Improve pressure ulcer risk assessment to improve care

Staff education must include aides to ensure success

An Indiana initiative to reduce pressure ulcers throughout all areas of healthcare has resulted in a reduction of bedsores at more than 160 home health agencies, nursing homes, and hospitals participating in the project.

With pressure ulcers representing the most commonly reported medical error since Indiana started mandatory reporting in 2006, it made sense to look for ways to increase the identification of the risk of pressure ulcers and improve methods of preventing pressure ulcers, say project participants.

A key component of the Indiana Pressure Ulcer Initiative's collaboration among health care providers, which was launched in June 2008 and concluded in August 2009, was the focus on a pressure ulcer risk assessment at admission. At the start of the project, only 42.1% of participating agencies indicated that they always performed a pressure ulcer risk assessment within 24 hours of admission. After education and training regarding the use of assessment tools, the percentage of agencies performing a risk assessment within 24 hours of admission grew to 71.4%.

"We joined the initiative because we were seeing more patients with wounds," says Paula J. Long, RN, CHCE, administrator of Sullivan County Community Hospital Home Health and Hospice in Sullivan, IN. Not all of the wounds her nurses see are pressure ulcers, but she and her staff recognized the need to incorporate some best practices into their protocols to improve care of wounds, she adds.

Although her nurses were conducting skin assessments of all patients, they were not assessing the risk of pressure ulcer development in patients, points out Long. "One of the first steps we took was to implement the use of the Braden Scale to assess the risk of each patient," she explains.

In her staff education, Long emphasized the need to base interventions on the scores for each individual category of risk included in the Braden Scale, as opposed to the total risk factor score. "A patient may have an overall score that represents a mild risk of developing a pressure ulcer, but the patient's score in the shear and friction category might be severe," she says. "In this case, the nurse needs to focus on reducing the risk in that category," she explains. Interventions include lifting the bed-bound patient as opposed to sliding the patient or have the patients wear protective clothing, such as socks to minimize friction on heels and feet. "If you only look at the overall score, you will miss opportunities to prevent pressure ulcers," she adds.

To make it easy for her nurses to have all of the tools, such as the Braden Scale, documentation forms, intervention guidelines, and patient education material required for the risk assessment, Long developed a Pressure Ulcer Risk Assessment Packet. "I'm a believer in packaging everything you need in one packet, so all the nurse has to do is pick up one envelope," she explains. By pre-packaging everything, the agency saves the nurse time and ensures that she can complete the assessment accurately, she adds.

Communication Key To Success

Because the state-sponsored initiative included different types of health care providers, communication among providers improved, says Long. "By standardizing transfer reports and other information, we are aware of the patient's pressure ulcer risk as they are coming to us for care," she says.

As well as coordinating communication among providers, the initiative created online educational programs that home health staff can access, in addition to training provided through their own agencies. "We provided educational courses to all of our nurses and our home health aides," says Terri Edmiston, RN, MSN, clinical manager for Parkview Hospital Home Health and Hospice in Huntington, IN. One of the benefits of the pressure ulcer project was the development of tips and training suggestions to make pressure ulcer education more interesting, especially to the aides, she says. "Our aides are an important component of our pressure ulcer program, because they are with the patients more often than the nurses. And because they bathe the patients, they have an opportunity to assess the patients' skin for changes," she explains. "We stress the important role they play in the detection of pressure ulcers, since they are our 'eyes' on the patient on a day-to-day basis," she adds.

A key part of pressure ulcer education is the focus on communicating with other members of the patient care team, points out Edmiston. Nurses talk with patients and their families about how to prevent pressure ulcers and monitor skin changes, and the aides reinforce the teaching. "If an aide notices a change in the skin that a nurse should evaluate, the aide documents the change and calls the nurse," she says.

"We are fortunate to have a good relationship with the hospital's wound care nurses, so we always have experts we can call with questions," says Edmiston. "Not all agencies have this expertise in-house," she adds.

"I am receiving a lot more questions from nurses," admits Tonya L. Gudell, RN, WCC, performance improvement coordinator for St. Elizabeth Regional Health and Hospice in Lafayette, IN. As the wound care specialist for the agency, Gudell develops and presents the educational session and serves as a consultant to nurses and aides. "I am also seeing a great improvement in documentation," she adds. Not only are nurses regularly using the Braden Scale to assess pressure ulcer risk, but they also are routinely measuring and properly staging wounds, she says. "We really didn't have patients who developed pressure ulcers in our care, but we tell employees that our focus on assessment and proper intervention helps us do a better job of keeping patients comfortable and reduce their pain," she explains.

The biggest challenge her agency faced was data collection, says Gudell. "We needed a better way to monitor pressure ulcers, especially in our hospice, since those nurses don't use OASIS [Outcome and Assessment Information Set] like the home health nurses," she explains. She worked with their information technology department to develop a data collection tool that became part of their online documentation system. The tool added text to the nurses' notes to prompt the nurse to include a description of the wound, measurement, and staging. "The new format did require some training and the data collection is still a work in progress, but we are now able to monitor our progress throughout the agency," she says.

Gudell is happy that her agency participated in the initiative as a way to identify best practices that could be implemented at St. Elizabeth. "Everyone in other agencies [has] great ideas, and this initiative gave us an opportunity to share with others in order to better care for all patients."


• For information on the Indiana State Pressure Ulcer Initiative, go to the Pressure Ulcer Resource Center at The site contains free resources, such as the educational program developed by the initiative, links to related organizations and associations, data from the project, and a library of articles and presentations that can be used as resources.

• For a copy of the Braden Scale, go to any of the educational modules listed in the Pressure Ulcer Resource Center and click on the "tools" button in the upper right hand corner once you start the module. Course 2: "Preventing Pressure Ulcers: Assessment Process" contains the description of how to use the scale.


For more information about pressure ulcer assessment and interventions, contact:

• Tonya L. Gudell, RN, WCC, Performance Improvement Coordinator, St. Elizabeth Regional Health and Hospice, 1415 Salem Street, Suite 202, Lafayette, IN 47904. Telephone: (765) 449-5046 or (800) 755-5650. E-mail:

• Paula J. Long, RN, CHCE, Administrator, Sullivan County Community Hospital Home Health and Hospice, 2200 North Section Street, Sullivan, IN 47882. Telephone: (812) 268-4311 ext. 5. E-mail:

• Terri Edmiston, RN, MSN, Clinical Manager, Parkview Hospital Home Health and Hospice, 240 South Jefferson, Suite C, Huntington, IN 46750. Telephone: (260) 373-9800 or (800) 533-2252. E-mail: