Nursing News

Hospital-acquired Pressure Ulcers Linked to Mortality, Readmissions

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By Debra Wood, RN, contributor 

October 12, 2012 - Medicare patients who develop pressure ulcers while hospitalized are more likely to remain in the facility longer than other patients and to be readmitted within 30 days of discharge; they are also more likely to die during their stay or within 30 days after discharge, according to a new study from the UCLA School of Nursing.

Hospital-acquired Pressure Ulcers Linked to Mortality, Readmissions
Although the study does not suggest causation, Courtney Lyder, ND, said that pressure ulcers are likely contributing to mortality.

“A lot of times people don’t think about [pressure ulcers], but this affects millions of people in the country,” said Courtney H. Lyder, ND, lead investigator on the study and dean of the UCLA School of Nursing in California. “It can be painful, and people can die.”

Lyder and his research team conducted a retrospective analysis of 51,842 randomly selected Medicare beneficiaries hospitalized in the United States in 2006 and 2007. They found 4.5 percent of the patients tracked acquired a pressure ulcer during their hospitalization. Most were on the coccyx or sacrum, followed by the hip and buttock and then the heels.

“We produced for the first time in the nation’s history the national rate for hospital-acquired pressure ulcers,” Lyder said. The authors also reported state rates, which ranged from 3.1 percent in Wisconsin to 5.9 percent in Pennsylvania.

The Centers for Medicare & Medicaid Services-funded study also found 11 percent of patients with hospital-acquired pressure ulcers died in the hospital and 15.3 percent died within 30 days of discharge, compared with 3.3 percent of patients without pressure ulcers dying in the hospital and 4.4 percent within 30 days of discharge. The patients with pressure ulcers had multiple co-morbidities.

“This is the first study we have by looking at Medicare beneficiaries that shows a correlation, but we cannot say there is an association, that having the pressure ulcer led to their death,” Lyder said. However, “if you see multiple comorbid conditions, you can predict those are the people most vulnerable.”

Mean length of stay was 11.6 days for those with hospital-acquired pressure ulcers and 4.9 days for those without the sores. Twenty-two percent of patients with a hospital-acquired pressure ulcer were readmitted within 30 days, compared with 17.6 percent of the other patients.

Sixteen percent of the patients who entered the hospital with a pressure ulcer developed one on the contralateral body part. The researchers reported their findings in the Journal of the American Geriatrics Society.

Lyder encouraged hospitals to identify patients at high risk for pressure ulcers and implement preventive interventions immediately upon admission.

“We, as health care providers and clinicians, need to be more aggressive about identifying those people more vulnerable to pressure ulcers and institute interventions sooner rather than later,” Lyder said. With shorter admissions, “time is not on our side. Hospitals must become much more astute to this issue.”

Best practices 

The Association for the Advancement of Wound Care has issued pressure ulcer guidelines, which include conducting a thorough assessment, not only of the patients’ skin, but also nutritional status, medical history and risk factors. The standards of care call for repositioning to reduce pressure, friction and shear, with frequency determined on patient need, but at least every two to three hours; use of lift sheets or devices as needed; use of a trapeze or side rails to let the patient assist with repositioning; and avoiding standard mattresses and sheepskins without added heel and elbow protection.

Hospital-acquired Pressure Ulcers Linked to Mortality, Readmissions
Lisa Owens, BS, RN, CWOCN, said preventing pressure ulcers requires education and reminders about good nursing care. Photo credit Kevin Parks, Mercy Medical Center

“It is about turning, repositioning and off-loading the pressure, as basic as that, which sounds easy to do, but it doesn’t stay in the forefront of people’s thoughts,” said Lisa Owens, BS, RN, CWOCN, program manager of the Wound Ostomy and Continence Department at Mercy Medical Center in Baltimore, whose pressure-ulcer rate typically remains below 1 percent.

Two Mercy nurses together assess every patient admitted within two hours. They monitor food intake and consult dieticians. They use barrier creams to protect the skin if the patient is incontinent and order specialty beds for at-risk patients.

“It’s not rocket science, just the basics of core nursing care,” Owens said.

But nurses need reminders about those practices. Owens said frequent education, often at the bedside, keeps pressure ulcers top of mind. Unit-based skin champions serve as resources to fellow nurses.

Hospital-acquired Pressure Ulcers Linked to Mortality, Readmissions
Stephanie Campbell discusses how to diagnose and treat pressure ulcers during Burke Rehabilitation Hospital’s Wound Healing Teaching Day.

Stephanie Campbell, RN, assistant director of nursing at Burke Rehabilitation Hospital in White Plains, N.Y., also attributed keeping nurses aware of best practices with helping the hospital keep the acquired pressure ulcer rate at zero since fall 2011. Patients are assessed on admission and weekly thereafter. All patients are on specialty beds. Occupational therapists consult on wheelchair cushions. 

Swedish Medical Center in Seattle brought nurses and nurse quality leaders together to work through pressure ulcer processes about two years ago. It adapted a validated pressure-ulcer assessment scale and programmed alerts into the electronic medical record to add the score and prompt nutrition consults and specialty bed orders when indicated. Nurses assess skin on admission and on each shift. Patients are turned regularly.

Charge nurses know which patients are at high risk. Each week, nurse managers discuss cases.

“We get just-in-time [information] about the events that happen, and we figure out how to have that event not happen again,” said Donna Strand, RN, MN, CNE-BC, director of clinical education and practice at Swedish, which has had only one hospital-acquired pressure ulcer this year. “We were devastated with the one we caused. The good new is, every nurse manager knows what caused that pressure ulcer.”

In addition, Strand believes an increased use of safe-handling equipment, including ceiling lifts, slide sheets and HoverMatts which decrease shear, has contributed to a decline in pressure ulcers.

Cone Health in North Carolina has found success by replacing its cotton/polyester sheets, pillowcases, gowns and underpads with ones made from an engineered fabric called DermaTherapy, which has a smooth weave with thin channels to wick away moisture and an antimicrobial molecule imbedded in the fibers.

Using the therapeutic linens reduced the health system’s pressure ulcer rate by 81.5 percent, and Cone has switched all of its acute-care facilities to the silky linens. Patients arriving with a wound were more likely to have it heal when using the new linens. When piloting and studying use of the new materials in multiple trials, both groups of patients received pressure-reduction positioning, nutritional management and incontinence management. 

“These are not your grandmother’s sheets,” said Laurie McNichol, MSN, RN, GNP, CWOCN, at Cone’s Wesley Long Hospital in Greensboro, who initially was skeptical a linen change could reduce pressure ulcers. But with the results of the multiple studies, “I’m a believer now.”



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