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Pressure ulcer prevention

Introduction

A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction that often occurs in bed- or chair-bound individuals.

Once considered an inevitable result of hospital or nursing home care, pressure ulcers are seen as a patient safety issue and a preventable source of unnecessary harm. Increased attention is being focused on prevention because the prevalence of pressure ulcers has remained relatively constant over the past 20 years, despite the investment of time and money in many prevention strategies.

Recognizing the need for a multidisciplinary approach, there has been a dramatic response by many national organizations calling attention to this problem and offering guidelines, tools and approaches for prevention. Among those organizations and national initiatives that have most recently focused on prevention efforts are the Institute for Healthcare Improvement’s Five Million Lives Campaign, the National Quality Forum (NQF) "Safe Practices," and the Joint Commission 2007 National Patient Safety Goals and other nursing and professional groups. Evidence-based guidelines have also been published by a number of organization and implementation of these proven practices provide the best opportunity for decreasing incidence and improving outcome.

Information on these key resources and guidelines are available in the resource section.

Size of the problem –morbidity and mortality

According to recent estimates, 1.3 million to 3 million adults have a pressure ulcer, with an estimated cost to heal each ulcer of $500 to $40,000. The incidence of pressure ulcers varies greatly by clinical setting: 0.4 to 38.0 percent for hospitals, 2.2 to 23.9 percent for long-term care, and 0 to 17 percent for home care. Pressure ulcers in elderly persons have also been associated with increased mortality rates. For more discussion of morbidity and mortality see Lyder and colleagues.  

Risks and contributing factors for pressure ulcer development

Many studies note that risk for pressure ulcers are predictable, pointing the way to successful prevention methods. One key factor is skin integrity, and it is known that it can deteriorate within hours under certain conditions. Wet, moist skin is more vulnerable to skin disruption and ulceration, although dry skin is a risk factor as well. Clinicians note that continual pressure, especially over bony prominences, increases risk, leading to use of pressure-relieving surfaces. Making frequent assessment prevents minor problems from becoming major ulcers. The NQF emphasizes this with the following Safety Practice:

"Evaluate each patient upon admission, and regularly thereafter, for the risk of developing pressure ulcers. This evaluation should be repeated at regular intervals during care. Clinically appropriate preventive methods should be implemented consequent to this evaluation." See NQF Safe Practices


Other identified risk factors are:

For more discussion of risk and contributing factors see Reddy and colleagues.

 

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