For help with healing, please click on Links and go to the WOCN to find a nurse wound specialist in your area.

 2011 NPUAP

Since submission of the NDF study, Medicare and most insurance companies have announced that the expense of treatment of hospital-caused pressure ulcers will no longer be reimbursed.  The State of New Jersey has passed a law requiring all nursing homes to replace all mattresses with pressure redistribution types.  And many hospitals have implemented the NDF Prevention Protocol resulting in the near eradica-
tion of pressure ulcers.

Click above on NDF Prevention Proto-
col for the full text of the NDF study
that started it all.
Home of the NDF Prevention Protocol
Follow us at
Hospitals that Have Adopted the Essentials of the NDF Prevention Protocol
If They Can Do It,  Why not You?

NDF Prevention Protocol
Hospitals Able to Drive Incidence to Near Zero 

Following is a small selection of hospitals that have reported that they have been able to reduce hospital-caused incidence of pressure ulcers to near zero by instituting the essential elements of the NDF Prevention Protocol . (The nation-wide incidence is reported as 7 - 9 percent.)  The
 NDF makes no claim that each hospital took action based on NDF recommendations, but only that they did take the essential steps of Braden Scale risk assessment at time of admission,  followed by placement of all at-risk patients on special pressure-reducing support surfaces.

Baystate Medical Center – Springfield, MA

"Rates over last 3-6 years have been at zero or near zero rates.We developed and implemented reliable processes/systems/interventions to assess skin integrity using an objective standardized tool (Braden Scale) for all patients on admission and regularly after that (every 24 hours and as needed in higher risk patients).  Daily skin observation is done by all clinicians in contact with the patient.  Pressure relief surfaces/mattresses were put in place in 1995 on all nursing units and in the Operating Rooms".

Zero Pressure Ulcers 
Binghamton General Achieves Goal 

The following press release, issued Jan 28, 2010, describes the tremendously encouraging news that a hospital group in Binghamton, NY was able to eradicate bedsores for the last quarter of 2009.  They accomplished this with a combination of Braden Scale risk assessment, dedicated nursing, and an investment in proven pressure-relieving  support surfaces throughout both hospitals.  They essentially put into effect the NDF Prevention Protocol ( Advances in Skin & Wound Care, July 2008). 

"Zero pressure ulcers: That's the goal of every nurse, therapist, physician, and other health care professional who works with patients. It's a difficult goal to attain, but one the United Health Services Hospitals has just reached for the first time ever.One important step was replacing the mattresses in patient rooms throughout. Wilson and Binghamton General. United Health 
Services made a considerable financial investment in the new mattresses , with bedsore-
reducing surfaces".

Claxton-Hepburn Medical Ctr Ogdensburg, NY

"Stage 4 pressure ulcers have been reduced to zero.
The Braden at-risk assessment is completed on admission and every 12 hours. The screen to complete is automatically added to the care plan and compliance is not an issue. In 2012, we
 are working with the Emergency Department to complete this on patients who are being 
admitted to earlier identify patients who need pressure ulcer prevention measures. 

Our intensive care unit has 100% pressure redistribution beds; acute Rehab Unit has about 50% and Med/Surg 50%. The nurse manager has budgeted for additional pressure redistribution mattresses for 2012 and plans to work towards all beds having pressure redistribution
 mattresses over the next 5 years"

Genesis Medical Center - Davenport, Iowa 

"The project drew on recommendations from the Wound, Ostomy, and Continence Nurses (WOCN) Society, which were based on the risk factors identified  on the Braden Scale for Predicting Pressure Sore Risk.

The standard interventions were as follows: 
Turning at-risk patients every two hours minimally, Placing a pressure-reducing overlay on the
 bed of every patient at risk
Elevating bony prominences of those at risk.

Prevalence rates for both the pulmonary and oncology units decreased to zero in the first quarterly prevalence survey following the project's initiation and have remained at zero through the end of calendar year 2006..."

