By Janel Nour-Omid
Patients hospitalized with an extended illness sometimes develop pressure ulcers, also referred to as bed sores, pressure sores, Decubitus sores, or pressure injuries.
By definition, pressure ulcers (NLM, 2019) “are areas of damaged skin caused by staying in one position for too long. They commonly form where your bones are close to your skin, such as your ankles, back, elbows, heels and hips.”
This offers an overview of the prevalence and risk of pressure ulcers, as well as prevention strategies including the use of workflow monitoring and purposeful rounding by Vitalacy (Nour-Omid, 2019). I use the term pressure ulcer throughout this post for consistency and alignment with academic and medical citations.
The Prevalence of Pressure Ulcers
Pressure ulcers, a nursing concern for many years, have been found in examination of Egyptian mummies (Agrawal and Chauhan, 2012) dating from more than 5,000 years ago. Florence Nightingale (1860) understood the challenge of treating pressure ulcers, writing, “If he has a bedsore, it’s generally not the fault of the disease, but of the nursing.”
Pressure ulcers are a common, costly and preventable condition, according to “Preventing Pressure Ulcers in Hospitals: A Systematic Review of Nurse-focused Quality Improvement Interventions” (Soban et al, 2011).
Pressure ulcers are an expensive illness to treat. “An estimated 2.5 million pressure ulcers are treated in U.S. hospitals each year, adding $11 billion annually to health care costs,” according to “A New Vision for Preventing Pressure Ulcers” (Sen et al, 2018).
The Risk for Pressure Ulcers
The National Pressure Ulcer Advisory Panel (NPUAP, 2018), an independent not-for-profit professional organization dedicated to the prevention and management of pressure injuries, presents four risk factors for the development of pressure ulcers:
Patients who must stay in bed or can’t move due to illness.
Patients who can’t move because it’s too painful.
Patients who are having surgery that might last three or more hours.
Patients who use a wheelchair or sit for long periods of time.
Prevention Strategies for Pressure Ulcers
Understanding the patient’s health status, frequent turning and patient rounding, and patient monitoring are three prevention strategies for pressure ulcers.
Understanding the health status of each patient upon entering the hospital is a first step in preventing the development of pressure ulcers. Multiple risk factor scales (Cooper, 2013) have been developed, including the Braden Scale for Predicting Pressure Score Risk (Bergstrom et al, 1987), a tool often used in the U.S. This assessment tool, used in 30 countries, helps nurses and other caregivers to evaluate patients on risk factors including sensory perception, skin moisture, activity, mobility, friction and shear, and nutritional status. Caregivers use this tool to quantify their patients’ risk for developing a pressure ulcer by scoring them from low- to high-risk on these factors.
Frequent turning and purposeful rounding. Turning the patient every two hours is a basic best practice for the treatment of pressure ulcers, as stated in Preventing Pressure Ulcers in Hospitals (2014), a toolkit from the Agency for Healthcare Research and Quality. The NPUAP supports this approach with its Pressure Injury Prevention Points (2016), a checklist for risk assessment, skin care, nutrition, and repositioning and mobilization. Purposeful rounding is another technique that ensures the adequate duration and frequency of patient room visits (Nour-Omid, 2019). Research has shown that frequent rounding reduces patient falls and skin breakdown while resulting in improved Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and patient experience scores.
Monitoring of patients at risk for or with pressure ulcers ranks as a primary prevention solution for treatment of this condition. “Monitoring is the linchpin that formed the foundation for the long-term, systemwide undertaking of the prevention of pressure ulcers and that created the climate for change and continued momentum,” Harrison et al, 2008, noted in “Pressure Ulcer Monitoring: A Process of Evidence-Based Practice, Quality, and Research.” In this study, the Ottawa (Canada) Hospital, an acute care teaching hospital, developed a pressure ulcer monitoring system with guidelines for pressure ulcers prevention and created the culture change required to maintain monitoring momentum. With 25 percent of their inpatient population at “high risk,” they reduced the prevalence of pressure ulcers from 18 to 14 percent during a seven-year period. Combining clinical decision making with the monitoring of patients, Wilborn (2015) offers optimal approaches and best practices for preventing pressure ulcers. One of the tools is the Braden Scale, discussed earlier in this post. Looking back on 25 years of use of this important resource, Braden (2012) concluded that “the best care is prescribed when the Braden Scale is used in conjunction with nursing judgment.”
