Hospital Harm: Pressure Ulcer

Overview

Healthcare Excellence Canada has developed this Hospital Harm Improvement Resource – a compilation of resources to support patient safety and improvement efforts.

A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated (European Pressure Ulcer Advisory Panel et al., 2019). Pressure ulcers cause considerable harm to patients, hindering functional recovery, frequently causing pain, and the development of serious infections. Pressure ulcers have also been associated with an extended length of stay, sepsis, and mortality (IHI, n.d.).

Pressure ulcers are also known as bed sores and are categorized in four stages:

• Stage I: The skin is a slightly different colour, but there are no open wounds

• Stage II: The skin breaks open and an ulcer forms

• Stage III: The sore becomes worse and creates a crater in the tissue

• Stage IV: The sore is very deep causing extensive damage; these sores can harm muscle, bone, and tendons

Any stage III or stage IV pressure ulcer acquired after admission to hospital are designated as 'Never Events'. Stage III and IV ulcers can lead to serious complications such as infections of the bone or blood (sepsis) (CPSI, 2015).

Pressure ulcers (PU) continue to be a significant health concern as the population ages and the complexity of care increases across all care settings (RNAO, 2011). A literature review done in Canada in 2004 found that the overall prevalence of pressure ulcers across all institutions studied was 26 per cent. Although 50 per cent of these were Stage 1 ulcers, this data is still disturbing (Woodbury & Houghton, 2004). The total net adjusted hospitalization cost of a hospital-acquired PU in Ontario was CA $44,000 to $90,000, compared with CA $11,000 to $18,500 for a pre-admission PU (Chan et al., 2013).

Accreditation Canada has included pressure ulcer prevention as a Required Organizational Practices (ROP) in its 2020 handbook, the guidelines specify that pressure ulcer prevention strategies require an inter-disciplinary approach and support from all levels of an organization. It is useful to develop a plan to support comprehensive education on pressure ulcer prevention, and to designate individuals to facilitate the implementation of a standardized approach to risk assessments, the uptake of best practice guidelines, and the coordination of healthcare teams (Accreditation Canada, 2020).

Risk Factors

Assessment of certain categories of patients requires that the clinician be aware of and assess for specific factors that may increase risk for skin breakdown or affect healing of pressure injuries. Advancing age, decline of general nutritional and mental status, decreased mobility, sensory perception deficits, incontinence and the changing characteristics of the skin have been identified as a predictor of pressure-related injuries. Risk is increased for those with hypotension, contractures, or a history of cerebral vascular accident. Pressure injury incidence and prevalence rates remain higher in critical care areas due to the numbers of severely compromised patients. In the severely obese it can be challenging to assess skin and visualize all bony prominences. Surgical patients have an especially high risk of developing intra-operative pressure injuries due to the prolonged pressure from immobility during the intra-operative and immediate post-operative periods. In many terminally ill patients, multiple factors and co-morbid conditions increase their risk for the development of pressure injuries and need to be identified (Norton et al., 2018).

Importance to Patients and Families

Patients rightfully expect safe care, and healthcare providers strive to deliver care that results in better health and safe, effective outcomes for patients. Unfortunately, events that harm patients do occur while care is being provided, or as a result of that care. While risk is an inherent part of care, we know that many of these events that cause harm can be prevented using current knowledge and practices. (CPSI, 2015).

Patients and families are aware that pressure ulcers are painful and slow to heal; and that ulcers are often seen as an indication of poor quality of care. When caregivers practice the best care every time, patients can avoid needless suffering (IHI, 2012).

Patient Stories

The Swans' Story (patient video) (NHS Midlands and East, 2012)

Richard developed an avoidable pressure ulcer during respite at a nursing home. The experience has inspired him, together with his caregiver and wife Doreen, to help inform and educate in the hope that together we can eliminate avoidable pressure ulcers.

Pressure Injury Prevention – Jessie's Story (patient video) (AHS Channel, 2019)

Jessie tells his story of his spinal cord injury leading to his experience with multiple pressure injuries and prevention.

Success Stories

Implementation of Turning Clocks for Pressure Ulcer Prevention and Management

The use of an individualized repositioning schedule is a recommended strategy for prevention and management of pressure ulcers. As individuals' needs differ, it is often a challenge to communicate specific repositioning schedules to care staff, which may result in inconsistent positioning. The literature suggests that using a visual cue, or diagram with body positions, may be a helpful reminder of resident positioning schedules (HSO, Leading Practices Library).