By Wurster, Joan
Executive Summary * Pressure sores have plagued the nursing profession for many years as a major health care problem in terms of a patient’s suffering and financial cost.
* Pressure sores are increasingly common in hospitalized patients in the United States with a 63% increase from 1993 to 2003.
* The nurse leader is accountable for the occurrence of pressure sores, a nurse-sensitive indicator, by a scorecard which is benchmarked against other facilities.
* The nurse leader must take a systematic approach in the prevention of pressure sores, with the strategy being consistent and motivating to the staff in order to improve patient outcome.
* The chief nursing officer, the unit manager, and the bedside nurse must all collaborate to prevent tissue injury in patients at risk for developing pressure sores and to promote wound healing in patients with existing breakdown.
PRESSURE SORES HAVE PLAGUED the nursing profession for many years as a major health care problem in terms of a patient’s suffering and financial cost. A hallmark of quality nursing care is excellent skin care. Hospitals evaluate themselves based on the prevalence of skin breakdown (Suddaby, 2006). In the United States, approximately one million people are affected by pressure sores, with a cost of $1.6 billion annually. Stage 1, 2, and 3 pressure sores cost an estimated $2,000 to $30,000 per hospital stay, while a stage 4 pressure sore is estimated as high as $70,000 (Moody, Gonzales, & Cureton, 2004).
With an increasing demand for proof of quality patient care from legislators, payers, business leaders, and the public, the American Nurses Association (ANA) responded, in 1995, with the Safety and Quality Initiative. This resulted in the development of a national nursing database measuring the impact of nursing care and patient outcomes, driven by data and evidence- based practice, a standard toward which, Medicare and the Joint Commission on Accreditation of Healthcare Organizations are gravitating. Medicare developed a program, pay-for-performance (P4P), designed to reward providers for improving quality of care and exceeding specific benchmarks in regards to pressure sores using a national quality database known as the National Database of Nursing Quality Indicators (NDNQI) (Haberfelde, Bedecarre, & Buffum, 2005). The NDNQI is a proprietary database of the ANA. Data are collected and evaluated on unit- specific nurse-sensitive indicators from hospitals throughout the United States. Quarterly reports contain charts and maps comparing hospital unit averages with national averages. These reports enable hospitals to benchmark one institution against another. Pressure sores are used as a nurse-sensitive indicator because it is believed that the greater quality and quantity of nursing care, the greater the patient outcome.
Common Risk Factors
Pressure sores are increasingly common in hospitalized patients in the United States with a 63% increase from 1993 to 2003; the mean length of stay specifically for pressures sores was 13 days, with a cost of approximately $38,000 (Russo & Elixhauser, 2006). Early intervention is the key to the prevention of pressure sore development. Nurses must be educated and aware of the signs of tissue breakdown and factors that place patients at risk. Although there are more than 100 risk factors identified in the literature (Lyder, 2003), six of the most common risk factors will be discussed.
1. Reduced mobility is the most important element in the breakdown of tissue and the development of pressure sores (Clay, 2000). Tissue necrosis develops when soft tissue is compressed, usually between an external surface and a bony prominence for a prolonged period of time. Immobility or decreased mobility can be caused by sedation, restraints, trauma, dementia, or a disease process.
2. The nutritional status of an individual plays a significant role in tissue perfusion and skin integrity. Thin people who have little padding over bony prominences are more susceptible to pressure sores. Malnourished individuals are at a higher risk for tissue breakdown, as proteins and vitamins aid in the prevention of pressure sores by increasing tissue and cell wall integrity. Supplements and micronutrients play a major role in maintaining tissue integrity; likewise, deficiencies and deficits are detriments to wound healing (Williams & Barbul, 2003).
3. According to the National Pressure Ulcer Advisory Panel (NPUAP, 2001), incontinence of urine and feces can cause skin irritation and tissue damage especially with frequent washing using soap and water. Frequent washing causes excessive drying, friction, and irritation which could cause further skin breakdown.
4. Medications, such as sedatives and analgesics, particularly in the critically ill patient, can cause a reduced sensation and immobility (Clay, 2000). Patients placed in drug-induced comas or chemically paralyzed receiving neuromuscular blockades are at an exceptionally high risk since they are unable to communicate or move on their own.
