Clinical TopicsPatient SafetyPractice MattersWorkplace ManagementWound/Ostomy Care

“Bundle” up to prevent pressure ulcers


Pressure ulcers aren’t always simple wounds that eventually heal with the right treatment. They can have devastating effects on the quality of life for both patients and their families. What’s worse, they cause thousands of deaths each
year, particularly among the elderly. In many more cases, they probably contribute to death even if they aren’t listed as the cause.

An estimated 2.5 million patients in the United States develop pressure ulcers, and we spend about $11 billion for their treatment. With Medicare no longer reimbursing healthcare facilities to treat certain types of hospital-acquired pressure ulcers, your nursing care may come under suspicion if your patient develops one.

This article explains how to make pressure ulcer prevention a part of your everyday nursing practice. By using the “bundle” approach and practicing
the Golden Rule, you can develop a prevention program on your unit or in your facility.

Getting personal about pressure ulcers

Imagine that an illness or trauma puts a beloved aunt in the hospital. Although she’s getting better thanks to prescribed drugs and treatments, she develops
a pressure ulcer. How do you think you’d feel?

I’ve heard nurse colleagues justify a patient’s pressure ulcer as a natural part of acute illness and hospitalization. “We saved the patient’s life,” they reason. “A pressure ulcer is the least of his worries.” I can only assume these nurses have never had a family member develop a pressure ulcer while hospitalized.
If they had, I’m sure they’d take a different view. Far from expecting an ulcer to form because it’s a “natural part” of illness, chances are they would try to ensure that all measures were taken to prevent one—and if one developed, they’d consider it completely unacceptable and a sign of poor nursing care.

Even Superman can get them

In 2004, pressure ulcers got a lot of publicity when Christopher Reeve, the actor who played Superman in two movies, died from sepsis caused by a pressure
ulcer. The public found his case compelling because of the irony that the ventilator-dependent quadriplegic would die from something so seemingly
banal as a pressure ulcer.

If Reeve, whose wealth enabled him to receive state-of-the-art medical care, could succumb to a pressure ulcer, how can healthcare providers prevent pressure ulcers in those who are much less affluent—especially those whose medical coverage is limited after hospital discharge?

Are pressure ulcers preventable?

Many clinicians believe all pressure ulcers are preventable, while admitting that some may be harder than others to prevent and require more aggressive
intervention. But the truth is some pressure ulcers may not be preventable. Why? Think back to basic anatomy and the organ systems: The skin is the largest organ of the body. If your patient is in multisystem organ failure with his kidneys, liver, and heart all failing, his skin is likely to fail, too.

Whether or not you view pressure ulcers as preventable, make sure to accurately document the patient’s condition and all interventions taken to prevent them.

A “never event”

As you probably know, the Centers for Medicare & Medicaid Services recently stopped reimbursing healthcare facilities for the added cost of treating “never events.” Defined as “reasonably preventable” hospital-acquired conditions, “never events” include surgery on the wrong body part, mismatched blood transfusions, certain infections, and stage III and stage IV pressure ulcers. Hospitals can’t charge patients directly for treating these conditions, either. The idea is that refusing to pay for treatment of “never events” will cause their rates to decline.

Actually, this “do-not-pay” policy first went into effect a few years earlier in long-term care facilities. In 2007, a published study reported on the outcome of a nationwide project that aimed to reduce pressure ulcer incidence and prevalence at 52 longterm care facilities. Recommended practices were implemented using quality improvement methods; the facilities monitored monthly pressure ulcer incidence and prevalence, healing, and adoption of key care processes. The results were impressive: The total number of new hospital-acquired stage III to IV pressure ulcers declined 69%.

The Medicare policy has put nursing care under the microscope. Now is our time to shine—to contribute to the financial health of our facilities while providing the highest-quality care.

The bundle approach to prevention

The Institute for Healthcare Improvement (IHI) promotes the “bundle” approach to pressure ulcer prevention. A bundle is a set of straightforward practices—simple interventions that when combined, lead to positive patient outcomes.

The power of the bundle lies in its all-or-nothing nature. To achieve desired results, caregivers must complete all parts of the bundle. Using this concept along with the 2003 “Guideline for pressure ulcer reduction” from the Wound, Ostomy, and Continence Nurses Society, multiple hospitals developed their own bundles even before IHI published “Prevent pressure ulcers: How-to guide” as part of its 5 Million Lives Campaign. In most facilities, these bundles were part of a larger pressure ulcer prevention program and proved crucial to pushing pressure ulcer rates below the national average.