Hazleton General Hospital – Hazleton, PA
"If a patient is at risk for pressure ulcers with a Braden scale of 18 or less, the staff addresses 
skin integrity issues on the plan of care.  Nursing interventions include inspection of skin, every shift, proper management of moisture and cleansing of skin, nutritional iterventions, turning and repositioning every 2 hours, use of support surfaces as indicated, and heels elevated from bed surface while in bed.

In 2011, our Facility Acquired Pressure Ulcer Prevalence ranged from 1% - 3%. (This compares 
to a range of ?2% - 5% in 2010.)"

Holy Spirit Hospital — Camp Hill, PA

Percent of Patients Receiving Pressure Ulcer Admission Assessment:  Data is collected on a quarterly basis. Our goal of 100% has been maintained for this past year.For the last year or so we have been stocking  static air mattresses on the units instead of staff having to call Central Supply and wait for them to be sent.  They are now able to place an air mattress on the bed as patients are admitted or become at risk.  Pressure Ulcer Incidence per 100 admissions:  Our initial goal of 0.6% has been maintained.  Average for the year is 0.58%."

The Nebraska Medical Center – Omaha, NE

Percent of Patients Receiving Pressure Ulcer Admission Assessment = 96.2% 
Percent of At-Risk Patients Receiving Full Pressure Ulcer Preventative Care:
        1) Daily inspection of skin for pressure ulcers = 98.9%
        2) Proper management of moisture, including both cleaning and moisturizing skin = 79.1%  *(Using NDNQI's definition of mositure management, 
documented and observed)
        3) Optimization of nutrition (MD ordered dietary recommendations) = 87.9%
        4) Repositioning every two hours = 79.1% *(Using NDNQI's evidence of being  repositioned as prescribed - coming solely from documentation )
        5) Use of pressure-relieving surfaces = 93.1%
• Pressure Ulcer Incidence = 0% April 2010." 

New Hampshire
New Jersey
South Dakota
West Virginia

New Mexico
New York
North Carolina
North Dakota
Rhode Island
South Carolina
The information presented for each state has been derived from the 2008 report, "A National Survey of Medical Error Reporting Laws" published by the Yale Journal of Health Policy, Law, and Ethics.  Please research your state laws and send an e-mail to to help the NDF to update the data.
Does your state require full public disclosure of hospital-caused medical errors, including pressure ulcers?  Exposure of guilty hospitals may be the most effective tool available for ending their ugly secret of bedsores. Please scroll down to find the current status of disclosure laws in your state. 

TED IN 2006 AND PUBLISHED IN 2008, CONCLUDED: "Risk assessment of all admitted patients followed by provision of specialized support surfaces to all deemed to be
at risk offers real hope of reducing 
the present very high rate of hospital-caused pressure ulcers."

Read More.....


PURPOSE: Measurement of pressure injury (PI) prevalence allows benchmarking within and across facilities; the International Pressure Ulcer PrevalenceTM (IPUP) Survey includes a variety of care settings. The purpose of this study is to present 10 years of US prevalence and limited demographic data (2006-2015) by care setting.

METHODS: Facilities volunteer to participate in the IPUP Survey. Internal clinical teams collect data during a predetermined 24-hour period that includes pressure injury prevalence, demographics, and other pertinent clinical information. Aggregate data was analyzed for this study.

RESULTS: The sample for this study was 918,621 patients in the United States; data collection spanned 2006 to 2015. The overall prevalence (OP) of PI in all facilities declined from 13.5% (2006) to 9.3% (2015). Facility-acquired prevalence (FAP) declined from 6.2% (2006) to a range of 3.1% to 3.4% (2013-2015). Acute care OP was 13.3% in 2006 and declined to a range of 8.8%to 9.3% (2012-2015). Facility-acquired prevalence in acute care declined from 6.4% (2006) to 2.9% in 2015, with 2008-2009 showing the most aggressive decline. Long-term acute care (LTAC) had the highest OP at 32.9% in 2006; it declined to 28.8% in 2015. The LTAC-FAP was 9.0% in 2006; it declined to 5.6% in 2015. Recently, the long-term care (LTC) FAP rose from 3.8% in 2013 to 5.4% in 2015. The rehabilitation facility FAP was 2.6% to 2.8% over the last 3 years. Average patient age declined in all care settings with the exception of LTAC and LTC. Braden Scale risk scores remained constant and weight increased in all care settings with the exception of LTC.

