Improving Outcomes by Implementing a Pressure Ulcer Prevention Program (PUPP): Going beyond the Basics

Hospital-acquired pressure ulcers (HAPUs) are a problem that has been under increased scrutiny in recent years. To help reduce the incidence of HAPUs and to improve their management, a burn unit-centered wound care team was established. The team decided to pursue two goals: to identify opportunities for improvement that may help prevent HAPUs and to evaluate all available support surfaces to identify those that might best help with pressure redistribution. To identify opportunities for improvement, the team studied each new case of HAPUs throughout our hospital with a forensic chart review for a 3-year period. To identify the best support surfaces to help reduce the incidence of pressure ulcers, we evaluated all support surfaces available at our institution by pressure mapping in healthy volunteers. From 3 years of collecting and reporting data for quality improvement, we identified 23 patients with HAPUs and obtained more than 800 data sets from pressure mapping in healthy volunteers. Most (23/24; 96%) patients with HAPUs identified in this series had undergone a surgical procedure. The results of the quality improvement studies are presented. We conclude that prevention planning of HAPUs needs to be improved in patients undergoing surgery, in particular. No single support surface can prevent pressure ulcers, but use of overlays may help reduce peak pressures over bony prominences.

Hospital-acquired pressure ulcers are serious clinical complications that can lead to increased length of stay, pain, infection, and, potentially, death. The surgical progressive care unit at Sharp Grossmont Hospital, San Diego, California, developed the multidisciplinary Healthy Skin Project to decrease the prevalence of hospital-acquired pressure ulcers. The previous treatment plan was reviewed and modified according to current evidence-based practice. The project consisted of 3 components: creation of a position for a unit-based wound liaison nurse, staff education, and involvement of the nursing assistants. The wound liaison nurse developed and conducted bimonthly skin audits, which revealed inconsistencies in clinical practice and documentation. Education for the staff was accomplished via a self-learning module, case presentations, and 1-on-1 training. In addition, a pressure ulcer algorithm tool was developed to demonstrate step-by-step wound management and documentation. From Spring 2003 through Summer 2006, the prevalence of hospital-acquired pressure ulcers ranged from 0.0% to 18.92%, with a mean of 4.85%. After implementation of the project, the prevalence decreased to 0.0% for 17 of 20 quarters, through 2011. Prevention and a multidisciplinary approach are effective in reducing the occurrence of hospital-acquired pressure ulcers.

This is a longitudinal study of the trend and seasonality in unit-level hospital-acquired pressure ulcer (HAPU) rates from 2004 to 2011, for 5447 acute care nursing units in 733 US hospitals. Unit-level HAPU rates decreased significantly during 2004-2007 (OR = 0.91, 95% CI [0.90, 0.91]) and the decreasing trend was much stronger during 2008-2011 (OR = 0.84 [0.83, 0.85]). Seasonal variations in HAPU rates were strong and consistent during 2004-2008, with the highest HAPU rate in Quarter 1 (Jan-Mar) and the lowest rate in Quarter 3 (Jul-Sep). During 2009-2011, the magnitude of this seasonality was greatly reduced, and only HAPU rate in Quarter 1 remained significantly higher than HAPU rates in other quarters.

Reducing Incidence and Prevalence of Hospital-Acquired Pressure Ulcers at Genesis Medical Center

The aim of this study was to identify current research on turning frequencies of adult bed-bound patients and inform future turning practices for hospitals based on evidence-based practice. We undertook a scoping review framework that provided a transparent and systematic methodology using 8 electronic databases (CINAHL, PubMed, Cochrane Library, ScienceDirect, PsycINFO, Scopus, ProQuest, and Web of Science) to identify articles published from 2000 to 2016. Articles were included if they focused on the prevention of hospital-acquired pressure ulcers related to the frequency of turning or repositioning of bed-bound patients. Literature search and data extraction were performed independently by 3 authors. The study followed the PRISMA guidelines. In total, 911 articles were identified, of which 10 were eligible. Of the eligible articles, 8 studies could not reach a conclusion on the effective frequency of turning and duration for repositioning patients to prevent the development of pressure ulcers. Only 2 studies found significant differences among the intervention and control groups. Results regarding turning and repositioning schedules are inconclusive; however, the topic needs further exploration to improve the outdated guidelines surrounding pressure ulcer prevention. This may, in turn, make the work of nurses more efficient and make treatment cost-effective for both the patients and the hospitals.