Benchmarking and auditing

To develop a successful pressure ulcer prevention program, you must know how your facility’s pressure ulcer prevalence rate compares to that of other facilities with similar patient populations. To do this, you can use benchmarking. You can also compare different units in your facility.

However, don’t simply rely on reported rates based on cases involving consultation with wound specialists. Such data can be inaccurate because of underreporting—or in some cases overreporting, as staff sometimes include conditions that aren’t truly pressure ulcers.

A formalized skin study or prevalence study should be conducted by a team trained to assess all inpatients. Before the study begins, the staff must receive formal education on pressure ulcer staging and on where to find specific elements of the audit they’ll be performing (either in the paper chart or the electronic record). The audit monitors the level of compliance in your facility, and usually consists of a list of things one would expect to see—for instance, a unit’s or facility’s compliance with preventive measures or its pressure ulcer prevalence rates.

For quality-control purposes, staff shouldn’t audit their own unit. (For information on how to set up a prevalence study, visit the website of the National Database of Nursing Quality Indicators at Both the overall pressure ulcer prevalence rate and the hospital-acquired pressure ulcer prevalence rate for your unit or facility should be determined. (See How to calculate pressure ulcer prevalence below.)

How to calculate pressure-ulcer prevalence

The prevalence rate provides a snapshot of pressure ulcers on the particular day in which all patients in unit or facility are assessed. This value can be used to track and trend pressure ulcer prevention. Be sure to determine hospital-acquired ulcer prevalence, which can reflect the quality of care provided.

How to Calculate Pressure Ulcer (PU) Prevalence:

(#of patients with a PU)/(Total # of patients assessed) x 100 = % prevalence

How to Calculate Hospital Acquired Pressure Ulcer (HAPU) Prevalence:

(#of patients with a HAPU)/(Total # of patients assessed) x 100 = % HAPU prevalence

Bundle elements

Once you know your facility’s or unit’s pressure ulcer prevalence rates, you can put the bundle concept to work. A successful bundle consists of key elements, starting with a thorough head-to-toe skin assessment on admission and then at least every shift for all patients. Risk assessment should be done at least daily. Using the Braden Scale as a risk assessment tool enables you to quantify the patient’s risk: the lower the score, the higher the patient’s risk of pressure ulcers.

Other typical elements of a bundle include turning and repositioning, nutritional assessment, bed elevation, incontinence care, and pressure relief. (See One hospital’s pressure ulcer prevention bundle by clicking on the PDF link above.)

The gold standard in prevention is patient turning and repositioning every 2 hours. (Some patients may require a more frequent schedule to ensure adequate blood flow to compromised areas.) Patients unable to turn on their own must be turned and repositioned by staff at least every 2 hours while in bed and every hour while sitting in a chair. To prevent heel pressure ulcers, use pillows or heel-lift devices to keep the patient’s heels from touching the bed. Elevate the head of the bed less than 30 degrees, unless contraindicated for other medical reasons. (For example, if the patient is at risk for aspiration or ventilator-associated pneumonia, raise the knees of the bed to prevent sliding and subsequent sheering injuries.)

Optimizing nutritional status

Using all available resources, evaluate the patient’s nutritional status and then maintain it at an optimal level. If possible, consult with a nutritionist as soon as possible. If you believe your patient’s nutritional status is compromised, urge the physician to order testing of C-reactive protein and prealbumin levels together, as this gives a better idea of current nutritional status than the albumin level alone. Also, ensure that patients aren’t kept NPO without nutrition for more than 72 hours.

Special beds and moisture management

A pressure-relief surface or special-care bed is recommended to help prevent pressure ulcers. Manage incontinence and moisture with a skin-care regimen, such as frequent cleansing and use of a moisture-barrier ointment. Clean the incontinent patient immediately and apply A&D Zinc Oxide after every incontinence episode. Together, these simple interventions can yield great results.

Education, audits—and education and more audits

For the bundle concept to work, the educational rollout, reinforcement, and culture change are mandatory. All nursing staff, including nursing assistants, should be included in the educational effort. Points to cover include Medicare’s “do-not-pay” policy for hospital-acquired pressure ulcers, your facility’s current pressure ulcer rates, and the expectation that these rates will decrease. Get the staff excited about pressure ulcer prevention. As nurses, this is our opportunity to make an impact and show the quality of the care we provide.