CONCLUSIONS: The OP and FAP in acute care and rehabilitation have declined significantly over this 10-year period. Analysis of OP and FAP in LTC and LTACs varied without any clear-cut directional trends. General facility demographic trends indicate that mean patient age has decreased, Braden Scale scores for pressure injury risk has remained constant, and weight has increased in most care settings.

*The International Pressure Ulcer Prevalence Survey:  2006 - 2015, JWOCN, Jan/Feb 2017
Back to Top of Page
Every hospital must be required to invest in sufficient effective support surfaces to be provided to every at-risk patient at admission.  If New Jersey can require that every nursing home must replace
 all beds with pressure redistribution types (New Jersey Law S-1517), surely each state can require
 that all licensed hospitals provide sufficient proven support surfaces.
Reducing Pressure Ulcer Incidence through Braden Scale Risk Assessment and Support Surface Use

Edward H. Comfort, PhD, is Executive Director at the National Decubitus Foundation, Aurora, CO. Submitted on July 5, 2006; 
accepted in revised form on April 17, 2007.


OBJECTIVE: To collect available evidence showing that some hospitals have been able to markedly reduce pressure ulcer incidence despite broad surveys in previous recent years that demonstrated little or no progress and to provide guidance to hospitals through analysis of the evidence showing incidence reduction to be expected by taking the measures indicated.

APPROACH: At the time of the article’s writing, a review of the literature was conducted using PubMed. References were sought that cited hospitals using the Braden Scale to identify at-risk patients and providing pressure-reducing surfaces to those found
to be at risk. Nine hospitals were so identified. Each hospital had reduced pressure ulcer incidence through risk assessment followed by intervention that included support surface provision. Statistical measures were used to establish confidence limits forthe noted improvements.

INTERVENTIONS: Each of the hospitals reviewed had implemented a policy of risk assessment of all admitted patients using the Braden Scale followed by implementation of best practices, generally including assignment of patients judged to be at risk to a pressure-reducing support surface.

MAIN OUTCOME MEASURES: Each hospital reported in the literature a rate of nosocomial prevalence, both before and after program implementation. All hospitals demonstrated improvement, although the amount of improvement varied widely.

MAIN RESULTS: Realizing that each of the hospitals reviewed started from different baselines, used different at-risk criteria, did not utilize the same support surface, and may have implemented a variety of additional interventions, it is perhaps not surprising that the 95% confidence interval for incidence oddsratio is broad, from 0.220 to 0.508 (meta-analysis), yet clearly significant. Cost savings due to reduced need for rental of expensive low-air-loss- or fluidized-bed therapy were reported.

CONCLUSIONS: Risk assessment of all admitted patients followed by provision of specialized support surfaces to all deemed to be at risk offers real hope of reducing the present very high rate of hospital-caused pressure ulcers. With the growing understanding that some pressure ulcers have their origin in deep tissue, it no longer makes sense to wait for the appearance of Stage I or II ulcers before taking action.


The past several years have seen an accumulation of evidence that pressure ulcer incidence in hospitals can be reduced markedly—in a number of cases nearly to zero—using risk assessment based on the Braden Scale. Several hospitals, cited in this article, have published results of internal studies demonstrating the benefits, including cost savings, of placing high-risk patients on specialized support surfaces upon admission, without waiting for Stage I or II pressure ulcers to develop. This study analyzes these results to arrive at a valid statistical measure of the incidence reduction to be expected by
hospitals undertaking to implement such a policy.

