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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.

Along with using the initial assessment during a patient's admittance, McInerney and her team determined that all patients with end-stage renal disease who were on hemodialysis and all patients using ventilators would automatically be required to wear the boots.

McInerney says it was important to empower staff members to use their discretion when judging whether the use of a boot is necessary with a particular patient.

"[Even though we were already using the] initial assessment—less than 13 on the Braden scale—and the boot protocol [as indicators], we also wanted to make it clear to staff that if they thought a patient was at risk, and they did not fall into predetermined categories, to give them a boot," says McInerney.

Visible success and results maintained
Since NCH first saw its pressure ulcer prevalence numbers drop between January and July 2002, the facility has continued to see success.

"The fact that the idea of lowering NCH's pressure ulcer prevalence has been drilled into the staff members' heads has really helped our numbers," says McInerney. "It's such a part of our life now, and I have no painful memories of this process."

McInerney created posters and flyers displaying a foot on a mattress with a red slash to illustrate that patients at risk for pressure ulcers should not have their feet on the bed, but rather elevated in a boot. In addition, NCH's CEO discussed the pressure ulcer rate in his weekly newsletter.

Another factor that helped NCH maintain a low pressure ulcer rate was the decision to upgrade the system's hospital beds. In 2004, nurses purchased pressure-relieving, continuous lateral rotation therapy air mattresses for critical care units, and other units in the hospital received pressure-reducing foam mattresses.

NCH continues to have great success keeping pressure ulcer numbers low. In the past two years, NCH's pressure ulcer rate has remained under 2%, reports McInerney.

"I attribute a lot of our success to the product itself," she says. "But you have to remember that it takes persistence. The idea of electronic records which force consults to make sure everyone is covered may cause some overlap. But compared to what you save on preventing pressure ulcers and that it is the right thing to do, one has to focus on the bigger picture."

With the economic crisis affecting the healthcare arena, hospitals large and small must tighten the budgetary belt. This difficult task weighs heavily on hospital CEOs across the nation. Should leadership positions be eliminated? Should nursing FTE's be cut?

Historically, one of the first hospital departments to experience the crunch is the nursing education department. Reimbursement for seminars and out-of-facility education is an easy expense to eliminate and monies once budgeted for training are frozen. With a short-term perspective, it's easy to believe these cuts will have little effect on hospital operations and those currently employed within the facility, but unfortunately, this is a false assumption.

The future of ongoing improvement in quality healthcare has a strong dependency on life-long learning that is hosted and encouraged by staff development departments and their educators across the country. It is a Joint Commission requirement that the competency of all clinicians be validated at least once per year, but without needed equipment and budgeted salaries for qualified practitioners to validate competency, that mandate cannot be met.

Each day there are evidence-based changes and updated techniques surfacing as the result of clinical research and testing of best practices around the world. Communicating these changes and teaching new techniques to clinical staff in healthcare facilities is the responsibility of staff development professionals and clinical educators. Positive patient outcomes rely directly on the skills and knowledge of the clinicians caring for them.

During the past year, several sentinel events and near misses have been reported related to the administration of Heparin. As a result, safety measures have been created and implemented in healthcare facilities around the world, such as a double check system in which two clinicians independently calculate the dosage of Heparin and then compare the calculated dose, and a tighter control of the anticoagulant by the hospital pharmacy. The need for clinician education and post-education validation was mandatory. Without this education, future critical events and deaths are likely to occur.

The Joint Commission defines negligence as a “failure to use such care as a reasonably prudent and careful person would use under similar circumstances.” The cost of nursing negligence by far outweighs the savings that staff development budget crunching results in, let alone dangers to our patients from medical errors caused by incompetent clinicians.

In light of these concerns, too stringent cuts from the staff development department's budget during economic hardship should be a warning sign. Consideration must be given to future costly litigation fees as a result of substandard care and the difficulty of launching new quality improvement initiatives without educated staff development professionals to oversee them.