5. Conditions that decrease tissue oxygenation or reduce oxygenated blood to the tissue, such as peripheral vascular disease, cardiac disorders, hypotension, arteriosclerotic disease, cigarette smoking, etc., are strong predisposing factors. Pressure sores are more susceptible to developing with any condition that reduces the quality or quantity of blood supply to the tissues (Clay, 2000).
6. Age is another high risk factor for pressure sore development and tissue breakdown, because elasticity, collagen, subcutaneous fat, and muscle diminish with increasing age. According to the NPUAP (2001), most pressure sores are preventable and, therefore, the incidence of pressure sores has been used as an indicator for quality patient care.
Executive Nurse Responsibilities
So, what can nurses do to prevent tissue injury and promote wound healing in patients with existing breakdown and what are the responsibilities and the role of nurse leaders? The executive nurse leader is responsible and accountable for the overall management of nursing services, including, nursing education, nursing practice, and nursing research. According to the ANA (2004), the nurse leader is responsible for ensuring that professional standards and values are maintained through the development, implementation, and evaluation of programs and that polices are supported by evidence. The nurse leader is accountable for the occurrence of pressure sores, a nurse-sensitive indicator, by a scorecard and is benchmarked against other facilities.
Nursing research is invaluable and an integral part of nursing care, which aids in shaping and delivering quality care regarding prevention and treatment of pressure sores. Understanding predisposing factors and the principles of pressure sore prevention, in conjunction with being able to select appropriate devices and equipment to reduce the risk of pressure sore development, are key factors to a successful prevention and treatment plan. The nurse leader must take a systematic approach in the prevention of pressure sores, with the strategy being consistent and motivating to the staff in order to improve patient outcome (Clay, 2000).
Initially, a risk assessment of the skin must be done systematically by using a risk assessment tool. One of the published and commonly used pressure ulcer risk assessment instruments is the Braden Scale (Braden & Bergstrom, 1988). The Braden Scale is a clinically validated tool that facilitates nurses and health care providers, scoring a patient’s level of risk for developing pressure sores. Six specific risk factors are consistently identified: sensory perception, moisture, activity, mobility, nutrition, and friction. These specific risk factors are rated from 1 to 4; with 1 representing the most severe and 4 representing no impairment; therefore, the lower the score the higher the risk for developing pressures sores. This tool enables nurses and staff to constantly and uniformly identify patients who are at risk, and to calculate the severity of risk. The NPUAP (2001) recommends that patients be assessed on admission and throughout their hospital stay.
Proper skin care is essential and must be implemented by using a mild cleansing agent followed by thoroughly rinsing the skin with water. It is recommended that the skin be patted dry without rubbing to avoid friction, and a moisturizing lotion be used to minimize excessive drying, especially with patients who are urine or feces incontinent (Clay, 2000). The Pressure Ulcer Prevention Protocol states patients should be turned at least every 2 hours while in bed, and every 15 to 30 minutes while in a chair (Hiser et al., 2006). The NPUAP (2001) recommends frequent turning, following the “rule of 30”: the head of the bed should not be elevated greater than 30 degrees and the body should be placed in a 30-degree lateral incline position on either side. Special cushioning devices and pressurereducing mattresses should be used and are beneficial in minimizing pressure, friction, shearing, and moisture. Mechanical injury to the skin from shearing forces and friction during repositioning and transferring maneuvers should be prevented by having the appropriate equipment and staff available. Lift sheets, transfer boarders, over-bed trapezes, and personal support devices with proper body mechanics should be used to facilitate these maneuvers when indicated to prevent staff injuries. Along with proper skin care, adequate nutritional intake must be assessed and managed, either by enteral or parenteral administration. When a patient is unable to consume enough nutrients orally, adequate nutrition must be obtained through tube feedings or hyper- alimentation. These interventions become increasingly challenging for the health care providers in the elderly and in patients with complex disease processes; especially with limited staffing. Addressing a Complex Issue
With today’s critical nursing shortage, it is no surprise that there would be an increase in hospitalinduced pressure sores given the complexity of this issue. Although nurses may complain there is not enough time to get everything done due to an overwhelming workload, a minimum nurse-patient ratio alone is probably not adequate to ensure quality of care. Patient acuity, nurse competence, institutional policies and procedures, and available supplies and equipment are essential to consider when confronting this issue and ensuring quality care. Equally important to consider is that proper treatment be implemented routinely and consistently in accordance with the institution’s policy and procedure manual. The responsibility ranges from the chief nursing officer to the bedside nurse to make sure treatment plans are implemented and evaluated, not just developed. Ultimately, it is the role and the responsibility of the executive health care leader to improve this nurse-sensitive indicator while reducing the cost of health care.