Pressure ulcers are a significant cause of death in hospitals,(1) although the recorded cause of death often disguises this fact. Redelings et al(1) conclude, ‘‘pressure ulcers are associated with fatal septic infections and are reported as a cause of thousands of deaths each year in the United States.’’ However, thesefigures are likely to be very low because, even in those cases where pressure ulcers were an important contributing factor, they are often unlikely to be listed as a cause of death.(1)

Despite the efforts of many people and organizations, the prevalence of pressure ulcers in hospitals remained unchanged at about 16% over a 6-year period from 1999 through 2004.2  The incidence of pressure ulcers in acute care facilities has varied between 7% and 9% over the same period.(2) During that 6-year period, about 70% of individuals developing new pressure ulcers were older than 65 years .(2)  The Braden Scale(3) was developed in 1988 as a means oF assessing the degree of risk of pressure ulcer development any individual patient faces. Six factors are considered: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. A score is assigned for each factor; factor scores can be added to arrive at a total score.

The US Department of Health and Human Services published the first edition of the Agency for Healthcare Research and Quality (AHRQ [formerly the Agency for Health Care Policy and Research, AHCPR]) Clinical Practice Guideline Number 3 in 1992.(4) This guideline, developed by the Panel for
the Prediction and Prevention of Pressure Ulcers in Adults, states that ‘‘individuals should be assessed on admission to acute care. . .using a validated risk assessment tool such as the Braden Scale. . . .’’(4)  The guideline further states, ’’Anyone assessed to be at risk should be placed on a pressure-reducing
device when lying in bed. . . .’’(4) Although relatively few hospitals have fully implemented these guidelines, this article describes the results obtained by those hospitals that have done so and have reported their results in the literature. 

 In addition to reducing pressure ulcer incidence, many facilities in the study were able to reduce costs because the support surfaces capable of preventing ulcers are far less expensive than those required(5) to facilitate healing once a Stage IV pressure ulcer has been allowed to develop.  Prevention is always the best approach.


An online literature search was conducted on PubMed, using keywords such as ‘‘Braden’’ and ‘‘support surface.’’ Those studies describing trials at acute care facilities that included factors of risk assessment and support surface assignment were selected. The outcomes achieved by the facilities identified during the literature search were reviewed. The summaries of results that follow do not, of course, include detailed data, analysis, or costs for each reported trial; cited references should be consulted for further information. Although some facilities presented results both including and excluding Stage I pressure
ulcers, the data inclusive of all pressure ulcers have been used here. Each of the studies included here reported on the effect of actions taken on the occurrence of hospital-caused pressure ulcers. Terminology differed among institutions, but the most common nomenclature used was nosocomial prevalence, referring to the number of ulcers found upon survey at a point in time that had not been present at admission. Nosocomial prevalence rate (incidence) refers to nosocomial ulcers divided by beds surveyed.

A 500-bed acute care facility in California(6) placed all admitted patients in its 44-bed AIDS/oncology unit on the ZoneAire(7) support surface (Hill-Rom Inc, Batesville, IN) during a 6-month trial in 1995. This was an initial trial to confirm the efficacy of the support surface. Monthly surveys on 9 occasions before the trial showed a total of 12 nosocomial ulcers. The incidence of ulcers during the trial period, which consisted of 7 monthly surveys from April 1995 through November 1995, and another unannounced survey in May 1996, was zero. Risk assessment tools were not used during the period of the study, but since
mid-1996, the Braden Scale evaluation has been used in the 500-bed hospital to determine which admitted patients are placed on the new beds. Purchase of the ZoneAire beds allowed an 83% reduction in rental costs for low-air-loss therapy.

A major university medical center(8) replaced its hospital beds at the end of 1995 and in early 1996. A newly available interface pressure-reducing support surface was chosen. In September 1996, after all of the new beds were in place, a survey of 262 patients found the rate of nosocomial ulcers to be 6%. This compares with rates of 19% and 21% in 2 preprotocol surveys (February 1992 and February 1995).