Driving Hospital-Acquired Pressure Ulcers to Zero

Hospital-acquired pressure ulcers (HAPUs) affect patients during hospitalisation, putting patients at risk for further complications. HAPU is one of the hospital quality indicators that require quality initiatives or programmes to minimise its occurrence and consequences. The aim of this study was to assess the effectiveness of a developed quality improvement programme in preventing HAPUs. This is a retrospective comparative study, which tracked the outcomes of pressure ulcer prevention programme (PUPP) for 5 years from 2014 to 2018. Data from 50 441 patients were collected from different units in a tertiary hospital in the eastern region of Saudi Arabia. The programme focused on building a wound care team; providing education to hospital staff, patients, and their families; and continuous data monitoring, in addition to follow-up visits after discharge. Implementation of the programme was successful showing a statistically significant reduction of HAPUs from 0.20% in 2014 to 0.06% in 2018 (P value <.001). The PUPP was effective in reducing the percentage of pressure ulcer cases. The programme can be extended and implemented in other hospitals.

A tertiary public hospital in Saudi Arabia set out in 2015 to establish a team focused on reducing hospital-acquired pressure ulcers (HAPUs). The pressure ulcer prevention program (PUPP) had a multifaceted approach and data were collected for a period of 5 years. The results showed a definite reduction in the incidences of HAPUs. Many such programs show similar positive results and echo many of the same considerations of risk, prevention strategies, and the need for early intervention. However, none of the other studies either replicate the hospital's PUPP nor the extent of the positive and lasting effect of the program. Eager to determine the contributing factor(s) in order that the project success could be continued and possibly replicated in other quality improvement projects, it was decided that an examination and comparison of other similar programs and their results would be necessary in order to uncover the answer. It was determined that the in-person in-home discharge follow-up portion of the program most likely had the largest effect on the outcomes. Outcomes that were supported by the pre-work completed during the hospital portion of the PUPP towards reducing HAPUs and readmissions.

The incidence and prevalence rates of pressure ulcers in the paediatric population: A meta-review of systematic reviews.

ACP Guidelines for Preventing, Treating Pressure Ulcers

&lt;p&gt;Although great strides have been made to tackle hospital-acquired pressure ulcers (HAPUs), there is a need for greater recognition of device-related pressure ulcers (DRPUs), including their causes, management and prevention. This consensus statement, an updated second edition, aims to continue raising awareness of these largely preventable injuries and, crucially, to stimulate action. DRPUs are relatively common and account for a growing proportion of HAPUs. Updated information on the incidence of DRPUs is described in chapter 1. Although it is recognised that DRPUs increase the financial burden of healthcare, there is little formal analysis of their economic impact. This needs to be addressed; robust evidence on the burden of DRPUs and the value that can be released by adopting prevention strategies is needed to help drive action. Our understanding of the pathophysiology of DRPUs has improved significantly over the past few years; this is described in chapter 2. One crucial difference between PUs and DRPUs is that body-weight forces are less significant in DRPUs, with the force being exerted from a device that is typically strapped or taped onto the body. Devices and their securement may generate high stress concentrations in tissues, leading to cell and tissue-damage pathways associated with sustained deformation. As more evidence is published on DRPUs, recurring themes are emerging, as outlined in chapter 3: The most vulnerable patients are bearing the brunt of DRPUs; paediatric and neonatal patients, and all those needing critical care are particularly susceptible. During the COVID-19 pandemic, a new high-risk population (people with severe COVID-19 infection) emerged. They are at increased risk of DRPUs because of their need for prolonged ventilatory support, especially when 'proning' Devices associated with DRPUs are often used to perform essential, life-saving functions. They include continuous positive airway pressure (CPAP) masks or endotracheal tubes. Minimising their use is clearly not an option, so practice innovation is needed Although the most common locations for DRPUs are the face, ears, lower legs and heels, any location where a device comes into close contact with the skin can be at risk. In the same vein, any device, whether needed for a medical purpose or not, has the capacity to cause injury if its use is not properly managed. Vigilance is needed for all patients. What can be done? The importance of routine risk assessment is covered in chapter 4. Although use of a validated risk assessment tool is the vital first step, this will not be enough on its own. Several steps can be taken to ensure the safe use of devices. These are described in chapter 5 and include device repositioning, cushioning with prophylactic dressings and moisture control (only where possible and clinically appropriate). Of key importance is the development of an institutional protocol and champions to ensure all necessary steps are adopted. For any of these changes to be put into practice, awareness of DRPUs needs to increase. A number of proposals are outlined in chapter 6. A change of focus among health professionals and policy makers, along with more investment in education and training, are needed. All patients being managed with a medical device must be considered as at high risk. The pandemic introduced the world to the problem of DRPUs in health professionals caused by the extended wear of personal protective equipment. Health professionals also have a right to expect institutional protocols and provision of devices that protect them from DRPUs. Cutting-edge ideas and technologies that may be available in the future are described in chapter 7. When designing new products, manufacturers of medical devices have a duty of care to investigate the risks of DRPUs associated with their products and mitigate them, wherever possible. Our developing understanding of how the design, structure and materials used in medical devices contribute to DRPUs will help us develop new solutions for tomorrow. The first step is for everyone involved to ask themselves, 'what can I do to help?' There is work to be done-your journey to reduce DRPUs starts here!.&lt;/p&gt;