Once everyone has been educated about the bundle concept and elements, compliance with these elements must be audited. Develop a checklist for them—what you expect to see or not to see. Identify who will be involved in the audit. The more direct-care staff members that can be involved, the better the final results are likely to be. Ideally, nursing staff should go from patient to patient to see which bundle elements are being completed and which ones may require staff reeducation.

Staff auditors can help your unit or facility make a positive change. This form of peer review gives direct caregivers a clearer understanding of the quality improvement process as well as their unit’s practices and how these measure up to expectations. Then staff can educate peers on the findings. Audit results also may show areas where improvements should be made and may identify other educational deficiencies that must be corrected to achieve positive outcomes.

Performing frequent prevalence studies will help your facility detect any increase in pressure ulcer rates that may relate to a particular systems issue, such as lack of available equipment or decreased personnel in a certain area or unit. These studies also may suggest where to focus your efforts if a particular unit in your facility has a higher pressure ulcer rate than others; conversely, if one unit has a lower rate, it can be studied to determine what’s being done right.

The results of prevalence studies should be communicated to all staff. Physicians, nurses, and nursing assistants in particular need to be aware of pressure ulcer rates; if they don’t know a problem exists, they can’t fix it. Likewise, if they don’t know their actions are improving patient care outcomes,they’re unlikely to keep making that extra effort.

Practice the Golden Rule

In many cases, nurses are being held accountable if their patients develop pressure ulcers while under their care. And with the new Medicare rules linking quality of care to a facility’s financial health, it will be obvious to all when preventing pressure ulcers isn’t a priority.

As nurses, we need to be aware of the financial aspects of health care while not allowing them to become the primary driver of our care. What should drive us is the expectation that every patient receives the same care we’d want and expect our own family members to get. The Golden Rule tells us to do unto others as we want others to do unto us. In essence, it steers us back to the basics of nursing, the basics of life. Imagine what health care would be like if we all followed the Golden Rule.

Selected references

Ayello E, Lyder C. Protecting patients from harm: preventing pressure ulcers in hospital patients. Nursing2007. 2007;37(10):36-40.

Baldelli P, Paciella M. Creation and implementation of a pressure ulcer prevention bundle improves patient outcomes. Am J Med Qual. 2008;23(2):136-142.

Christopher Reeve dies at 52.
film/3732310.stm. Accessed February 27, 2009.

Eliminating serious, preventable, and costly medical error–never events. Centers for Medicare & Medicaid Services. May 18, 2008. Accessed February 27, 2009.

Institute for Healthcare Improvement. Prevent pressure ulcers. 5 Million Lives Campaign. Getting Started Kit. Cambridge, MA; 2008. Accessed February 27, 2009.

Krasner DL. “Never.” Never say “Always.” Never Say “Zero.” 2008.
Healthy Skin. 2008;5(3):34-35.

Lyder C. Pressure ulcer prevention and management. JAMA. 2003;289(2):223-226.

Lynn J, West J, Hausmann MS, et al. Collaborative clinical quality improvement
for pressure ulcers in nursing homes. J Am Geriatr Soc. 2007;55(10):1663-1669. Accessed February 27, 2009.

Medicare project proves pressure ulcers can be stopped in nursing homes. Senior Accessed February 27, 2009.

National Database of Nursing Quality Indicators. http://www.nursing Accessed February 27, 2009.

Ratliff C, Bryant D. Guideline for Prevention and Management of Pressure Ulcers. Glenview, IL: Wound, Ostomy, and Continence Nurses
Society; 2003.

Reddy M, Gill S, Rochon P. Preventing pressure ulcers: a systematic review. JAMA. 2006;296(8):974-984.

Redelings M, Nolan L, Sorvillo F. Pressure ulcers: more lethal than we
thought? Adv Skin Wound Care. 2005;18(7):367-372.

Whittington K, Briones R. National Prevalence and Incidence Study:6 year sequential acute care data. Adv Skin Wound Care. 2004;17:490-494.

Mary Elizabeth Paciella is a clinical nurse specialist at Stony Brook University
Medical Center in Stony Brook, New York.

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