Obtaining Institutional Support: Complicated Pressure Ulcers

No quality initiative is successful without hospitalwide commitment. Getting the administration’s support is a must to get that commitment. The quality improvement team needs the backing of the hospital leadership for its effort to be effective.

Quality improvement generally requires changes on multiple levels, not only at the physician level. Having an administrator as a committed member/leader of the team goes a long way in making this change a reality. The project will require dedicated personnel, access to information, and financial support. The hospital leadership has to be convinced that this project is in its best interest and in the best interest of the patients it serves, so that it backs the effort. The team and the administration should maintain open lines of communication to monitor progress and to address obstacles or opportunities as they arise.

Task

Meet with members of the administration team and have prepared talking points, and ideally some preliminary information you collected demonstrating the need for the administration’s attention. Here are some ideas for talking points.

Talking Points

Hospitalized patients are at high risk for the development of pressure ulcers

• The incidence and prevalence of pressure ulcers in hospital settings vary widely from study to other for a variety of factors but are estimated at 7.1% and 14.8%, respectively.^1,12,13
• Persons with impaired sensation, prolonged immobility, or advanced age are at higher risk of the development of pressure ulcers or of the progression of existing ones.
• The population of persons with lifelong functional impairments continues to grow, and preventing secondary complications becomes an increasingly prominent concern.
• Elderly patients admitted to acute-care hospitals for nonelective orthopedic procedures such as hip fractures are at even greater risk, with a 36% incidence of pressure ulcers.²

Pressure ulcers lead to substantial inpatient costs, morbidity, and mortality

• Estimates of the total costs of pressure ulcer treatment vary widely, from $2 to $11 billion a year.^3–7
• It is estimated that 2.5 million patients are treated for pressure ulcers in U.S. acute-care health facilities each year.^3,7
• The cost of treatment is $2000–$40,000 per pressure ulcer, depending on development stage.^2,5,8
• These costs alone, without the cost of human suffering, demonstrate the importance of preventing pressure ulcers and of cost-effective treatment practices.
• Approximately 60,000 people die each year from complications of pressure ulcers.^5,6
• The development of pressure ulcers has been associated with a risk of death 4.5 times greater than that for persons with the risk factors but without pressure ulcers.⁹
• Patients predisposed to pressure ulcers are at higher risk of morbidity and mortality. Infection is the most common major complication of pressure ulcers.

Effective measures to prevent hospital-acquired pressure ulcers

• There are established measures to prevent the development of pressure ulcers.^14,15
• A multidisciplinary team needs to be formed to ensure implementation of these measures or interventions.
• Interventions should be monitored and documented.
• Specific details that are required include who should provide the care, how often it should be provided, and the supplies and equipment needed.
• Results of the interventions and the care being rendered should be documented.
• To ensure continuity of care, documentation of the plan of care should be clear, concise, and accessible to every caregiver.
• Patient education is of utmost importance.
• Patients and everyone involved in their care should have the knowledge necessary to prevent the formation of pressure ulcers.
• Comprehensive educational effort throughout the hospital to increase awareness of the magnitude of the problem and the measures to address it.

Financial Implications for the Hospital

In 2008 CMS announced as of October 2008 it will no longer pay for stage III or stage IV pressure ulcers acquired during a hospital stay. Studies indicate that length of stay (LOS) was between 2 and 5 times longer than the typical LOS for patients who develop pressure ulcers in the hospital.^10,11

A quality initiative to prevent the development or progression of pressure ulcers is aligned with hospital goals. In an environment of public reporting of information, reducing pressure ulcers will help improve the image of the institution. In a pay-for-performance climate, reducing pressure ulcers will ensure the hospital is not loosing dollars because of preventable condition.

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2. Baumgarten M, Margolis DJ, Orwig DL, et al. Pressure ulcers in elderly patients with hip fracture across the continuum of care. J Am Geriatr Soc. 2009;57:863–870.
3. Beckrich K, Aronovitch SA. Hospital acquired pressure ulcers: a comparison of costs in medical vs. surgical patients. Nurs Econ. 1999;17:263–271.
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7. Institute for Healthcare Improvement. 5 million lives campaign, 2007.
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11. Miller H. Cost implications of the pressure ulcer treatment guideline. Center for Health Policy Studies. 1994.
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13. Whittington K, Briones B. National Prevalence and Incidence Study: 6-year sequential acute care data. Adv Skin Wound Care. 2004;17:490–494.
14. Cuddigan J. Pressure ulcers in America: prevalence, incidence, and implications for the future. An executive summary of the National Pressure Ulcer Advisory Panel monograph. Adv Skin Wound Care. 2001;14:208–215.
15. Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. JAMA. 2006;296:974–984.