Objective To analyze the continuous monitoring results of pressure ulcer, so as to provide scientific basis for the prevention and treatment of pressure ulcer. Methods Based on the results of continuous monitoring of pressure sores in hospitalized patients in People's Hospital of Longyou between 2009 and 2016, the prevalence rate, incidence rate and distribution characteristics of pressure sores were obtained by retrospective statistical analysis. Results There were 112 206 cases monitoring during eight years. Pressure ulcer prevalence rate was 0.54%. The incidence rates of primary diagnostic pressure ulcers and hospital acquired pressure ulcers were 0.47% and 0.07%, respectively. ICU had the highest prevalence rate accounting for 4.25%. In all pressure ulcer patients, male to female ratio was 2.124∶1, and the average age was (70.57±19.89) years old with 62.71% of people over 70 years old. There were 606 pressure sore cases with a total occurrence of 917 pressure ulcers and 1.513 bedsores per patient. The most common site was the end of the sacral pressure sores which accounted for 53.00%, followed by the ministry of the iliac crest of 12.98%, and the ankle of 10.47%. Pressure ulcer in phase Ⅱ was most common stage, accounting for 46.78%, followed by phase Ⅲ of 20.28%, and phase Ⅰ of 13.09%. Conclusions The results show lower existing and incidence rates in our hospital than those reported in present domestic literatures. Aged male patients are of high incidence pressure ulcers. The sacral pressure ulcers and the phase Ⅱ ulcers are most common. Continuous monitoring and prudent management can effectively reduce the incidence of pressure ulcers. Key words: Incidence; Pressure ulcer; Monitoring

Prevalence and incidence of pressure ulcers in Japanese long-term-care hospitals

A survey of pressure ulcer education within pre-registration radiography courses

The number of hospital patients who develop pressure sores has risen by 63 % over the last 10 years, and nearly 60,000 deaths occur annually from hospital-acquired pressure ulcers. It has been estimated that it costs between 1.5 and 5.0 billion dollars a year to manage pressure ulcers in the United States [1]. In the United States in October of 2008, the Centers for Medicare and Medicaid Services announced that it will stop reimbursing hospitals for treating reasonably preventable conditions—pressure ulcers are among these conditions. That announcement has put hospitals into a state of anxiety, and with good reason, up until now, the majority of hospitals focus on the treatment of pressure ulcers, rather than preventing them. Section 5001(c) of the DRA required the Secretary to identify, by October 1, 2007, at least two conditions for which hospitals under the IPPS (Inpatient Prospective Payment System) would not receive additional payment beginning on October 1, 2008, if the condition was not present on admission. The conditions (a) must be of high cost or high volume or both, (b) must result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. For discharges occurring on or after October 1, 2008, hospitals would not receive additional payment for cases in which one of the selected HACs was not present on admission. That is, the case would be paid as though the secondary diagnosis was not present. Pressure ulcers are one of the hospital-acquired complications that CMS deems to be preventable, and as a result, prevention is on the forefront of all hospital policies. Pressure ulcers can affect any patient that has limited mobility due to illness or disease. There are some patient populations that are at greater risk than others. Individuals with spinal cord injuries have a high incidence of pressure ulcer development. It has been estimated that 25 % of individuals will develop a pressure ulcer in a year, with 85 % having at least one pressure ulcer in his/her lifetime [1]. Individuals aging with spinal cord injuries will have increased risk as age-related changes affect the strength and elasticity of the skin. Niazi et al. found that the recurrence rate for patients with spinal cord injuries who develop pressure ulcers was 35 % [1]. The treatment of pressure ulcers is approximately 25 % of the cost of caring for individuals with spinal cord injury. The cost of prevention is approximately 10 % the cost of treatment [1, 2]. Another population at greater risk for pressure ulcer development is the elderly especially those in long-term care facilities. Twenty-five to thirty-five percent of elderly patients in these facilities develop pressure ulcers during their length of stay. Prevention is the key to improving these patients’ quality of life and reduces the burden that pressure ulcers place on our healthcare systems.