Another university hospital(9) conducted 1-day surveys of its 750-bed hospital in 1993, 1995, and 1997. The prevalence rate of nosocomial ulcers was 14% in 1993, 8% in 1995, and 6% (3% excluding Stage I) in 1997. Risk assessment based on the Braden Scale was introduced during the 1997 study for every hospitalized patient. Improved survey results were thought to be, at least in part, because ‘‘support surface selection criteria were developed and consistently applied, and the hospital purchased several pressure-relieving beds in order to reduce cost and ‘‘waiting times for rental beds.’’9

An acute care hospital in Hawaii implemented a program of risk assessment followed by support surface assignment in 1996.(10) The nosocomial pressure ulcer prevalence rate in this 159-bed acute care facility was found to be 31.4% (25.7% excluding Stage I) during a 1995 survey. During the first quarter
of 1996, the Braden Scale was implemented as the risk assessment tool of choice at the hospital. New ZoneAire pressure-reducing support surfaces were purchased. Those admitted patients who were judged to be at risk were placed on the beds. The nosocomial prevalence rate was reduced to 14.9% (5.9% excluding Stage I) in October 1996 and to 4.7% (1.5% excluding Stage I) in September 1997.(10)

 A Texas hospital(11) conducted the first in an annual series of pressure ulcer–prevalence surveys during 1996. This survey found the prevalence rate of hospital-acquired ulcers to be 18%, or 158 patients. Nosocomial prevalence rates dropped to 10%, or 183 patients, in 1997 and to 9%, or 157 patients, in 1998. Although the authors stated that risk assessment using the Braden Scale and a ‘‘specialty mattress/bed protocol’’ were in place before the 1996 survey, they speculated in this articlethat the designation of unit skin care resource nurses following that survey led to greater care and emphasis in the implementation of these practices.

A 500-bed hospital in Illinois(12) implemented the AHCPR Guidelines in 1998. Risk assessment through use of the Braden Scale was instituted. A measure of incidence was chosen as the preferred indicator of the effectiveness of prevention strategies to reduce nosocomial pressure ulcers. Data collection was
initiated through participation in the 1998 KCI/Novation National Prevalence and Incidence Study.(13) Because the average length of stay at this hospital was 4.8 days, a second survey was taken after 5 days to obtain the data needed to calculate incidence. After 1 year, pressure ulcer incidence decreased from 14% to 9%.

A teaching hospital in Georgia reported(14) the success of its wound care program in 1999. Prevention protocols, including the use of the ZoneAire support surfaces throughout the hospital, resulted in the reduction of the nosocomial prevalence rate from 16.5% to 3.5%. The reduction was from 9.5% to 1.2%
excluding Stage I ulcers. 

Young et al(15) described a successful attempt to reduce nosocomial pressure ulcer incidence at an 877-bed tertiary teaching hospital in Florida. The prevention program was initiated in January 2000. ‘‘The first and primary responsibility was to identify high-risk patients without pressure ulcers. At risk individuals were identified by the Braden Score.’’ During the 2000–2001 period, 97% of patients received an initial skin
assessment within 24 hours of admission. This project was successful in reducing the incidence of nosocomial ulcers between 1999 and 2001 by 55% including Stage I ulcers and by 50% when Stage I ulcers were excluded.

A 243-bed acute care medical center in Pennsylvania(16) replaced traditional foam mattresses throughout the hospital with a new support surface, Isoflex (Gaymar Industries Inc, Orchard Park, NY), designed to reduce pressure and shear. The hospital has a policy of assessing patient risk of developing
pressure ulcers using the Braden Scale upon admission. In 1999, an audit of 108 patients found the prevalence rate of nosocomial ulcers to be 5.5%. A similar audit of 128 patients in October 2000, 3 months after implementing the new support surfaces, found the prevalence rate of hospital-acquired
pressure ulcers to be 3.1%. The number of ulcers Stage II and above decreased dramatically from 8% to 2%.(16)


Each of the aforementioned hospitals undertook a program of risk assessment followed by action directed at all admitted patients as of a definite time. Although the key action undertaken was not exactly the same in all cases, for the most part, provision of a specialized support surface was involved.
Table 1 illustrates the nosocomial prevalence rate reported at each hospital before and after instituting such a program. 

