Minnesota Alliance for Patient Safety (MAPS) convened a group of experts to study best practices for preventing and treating pressure ulcers. The experts worked with MAPS, the Institute for Clinical Systems Improvement, and Stratis Health, the state’s Medicare quality-improvement organization, to develop a protocol for preventing and treating pressure ulcers.That protocol was presented to about 150 health care providers, representing 75 percent of the state’s hospitals, at the Pressure Ulcer Prevention Summit in November 2005.
“Without this registry, and had we not seen this was an issue, this type of work would not have been done,” says Tania Daniels, director of patient safety for the Minnesota Hospital Association.
Team Building
Both Kiragu and Mary Murphy, R.N., clinical educator for supplemental staff at HCMC, attended the summit. Murphy returned ready to change the way staff assessed and treated wounds. “We came back and decided we needed to start skin-safety rounds and a skin-safety team,” Murphy says.
HCMC convened the team in December of 2005. The 24 members include physicians, nurses, physical and occupational therapists, and nutritionists. Between December and February of this year, the team met twice monthly and completed a course on skin care.
After the team got up to speed on how to prevent and treat pressure ulcers, members audited the skin health of patients on the hospital’s nine units that treat the most acute patients, including the ICUs and the surgical units. What they saw was eye-opening.
Team members inspected 188 patients from head to toe and found that 74 had pressure ulcers. Six of those were reportable stage III ulcers. That number was disheartening, considering the hospital had reported a total of five stage III ulcers during all of 2005.
Murphy convinced the hospital to give nurses who work in inpatient and ambulatory settings paid time to take a four-hour class on how to prevent and treat pressure ulcers and to add a special skin care module to the nurses’ annual training. She saw to it that a poster showing the basics of wound care was placed in an area where nurses gather. She also convinced HCMC to order wound-care carts that will make all the medicines and dressing needed for treating wounds readily available.
Finally, Murphy spread the word that anyone could page members of the skin care team when confronted with a wound needing treatment. The team uses those consults as an opportunity to emphasize the importance of catching and treating pressure ulcers early, explaining that a stage I wound can heal in 24 hours, if the pressure is removed.
Getting Results
Those efforts paid off quickly. When the skin team found a young man in a coma who had two stage III pressure ulcers about the size of a quarter on the back of his head, they created a skin-care plan that included applying gel to his skin, turning him every two hours, and placing his head on a special pillow that can form a pocket of air around the wound.
Nurses educated his family about his condition and instructed them to not let him disturb his bandages. Team members also consulted with a nutritionist to make sure the patient was being tube-fed the correct amount of food (the body needs good nourishment in order to heal damaged skin). Two and half weeks later, the man’s ulcers were healed, Murphy says.
By the time of HCMC’s next skin team audit in March of 2006, the number of pressure ulcers dropped by nearly half. The audit team found 49 ulcers and only one reportable stage III ulcer in the 178 patients they inspected.
Working the Workflow
The key to preventing serious pressure ulcers is integrating skin checks and patient adjustments into a nurse’s daily routine, says Jane Pederson, M.D., director of medical affairs at Stratis Health. Pederson was involved in developing the protocol for treating and preventing pressure ulcers. “Theoretically, if we looked at everyone’s backside every shift, we’d catch everyone, but it’s not happening,” she says.
Nursing homes generally lead hospitals in terms of making pressure ulcer prevention part of people’s jobs. Pederson explained how one facility in Delaware restructured the workload so each day two nursing assistants took responsibility for turning patients.
However, in a hospital, the challenge is to treat the acute illness and still find time to assess skin and execute treatment plans. That’s not always an easy task, considering some treatment plans call for patients to be turned hourly. “When you talk to nurses, it isn’t that they don’t understand the importance of preventing pressure [sores], but it is very hard to put it into their work flow,” Pederson says.
Physicians also need to be aware of what they can do to help patients avoid an advanced-stage pressure ulcer. Pederson says they should know the basic risk factors for skin problems and sort out the etiology once a wound develops.
Pressure, arterial problems, venous stasis, or neuropathy can cause a wound on a person’s leg, for example. “Each of these etiologies has a different treatment, and you’ve got to know which one you’re dealing with, and that is the realm of the physician,” she says.
Pederson believes electronic medical record systems will help nurses and physicians know which patients are high-risk so that they automatically order a pressure-relieving bed, chair cushion, and turnings.
She also expects efforts such as HCMC’s will help lead to change at other facilities. “As we get better at systematically looking for these ulcers, it is going to help us and push us to change to get the best practices incorporated into the daily work flow of physicians and nurses.” MM
Scott Smith is a staff writer for Minnesota Medicine.