Improve risk assessment for pressure ulcers

Educate aides to ensure success

An Indiana initiative to reduce pressure ulcers throughout all areas of health care has resulted in a reduction of bedsores at more than 160 organizations 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 between 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 project's start, 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.

Although her nurses were conducting skin assessments of all patients, they were not assessing the risk of pressure ulcer development in patients, Long says. "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."

Interventions include lifting the bed-bound patient, as opposed to sliding the patient, and having 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," Long 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. The prepackaging saves the nurse time and ensures that she can complete the assessment accurately, Long says.

Because the state-sponsored initiative included different types of health care providers, communication between 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."

In addition to coordinating communication between providers, the initiative also created online educational programs that 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."

A key part of pressure ulcer education is the focus on communicating with other members of the patient care team, points out Edmiston. Not only do nurses talk with patients and their families about how to prevent pressure ulcers and how to monitor skin changes, but also 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. Not all agencies have this expertise in house."

Tonya L. Gudell, RN, WCC, performance improvement coordinator for St. Elizabeth Regional Health and Hospice in Lafayette, IN, says, "I am receiving a lot more questions from nurses." 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, Gudell 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 help us do a better job of keeping patients comfortable and reduce their pain," she explains.

The biggest challenge faced by her agency 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. Gudell 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," Gudell says.

She 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," Gudell says.