Best wound practices emerge from study at Premier hospitals

Benchmarking shows how to save money

By incorporating proven wound care practices, hospitals can improve the care of patients with pressure ulcers, reduce costs, and improve patient satisfaction, according to a major benchmarking study of best practices.

The study, conducted by Premier, (formerly the SunHealth Alliance), in Charlotte, NC, describes 54 separate "best practices" that were performed at the four benchmark hospitals that achieved superior performance in caring for pressure ulcer patients.

Forty-two hospitals affiliated with Premier, which provides centralized operations and services, participated in the study. None were named. All of Premier’s hospitals are located in southern states, and range in sizes from fewer than 100 to more than 1,200 beds. Half of the hospitals had from 200 to 500 beds.

More than 5,300 patients at the hospitals were risk assessed and examined for pressure ulcers. A third (36%) of the study hospitals reported that the cost of managing pressure ulcers was a serious problem, while more than half (53%) said it was somewhat of a problem. The remaining 11% said it was not a problem. Three quarters of the hospitals reported that they had wound care protocols in place, 55% said they had multidisciplinary wound care teams, and 42% said they did not perform prevalence studies.

Study results showed that prevalence rates for hospital-acquired pressure ulcers ranged from 1% to nearly 30%, though the majority (71%) reported prevalences ranging from 5% to 20%.

Nine success factors

Best practices were organized under nine success factors deemed critical to the success of a pressure ulcer program: content, ease of use, patient satisfaction, staff education and awareness, efficacy, staff inclusion, tracking and use of information, physician involvement, and continuum of care.

Of the 54 best practices listed in the study, the following stand out as key, says Sherri Daughtridge, a benchmarking consultant for Premier.

Use multidisciplinary approach.

Encourage many disciplines to participate in the development of your pressure ulcer protocol. This creates a well-rounded program that helps each discipline see the role it plays in the prevention and treatment of pressure ulcers. All four benchmark hospitals maintain established skin/wound care teams represented by disciplines such as pharmacy, nutrition/dietary, materials management, medical staff, social services, physical and occupational therapy, nursing, and enterostomal therapy.

Use protocols.

Develop clinical protocols or paths to prevent and manage pressure ulcers. Such protocols streamline the management of pressure ulcers and allow skin integrity to be managed from the physician’s office, through the inpatient stay, and into the home. They also help ensure that all providers are "speaking the same language."

Use AHCPR guidelines.

Incorporate the Agency for Health Care Policy and Research (AHCPR) Prevention of Pressure Ulcer Guidelines and Treatment of Pressure Ulcer Guidelines to support the recommendations in your hospital’s protocol. All of the benchmark hospitals incorporated the AHCPR’s findings into their wound care protocols.

Do risk assessments.

Use a risk assessment tool with established validity and reliability. All of the benchmark hospitals used either the Braden or Norton scales to assess patient risk for skin deterioration and breakdown.

Make protocols accessible.

Have a quick reference of the pressure ulcer protocol easily accessible to the staff. One of the benchmark hospitals kept laminated sheets at each bed showing the pressure ulcer staging system (which included pictures of pressure ulcers from stages I to IV) and the decision trees for specialty bed usage. The hospital also produced a grid of wound descriptions and treatment and product options based on the cost of the products and the frequency of use. Another hospital had a laminated sheet containing summaries of the major prevention and treatment points from its wound care protocol and stored it in a convenient location.

Monitor specialty beds.

Determine whether specialty bed usage is appropriate. One benchmark hospital received a weekly report from its specialty bed vendor showing when a particular bed was first put into service, why it was used, and the length of stay of the patient assigned to it. Another facility applied its specialty bed renewal criteria to determine if patients needed to be left on or removed from the bed. The director of nursing followed up with managers who did not complete the renewal reports. When specialty bed usage got too high, enterostomal therapists monitored specialty bed patients. If bed use was deemed inappropriate, word was passed on to the patient’s physician.

Another hospital in the study compared costs during its first year of monitoring bed usage to those of the previous year and documented $250,000 in savings. Another $300,000 was saved between the first and second years of monitoring. During that time, the prevalence of hospital-acquired wounds dropped 8%. The savings funded a second staff position for wound care.

Begin discharge planning early.

Benchmark hospitals started discharge planning at the time of admission and evaluated each patient’s skin in preparation for discharge. They also brought in a home health nurse at the beginning of the patient’s hospital stay.

Build your reputation.

Establish your reputation as a resource and an expert with the long-term and home care community. One of the benchmark hospitals offered free enterostomal therapy for home health agencies that later contracted with them to provide these services. Another benchmark hospital distributed business cards and letters explaining the services it could provide to long-term care facilities, home health agencies, and families. It also made specific physicians (those who had a high census of patients at other facilities and agencies) aware of its services.

Designate your experts.

Designate a nurse on each unit as a skin resource person. This person not only helps to maintain the skin care program but also serves as a liaison between the wound care specialist and the unit staff. Two of the benchmark hospitals applied this practice.

Intangible rewards

In addition to the financial benefits reaped by some of the hospitals during the study period, equally important was the increased awareness among hospital clinicians and administrators of the consequences and impact of hospital-acquired wounds. "It’s a big issue. A lot of the clinicians who deal with these wounds were frustrated because the problem wasn’t considered important or was seen as just a nursing problem at their institution," says Daughtridge.

In addition, the study hospitals learned the importance of tracking the prevalence of hospital-acquired pressure ulcers, making sure that their staffs understand what the data mean and involving as many people as possible in the development of wound care protocols and pathways.

Premier plans a formal follow-up study to determine which practices were adopted by participating hospitals and what results were achieved. For hospital groups who want to undertake their own benchmarking study, Daughtridge emphasizes that the data gathered must be accurate and comparable among institutions.

[Editor’s note: To receive the complete 72-page study, Best Practices in the Prevention and Treatment of Pressure Ulcers, contact Sherri Daughtridge, Premier Incorporated, P.O. Box 668800, Charlotte, NC 28266-8800. Telephone: (704) 529-3300. Fax: (704) 527-3654. The cost is $100.]