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Facility Lowers Rate of Pressure Ulcers

Briefings on Patient Safety, October 27, 2009

NCH Healthcare System in Naples, FL, has seen a considerable decrease in the prevalence of ulcers, along with a significant savings associated with its prevention plan.

"Assuming that each time a pressure ulcer case was prevented the cost would be $3,000, we calculated that NCH saved $11.5 million annually," says Joan A. McInerney, MSN, RN-BC, CWOCN, wound ostomy continence (WOC) nurse coordinator at NCH.

Over the five-year period from January 2002 to January 2007, NCH's rate of pressure ulcers dropped from 12.8% to 1.9%. During that time, the number of heel pressure ulcers alone dropped from 6.7% to 1.1%.

In January 2002, staff members at NCH realized the facility's prevalence of hospital-acquired pressure ulcers (HAPU) was 12.8%, high above the national average of 8.5%. Heel ulcers made up more than half of this number.

After hearing these statistics, McInerney and her partner, a newly hired WOC nurse, met with physicians, risk managers, and members of the leadership team to find a solution to help lower future heel ulcer outbreaks.

However, before McInerney and her fellow staff members had a chance to implement a new product, a patient in the critical care unit suffered a serious injury due to a heel ulcer.

This sentinel event, along with the recently discovered statistics, accelerated NCH's implementation of a new boot product to help lower the incidence of HAPUs, specifically on patients' heels.

At the time of the sentinel event, NCH was using the Braden Scale for Predicting Pressure Sore Risk and had implemented an electronic medical records system, says McInerney.

In 2002, NCH decided that when a new patient came into the facility, a nurse would assess the patient's skin integrity and ask him or her to answer a series of questions. Based on the assessment and the patient's answers, the computer would score the answers according to the Braden scale and all six subscales.

NCH staff members continue to use this practice to assess a patient's risk for HAPU upon admission to the facility.

"The electronic record allows us to capture every patient that is at risk for developing any sort or pressure ulcer," says McInerney. "We set up several alerts on the program in the event a patient qualifies for a boot, and automatic orders are placed, as well as needed consults with myself or the other wound ostomy continence nurse."

Trend analysis and boot protocol implemented
In addition to using the electronic record to determine whether a patient needs a boot, NCH also began a trend analysis of the prevalence of pressure ulcers every six months for the five years between January 2002 and January 2007.

The results of more frequently recorded pressure ulcers were seen almost immediately, and within the first six months, pressure ulcer prevalence dropped from 12.8% to 7.5%, McInerney says. Heel ulcers dropped from 6.7% to 3.5%.

"I was so excited and thrilled by the initial results with heel ulcers," says McInerney. "Everyone was very happy and maybe a little relieved that we seemed to be on the right track."

To further NCH's goal of improving pressure ulcer prevention, specifically heel ulcers, a team came together to search for a new boot and to develop specific protocols to determine which patients should wear the boot. The team consisted of McInerney, her partner, a critical care physician, a podiatrist, and a risk manager. The team solicited samples from boot companies, and from those options, staff members tried on the boots to see which ones elevated the heel. After some deliberation, the group chose the Heelift Suspension Boot by DM Systems in Evanston, IL.

The team—with the help of the chief medical officer, the chief nursing officer, an information technology staff member, and the heads of central distribution, the operating room, education, and critical care—determined protocols for which patients were to receive the boot.

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