Automated workflow monitoring and purposeful rounding present new solutions to pressure ulcer prevention
AHRQ 2014 describes a hospital that implemented an automated mechanism to identify patients at risk for developing pressure ulcers, along with a referral system for patients who were at risk on the Braden Scale. This new way of identifying and monitoring pressure ulcers increased awareness among the staff and helped them better target their efforts. Around the same time, the state’s department of public health came to the hospital for a site visit in response to a serious reportable event. The external review of clinical practices created additional urgency to keep rates low.
Vitalacy’s automated monitoring and purposeful rounding solution can improve pressure ulcer prevention. It tracks the frequency of caregiver’s entry and exit in every patient room to view detailed location-based rounding compliance data in real-time, eliminating the need for paper charts, checklists and other pen-and-pencil tracking systems. With these features, unit managers can identify gaps in rounding by reviewing hourly visits, verify which staff members visited which patients, and review visit durations to see if rounds met all requirements. Users can also subscribe to email or mobile app notifications to get helpful reminders for visiting specific patient rooms when necessary. All of these data are designed to be delivered back to the healthcare providers directly to help them ensure high care quality for their patients and, ultimately, to prevent pressure ulcers and other hospital-acquired conditions.
Janel Nour-Omid is the VP of Product and Marketing at Vitalacy. Her background in computer science, passion for design, deep fascination in human behavior and personal losses due to healthcare-associated infections drives her to build high-performing patient safety products that can be easily used by caregivers in healthcare settings.
Agency for Healthcare Research and Quality (AHRQ). Preventing Pressure Ulcers in Hospitals. A toolkit for improving quality of care. October 2014.
Agrawal K & Chauhan N: Pressure ulcers: back to the basics. Indian Journal of Plastic Surgery, May-Aug. 2012;45(2):244-254. doi: 10.4103/0970-0358.101287
Bergstrom, N. et al. The Braden Scale for predicting pressure sore risk. Nursing Research, July-August 1987;36(4):205-210.
Braden, BJ. The Braden Scale for predicting pressure sore risk - reflections after 25 years. Advances in Skin & Wound Care, February 2012;25(2):61. doi:10.1097/01.ASW.0000411403.11392.10
Cooper, K. Evidence-based prevention of pressure ulcers in the intensive care unit, Critical Care Nurse. December 2013;33(6):57-66. doi: 10.4037/ccn2013985
Harrison et al. Pressure ulcer monitoring: a process of evidence-based practice, quality, and research. The Joint Commission Journal on Quality and Safety, June 2008;34(6):355-359.
National Pressure Ulcer Advisory Council (NPUAC). Pressure Injury Prevention Points brochure. 2016.
National Pressure Ulcer Advisory Council (NPUAC). Stop Pressure Injuries. Worldwide Pressure Ulcer Prevention Day 2018 brochure.
Nightingale, F. Notes on nursing: what it is, and what it is not. New York: D Appleton and Company; 1860. HTML version at Celebration of Women Writers.
Nour-Omid, J: Introducing Vitalacy’s latest product updates: workflow monitoring & purposeful rounding. Vitalacy Blog, Feb. 20, 2019.
Sen D et al. A new vision for preventing pressure ulcers. IEEE Pulse, Nov. 15, 2018.
Soban LM, Hempel S, Munjas BA, Miles J, Rubenstein LV. Preventing pressure ulcers in hospitals: a systematic review of nurse-focused quality improvement interventions. Joint Commission Journal on Quality and Patient Safety, 2011;37(6):245-252.
U.S. National Library of Medicine (NLM). Medline Plus. Pressure ulcers, Feb. 2019.
Vitalacy, Inc. Finding new ways to prevent healthcare-acquired infections and conditions. 2019.
Wilborn, W. Pressure Ulcer Prevention Strategies. Nursing Made Incredibly Easy! November/December 2015;13(6):10-12.