Pressure Injuries: The Crucial Role of Nurses

The statistics are staggering. At 2.5 million cases per year, pressure injuries rank as the second-most common diagnosis listed on healthcare billing records. Every year, approximately 60,000 patients die of complications of pressure injuries, making it the eighth-most frequent cause of death in the United States.

Pressure injuries impact both the personal well-being of a patient and the financial well-being of a healthcare organization. Because the Centers for Medicare & Medicaid Services does not reimburse for hospital-acquired pressure injuries, these events can significantly reduce the ever-shrinking revenue stream of healthcare organizations. Organizational efforts for pressure injury prevention require cultural commitment, thoughtful planning, and, most of all, active engagement of the nursing staff.

While the development of policies and programs on pressure injury prevention is a multidisciplinary effort, the task of program implementation falls squarely on the shoulders of a steadily dwindling number of staff nurses. The Bureau of Labor Statistics estimates that 194,500 nursing job openings will be created annually over the next decade—many of them will not be filled. As the number of nurses in the workforce shrinks, staffing shortages may reduce the ability of healthcare organizations to deliver consistent, quality care to the patients they serve. Prevention of pressure injuries through observation, monitoring, and intervention is one of the important duties of nurses.

Coverys has analyzed closed claims data to better understand the factors contributing to pressure injuries and the impact those injuries have on healthcare organizations. This data provides valuable signals that can lend insight into existing vulnerabilities and allow healthcare organizations to implement proactive risk strategies. Coverys evaluated 4,634 events that closed between 2018 and 2021 and identified 850 specific events where nurses (RN, LPN, or student nurse) were directly involved in the alleged event. There were 82 nursing-related events that involved pressure injuries.


Below are some key insights gleaned from that data:



Organizations can prevent many pressure injuries by implementing and consistently adhering to a program to reduce pressure injuries. A well-designed pressure injury reduction program involves risk factor knowledge and understanding, continuous patient assessment, and consistent performance improvement initiatives. Consider the following when implementing or reviewing your organization’s pressure injury prevention program:

• Evaluate risk factors early and often. A head-to-toe skin risk assessment using a structured assessment tool should be done on admission and repeated at regular intervals throughout the patient stay. Admission assessments should include a history of skin breakdown, documentation of all wounds or areas of skin breakdown, and photographic documentation of all areas of skin breakdown. Develop an admission process that alerts staff to the potential for skin care issues based on the patient’s history and risk assessment. Utilize a validated assessment tool/template and ensure that it requires a detailed description of the area of skin breakdown (sinus tract, tunneling, granulation, sloughing, and eschar) to enhance continuity of care.
• Implement a formal skin care program. Establish a multidisciplinary skin care team to develop and support your organization’s pressure injury prevention program. The program should clearly address clinically relevant assessment, intervention, communication, and documentation. Key skin care program elements include:
  • Assessment and documentation requirements for high-risk factors for skin ulceration, such as immobility, malnutrition, incontinence, impaired mental status, and age.
  • Use of a structured assessment tool.
  • Necessity for obtaining informed consent if photographs are taken.
  • Frequency of checks and repositioning based on risk assessment and risk factors.
  • Guidelines regarding referrals to wound care specialists and communication with providers.
• Assess for device-related pressure injuries. Many patients, especially those who are elderly, frail, or undergoing surgery, require special equipment or medical devices, such as an oxygen nasal cannula, feeding tube, or bedside commode during their hospital stay. Prevention of pressure injuries resulting from equipment or device use is often difficult because this use may be frequent or continuous, and the apparatus may be rigid or ill fitting. Include in a routine skin assessment an evaluation of the skin that comes in contact with the equipment or device to identify early indicators of pressure.
• Communicate with the care team. Use structured communication techniques to relay pressure injury risk/status information during handoffs, when updating the attending provider, during patient transfer, and when care planning with the patient, family, and care team. Require a physician’s order for pressure injuries treatment protocols to ensure the attending physician receives concurrent communication.
• Educate ALL nursing staff. Implement formal pressure injury prevention education for nursing staff, especially those who work in long-term care/rehabilitation facilities. Include a competence-based curriculum for pressure injuries prevention and treatment. Because pressure injuries often begin during long stays in the emergency department (ED), provide pressure injury prevention training to ED nurses as well. Ensure that all staff use a structured assessment tool and common language to describe pressure injuries.
• Embed triggers in the reporting system. All staff should understand the importance of occurrence reporting to identify pressure injuries. Embrace and reflect patient safety culture principles and just culture. Consider updating occurrence reporting so it triggers an immediate notification to the quality director and wound care specialist to institute early intervention.
• Enlist patients, families, and caregivers. Develop formal educational materials for patients, families, and caregivers regarding pressure injury and skin care. Provide patient education on skin care for at-risk patients prior to patient discharge. Ensure that patient education is documented in the medical record. Look for patient education documentation when conducting focused medical record audits.
• Provide necessary tools. The prevention of pressure injuries requires an ample supply of equipment, materials, and staff. Ensure that nursing units are well staffed and stocked with sufficient supplies, such as multilayer foam bandages and dressings, barrier creams, wound rulers, cameras, and pillows. Consider using high-tech pressure reducing mattresses or pads for high-risk patients.

Pressure injuries are a significant challenge for healthcare organizations. While most pressure injuries are preventable, they are consistently responsible for a large number of malpractice claims every year. Successful pressure injury prevention efforts begin with organizational commitment and depend on continuous risk assessment and consistent adherence to a well-designed pressure injury prevention program.

Additional resources:

• AHRQ Pressure Ulcer Toolkit
• Institute for Healthcare Improvement (IHI)
• TJC Quick Safety Issue 25: Preventing Pressure Injuries
• CMS: Cross-Setting Pressure Ulcer Measurement & Quality Improvement

 
Copyrighted. No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.