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CE Article: Assess all patients to prevent pressure ulcers*

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After reading this article, you will be able to:

  • Describe strategies that can lower the rate of bedsores
  • Recall specific information to incorporate into educational programs for pressure ulcer prevention
  • Recognize three methods to alert staff of turning times for high-risk patients

Heightened awareness, new beds that provide pressure relief, and skin assessments on every patient entering the facility helped Baystate Medical Center in Springfield, MA, reduce its pressure ulcer rate from 20% to 0.8%.

The push to improve the rate for bedsores started in the mid-1990s, when one of the directors came to the hospital and said, "We can do better than this," says Jan Fitzgerald, MS, RN, director of quality and medical management for the division of healthcare quality at Baystate. To accomplish that, the 670-bed hospital:

  • Purchased state-of-the-art beds with pressure relief/reduction capabilities for all nursing units
  • Reviewed the literature and customized and adopted skin protocols based on guidelines of the Agency for Healthcare Research and Quality
  • Launched a skin resource committee with unit-based representation
  • Adopted the Braden risk-assessment tool that is used on admission and 48 hours after admission
  • Invested in certified wound-care nurses
  • Conducted quarterly prevalence studies, which were posted on the units

Assess every patient

Baystate, a mentor hospital for the Institute for Healthcare Improvement's (IHI) 5 Million Lives Campaign, assesses every patient who walks in the door, even those who might not be at high risk.

The hospital has computerized nursing assessment forms and system-generated orders, so the minute the patient is admitted, there are orders to do those assessments. Additionally, patients with nutritional problems receive a nutrition consult immediately. If they have a mobility issue, they also receive a mobility consult. Beds at Baystate provide pressure and heel relief.

The IHI, which has included the prevention of pressure ulcers as one of the six goals in its 5 Million Lives Campaign, is not the only group focusing on bedsores. Beginning October 1, CMS will no longer pay for the treatment of pressure ulcers if the patient acquired them in the hospital.

Doctors need to document

Consequently, doctors, not just nurses, need to make sure skin wounds are documented as present on admission, Fitzgerald says.

"If the doctor hasn't done a good job of documenting that the wound is present on admission, we will actually flag the chart, review it, and have the doctor look at the documentation," she says.

"What we say to the physician is, 'Hey, look, this was present on admission, it was in the nursing home notes, it was in the nurse's notes. You didn't address it here.'" Physician documentation, Fitzgerald adds, drives coding, so it's imperative that doctors indicate that wounds were present on admission.

Hospitals have a 24- to 48-hour window for some pressure ulcer cases. For example, if an 85-year-old woman falls in the bathroom and remains on the floor for three days before going to the hospital, she may not have a skin wound on admission.

"But in 24 or 48 hours, you've got to bet she's going to have a wound," Fitzgerald says. "The risk factors are there. We've done everything we could to prevent the wound from happening, but because of the preexisting factors, it's going to happen."

Pressure ulcers not only take a financial toll, they take a human toll as well. According to figures from the IHI's 5 Million Lives Campaign:

  • 1.3 million-3 million adults per year develop pressure ulcers
  • It costs an estimated $500-$40,000 to heal each pressure ulcer
  • Almost 60,000 patients die from complications related to pressure ulcers each year
  • In total, an estimated $11 billion goes to treating pressure ulcers

Read the IHI's 5 Million Lives Campaign How-to Guide to learn more about preventing pressure ulcers.

Focus on heels

At Conroe (TX) Regional Medical Center, a focus on heels reduced the pressure ulcer rate from 15% to 0.6% and saved the facility $1.9 million, all in one year.

Conroe, which comprises three hospitals, also purchased new boots for patients to relieve heel pressure. That, says Tina Meyers, BSN, RN, CWOCN, ACHRN, made a dramatic difference.

Like Baystate, Conroe used the Braden scale to assess risk and ordered new beds.

Meyers says those hospitals starting pressure ulcer prevention projects should review the available literature and use it as a foundation on which to base their protocols. A physician champion and experienced wound-care nurse are also critical to success.

"The recommendations are out there," Meyers says. "They just need to be followed."

Reassess when changes occur

Hospitals should not only assess patients at admission, they should also reassess when a patient's condition deteriorates or changes during their stay.

Most hospitals trying to reduce their pressure ulcer rates turn their at-risk patients every two hours, although research has not yet been conducted to support that time frame, Ratliff says. Some facilities use overhead announcements to remind nurses to turn patients every two hours, some use pagers to prompt staff to turn patients, and some put reminders at the front of the bed. "There are lots of little tricks," she says.

Wheelchair bound patients should be positioned more frequently. According to the Agency for Healthcare Research and Quality (AHRQ), these patients must be repositioned each hour. And if possible, small weight shifts should be conducted every 15 minutes. Read more prevention recommendations from AHRQ.

Extending education to all involved

A critical part of pressure ulcer prevention is making the right information available to all levels of healthcare providers, patients, families, and caregivers. The National Pressure Ulcer Advisory Panel (NPUAP) recommends facilities implement educational programs that are structured, organized, and comprehensive. These programs can include information about:

  • Etiology of and risk factors for pressure ulcers
  • Risk assessment tools and their application
  • Skin assessment
  • Selection and use of support surfaces
  • Nutritional support
  • Program for bowel and bladder management
  • Development and implementation of individualized programs of skin care
  • Demonstration of positioning to decrease risk of tissue breakdown
  • Accurate documentation of pertinent data

Learn more about pressure ulcer prevention from NPUAP.


  1. The Institute for Healthcare Improvement's 5 Million Lives Campaign How-to Guide at
  2. National Pressure Ulcer Prevention Panel at
  3. Agency for Healthcare Research and Quality prevention recommendations at

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