Get pressure ulcers near zero with these best practices

A recent development has put greater emphasis on pressure ulcer prevention in hospitals: The Centers for Medicare and Medicaid Services (CMS) will stop reimbursement for certain hospital-acquired conditions, including pressure ulcers, as part of an update to the hospital inpatient prospective payment system.

Unless pressure ulcers are documented as present on admission, CMS will no longer provide reimbursement — an extra incentive for organizations to get the number of pressure ulcers acquired in the hospital as close to zero as possible.

"In looking at our pressure ulcer rates, we didn't like the numbers we were seeing," says Beth Kaiser Schafer, RN, MS, director of professional practice at Hennepin County Medical Center in Minneapolis. "We did a gap analysis comparing our practice to national standards, and we didn't like where we were."

A group of staff was sent to a pressure ulcer summit in 2005, held by the Minnesota Hospital Association, to find the most current evidence-based practices. "From there, it was time to get out and apply what was best practice," says Schafer. "We educated a large number of our nurses, and put skin care best practices into our annual training for nurses."

The first and biggest challenge was to get direct clinical staff to buy in to the urgency of the initiative. "After we identified an organizational need, we had to drive down that need and make staff feel the same importance as we did," says Schafer. "We know that in their educational program, our nursing staff learn how to do skin assessment and prevent pressure ulcers, as well as how to care for skin. They know the right thing, but something must have been getting in the way of doing it."

The next step was to look at whether nurses had the supplies and equipment needed to put prevention strategies in place, and treat pressure ulcers if they occurred.

"We discovered that staff didn't have easy access to skin products when they needed them. People can't do what you want them to do, if they don't have those things," says Schafer.

After skin products were standardized, skin carts were created for the units with all the necessary products fully stocked. A skin care guide was developed and placed on the carts, as an easy reference for staff.

A designated person was hired to oversee the organization's wound and skin program, which includes coordinating the monthly meetings, skin rounds, and serving as an expert consultant for challenging wounds. Additional education was given on skin safety, with updated information about best practices for assessment, prevention, and intervention.

An organization-wide skin team of 20 members visits nine inpatient units each quarter, to conduct head-to-toe assessments on every patient. These data are analyzed, including the patient's age, gender, risk assessment scoring, timeliness of prevention strategies, and assessment of skin breakdown.

The team found a link between pressure ulcers and certain treatment protocols, and in other cases, the equipment being used. "We looked at what kind of mattresses we used and developed a mattress algorithm," says Schafer.

Monthly "skin meetings" are held with a team of champions from various units. "We discuss issues that members may have, and we work to improve them at either a unit or an organizational level," says Schafer. For example, an organization-wide approach to documentation in the electronic health record was recently implemented.

Quarterly data are collected on an organization-wide basis, and submitted to the National Database of Nursing Quality Indicators (NDNQI) database. Initially, the number of pressure ulcers identified in 2006 increased, but the number has since dropped 75% in the hospital's surgical intensive care units and 57% in other units for certain stages of pressure ulcers.

In addition, individual units do their own skin rounds and data collection. "Some of our units are doing weekly or monthly rounds so that they are sure they aren't missing anything," says Schafer. "This drives it down to the actual people in the areas where the patient care is occurring. It takes on a very personal level, and gets the staff very passionate about skin care."

Unit champions carry the message much more strongly than any one person can, says Schafer.

"We have had skin team members who were transferred to another unit, who asked to stay on the skin team of the previous unit because they want to continue to share their knowledge," she says. "There is nothing like peer-to peer-knowledge transfer to get things done. One person can't do it all."

In 1996, the University of Virginia's Health System's pressure ulcer prevalence rate was 8%. Although national prevalence statistics for pressure ulcers range from 10% to 17%, the organization set out to decrease its rates by implementing a pressure ulcer prevention program, including ongoing monitoring of pressure ulcer prevalence to measure outcomes.1

"We would like for our rate to be zero. There is no acceptable rate for someone developing a pressure ulcer," says Catherine R. Ratliff, PhD, APRN-BC, CWOCN, clinician and manager of the wound ostomy continence department.

For more than a decade, the hospital's wound ostomy continence nurses have done pressure ulcer rounds, something that most organizations have only begun implementing recently, says Ratliff.

The nurses analyze the data obtained during the rounds and distribute them to the appropriate administrators and clinicians, who use the data to benchmark the health system against itself, and against national benchmarks including the NDNQI.

Each year, prevalence rates are compared to previous years to identify trends. "For example, in the late 1990s the prevalence rate increased slightly. We attributed this to needing better support surfaces," says Ratliff. "We got new pressure redistributing mattresses for the hospital, and then the prevalence rate decreased again."

As a result of the below interventions, in 2006, the pressure ulcer prevalence rate was down to 5%, and has remained at this level throughout 2007. "We continue to implement interventions to hopefully decrease the rate," says Ratliff.

Here are key changes that were made:

  • A standardized wound assessment form is used, for consistency in documenting wound care.
  • Pressure redistributing mattresses are used on all inpatient units. These reduce pressure and also provide a more comfortable support surface for patients.
  • Comfort products such as egg crate mattresses and doughnuts were eliminated from the hospital storeroom, as these do not provide redistribution of pressure.
  • Modules on pressure ulcer prevention and specialty bed usage were written, and are available to the hospital staff electronically.
  • The Braden Risk Assessment Scale is used to identify patients at risk for developing pressure ulcers. A section on the hospital admission form was added to fill in the patient's score, with check off boxes listing interventions to reduce risks.
  • Algorithms on pressure ulcer prevention and treatment were developed and distributed throughout the health system to all disciplines.

Hospital staff regularly consult the wound team nurses to assist with the management of patients with pressure issues. "Our biggest challenge now is to continue to be vigilant about pressure ulcer detection and not to become complacent, thinking that we have done all we can do," says Ratliff. "That is never the case."


  1. Cuddgian, J, Ayello, EA, Sussman, C. Pressure ulcers in America: Prevalence, incidence, and implications for the future. National Pressure Ulcer Advisory Panel 2001: Reston, VA.

[For more information, contact:

Catherine R. Ratliff, PhD, APRN-BC, CWOCN, Clinician and Manager, Wound Ostomy Continence Department, P.O. Box 801424, University of Virginia Health System, Charlottesville, VA 22908. Phone: (434) 924-5641. E-mail:

Beth Kaiser Schafer, RN, MS, Director of Professional Practice, Hennepin County Medical Center, 701 Park Ave. S, Minneapolis, MN 55415. Phone: (612) 873-2557. E-mail:]