Each of the studies identified by the initial literature review reported on a procedure whereby risk assessment of all admitted patients based on the Braden Scale was implemented at a point in time. Analysis of these results involves combining studies with much in common, but involving a wide range of patient populations. Meta-analysis is the statistical procedure that allows conclusions to be drawn by combining several similar studies. A weighted procedure gives more importance
to the results of large studies than to small ones.

Table 2 presents the results of meta-analysis of the 9 studies considered in this investigation. Columns designated ‘‘control’’ present survey results at each hospital before implementing risk assessment, whereas ‘‘treated’’ columns show nosocomial prevalence after risk assessment was in place. The key statistic presented is the odds ratio. The odds are the number of patients developing pressure ulcers divided by the number who did not. The odds ratio is then the odds ‘‘after’’ (treated) divided by the odds ‘‘before’’ (control). If the procedure being tested made no difference, the odds ratio would be 1.

The analysis was performed using the random-effects model, rather than the fixed-effects model, thus avoiding the restrictive assumption that if all studies considered were sufficiently large, then they would give the same results. The upper and lower limits on the odds ratio are presented at a confidence level of 95%. These limits do include the null value of 1 for 2 of the included studies, but the combined results give the odds ratio as falling between 0.220 and 0.508. Because these limits do not include the null value of 1, the procedure being tested is statistically significant at the 95% confidence level.


Table 1.

Study Name Year Action Taken Before After % Reduction

Santa Clara 1996 Support Surface 3.6   0.0 100
Stanford     1996 Support Surface       20    7     65
Allegheny           1997         Various, incl. Bed      8             6                    25
Straub                1996         Support Surface      31.4          4.7           85
Scott & White     1997         Support Surface      18             9                     50
Trinity                 1998         Guideline No. 3       14             9                     36
Robert Packer     1999         Support Surface        5.5          3.1                  44
Augusta              1998         Support Surface      16.5          3.5                  79
Tampa                2000         Best Practices         *              *                     55

*Data not provided.

The programs put in place by the hospitals discussed above were not precisely the same. Some placed more emphasis on providing specialized support surfaces to at-risk patients than did others, and some had more elements of a risk assessment program already in place when they conducted the ‘‘before’’ surveys than did others. These results indicate that hospitals that put in place a similar program can expect to reduce the odds that a patient will develop a pressure ulcer by somewhere between a factor of 2 and 5.


Clearly, all hospitals should be performing risk assessment on all admitted patients at the time of admission, and all patients found to be at risk should be immediately placed on a support surface that has been demonstrated to significantly reduce pressure ulcer incidence when an ulcer is not already present
(eg, ZoneAire). However, on an even more fundamental level, the results of such a risk assessment must be shared with the patient and the patient’s family. The risk of pressure ulcer development in hospitals is very high, especially for older adults.

The Federal Centers for Medicare and Medicaid Services announced in August 2007 that as of October 2008 it will no longer reimburse hospitals for treating 8 ‘‘reasonably preventable’’ conditions if absent at admission. Pressure ulcers are among the most prevalent on the list. Hospitals therefore have significant financial incentive to take every possible step to prevent pressure ulcers. 

At-risk patients and their families must be advised of the importance of frequent repositioning, good nutrition, and avoidance of friction and shear before any sign of a pressure ulcer develops.

The support surface may not need to be an expensive high technology design to achieve promising results. Xakellis et al,(17) working at a 77-bed long-term care facility to implement the AHRQ guidelines,(4) provided inexpensive 2- and 4-in foam overlays to those patients determined to be at risk based on
Braden Scale assessment. They used a staged approach providing overlay alone, turning schedule alone (none had been in place before protocol implementation), or both turning schedule and overlay, depending on the level of risk identified. This approach was successful in reducing the 6-month
incidence rate from 23% preprotocol (16 of 69) to 5% postprotocol (3 of 63).