As the position of the chief nursing officer and the staff RN widens, the leadership role of the unit manager becomes pivotal to the performance of the unit in addressing nurse-sensitive indicators. A skin care plan to prevent tissue injury in patients at risk for developing pressure sores and to promote wound healing in patients with existing breakdown must be developed. The staff must be involved in planning, implementing, and evaluating the skin care plan for it to be effective. Developing a shared vision with a sense of team spirit within the unit can promote common interests and goals, which, ultimately, can lead to inspiration, motivation, and accountability (McGuire & Kennerly, 2006). The nursing staff must rely on the management skills of the unit manager to provide guidance with clear expectations while maintaining a challenging and effective approach. The role of the nurse leader is critical in shaping the environment of care; nurse executives play a vital role in quality patient care and safety. The chief nursing officer, the unit manager, and the bedside nurse must all collaborate to address this nurse-sensitive indicator and improve performance by exceeding benchmarks of the National Database of Nursing Quality Indicators.
Ultimately, it is the role and the responsibility of the executive health care leader to improve this nurse-sensitive indicator while reducing the cost of health care.
REFERENCES
American Nurses Association (ANA). (2004). Scope and standards for nurse administrators (2nd ed.). Washington, DC: Author.
Braden, B., & Bergstrom, N. (1988). Braden scale for predicting pressure sore risk. Retrieved July 31, 2007, from http:// www.ulm.edu/nursing/BradenScale.doc
Clay, M. (2000). Pressure sore prevention in nursing homes. Nursing Standard, 14(44), 45-52.
Haberfelde, M., Bedecarre, D., & Buffum, M. (2005). Nurse- sensitive patient outcomes: An annotated bibliography. Journal of Nursing Administration, 35(6), 239-299.
Hiser, B., Rochette. J., Philbin, S., Lowerhouse, N., TerBurgh, C., & Pietsch, C. (2006). Implementing a pressure ulcer prevention program and enhancing the role of the CWOCN: Impact on outcomes. Ostomy Wound Management, 52(2), 48-59.
Lyder, C. (2003). Pressure ulcer prevention and management. The Journal of the American Medical Association, 289(2), 223-226.
McGuire, E., & Kennerly, S. (2006). Nurse managers as transformational and transactional leaders. Nursing Economic$, 24(4), 179-185.
Moody, P., Gonzales, I., & Cureton, V.Y. (2004). The effect of body position and mattress type on interface pressure in quadriplegic adults: A pilot study. Dermatology Nursing, 16(6), 507- 512.
National Pressure Ulcer Advisory Panel (NPUAP). (2001). Pressure ulcers in America: Prevalence, incidence, and implications for the future. Reston, VA: Author.
Russo, A., & Elixhauser, A. (2006). Hospitalizations related to pressure sores, 2003. Healthcare Cost and Utilization Project, Statistical Brief #3. Retrieved October 13, 2006, from http:// www.hcup-us. ahrq.gov/reports/statbriefs/sb3.pdf
Suddaby, E. (2006). Skin breakdown in acute care pediatrics. Dermatology Nursing, 18(2), 155-161.
Williams, J., & Barbul, A. (2003). Nutrition and wound healing [Abstract]. The Surgical Clinics of North America, 83, 571-596.
JOAN WURSTER, MSN, RN, is Trauma Clinic Manager, St. Mary’s Trauma Center, West Palm Beach, FL.
Copyright Anthony J. Jannetti, Inc. Sep/Oct 2007
(c) 2007 Nursing Economics. Provided by ProQuest Information and Learning. All rights Reserved.
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