The National Pressure Ulcer Advisory Panel (NPUAP) convened a consensus conference in 2005 to deal with the issue of deep tissue injury.(18) One stated conclusion was that ‘‘deep tissue injury due to pressure exists as a form of pressure ulcer and is not well captured by current staging.’’ Following this conference, in February 2007 the NPUAP added 2 stages to the original 4. One of these is labeled, ‘‘Suspected Deep Tissue Injury.’’

An engineering text,(19) based on analysis of stress distribution in the vicinity of a bony prominence, concludes, ‘‘Therefore, pressure sores likely begin in the deep tissue.’’


Realization that most, if not all, pressure wounds have their origin in deep tissue explains why the practice followed by most hospitals of providing a specialty support surface only after the appearance of Stage I or II indicators has so often met with failure. Clearly, the only policy with any hope for success
must include the provision of pressure-reducing support surfaces to all at-risk patients at admission, before the appearance of any pressure wound indicator. This article has demonstrated that such a policy significantly reduces pressure ulcer incidence in hospitals.

Table 2.

Study Name  Control   Control   Treated   Treated   Odds     Lower    Upper
                    Total N     PrU      Total N    PrU        Ratio     Limit      Limit
Santa Clara     334         12          291       0           0.044     0.003    0.751
Stanford          311         62          262      18          0.252     0.156    0.407
Allegheny        331         25          315      19          0.753     0.408    1.390
Straub              34         12          127        6          0.091     0.031    0.268
Scott & White 158          28          157      14          0.455     0.229    0.901
Trinity*            330         46           330      30          0.617     0.379   1.006
Robert Packer 108         15           128        7          0.359     0.141   0.915
Augusta*         404         67           404     14           0.181     0.100   0.327
Tampa*           579         52y         579      23           0.419     0.253   0.695
Combined  0.335     0.220   0.508

*Population (N) calculated based on capacity and average occupancy rates.
yCalculated based on average incidence of 9%.(2)

1. Redelings M, Lee N, Sorvillo F. Pressure ulcers: more lethal than we thought? Adv Skin
Wound Care 2005;18:367-72.
2. Whittington K, Briones R. National prevalence and incidence study: 6-year sequential
acute care data. Adv Skin Wound Care 2004;17:490-4.
3. Braden BJ, Bergstrom N. Clinical utility of the Braden Scale for predicting pressure sore
risk. Decubitus 1989;2:44-51.
4. Panel on the Prediction and Prevention of Pressure Ulcers in Adults. Pressure Ulcers
in Adults: Prediction and Prevention. Clinical Practice Guideline, No. 3. AHCPR
Publication No. 92-0047. Rockville, MD: Agency for Health Care Policy and Research;
May 1992.
5. Comfort EH. Support surfaces for bedsore healing: correlation of engineering analysis
with clinical results. Presented at the 14th Annual Clinical Symposium on Wound Care;
September 30 to October 4, 1999; Denver CO. Poster 73.
6. Jacksich BB. Pressure ulcer prevalence and prevention of nosocomial development: one
hospital’s experience. Ostomy Wound Manage 1997;43:32-40.
7. Hill-Rom Corp. ZoneAire sleep surface: system performance evaluation. Batesville, IN;
Hill-Rom Corp. 1997.
8. Gamboa B, Moore SM. Hospital and Industry Collaborate to Share Risk and Improve
Patient Outcomes. Stanford University Medical Center; 1997.
9. O’Brien SP, Wind S, van Rijswijk L, et al. Sequential biannual prevalence studies of
pressure ulcers at Allegheny-Hahnemann University Hospital. Ostomy Wound Manage
10. Kaalakea G, Jackson D. Preventing nosocomial pressure ulcers: a ZoneAire sleep surface
success story. Batesville, IN: Hill-Rom CLS004. 1998.
11. Hopkins B, Hanlon M, Yauk S, et al. Reducing nosocomial pressure ulcers in an acute
care facility. J Nurs Care Qual 2000;14:28-36.
12. Robinson C, Gloeckner M, Bush S, et al. Determining the efficacy of a pressure ulcer
prevention program by collecting prevalence and incidence data: a unit-based effort.
Ostomy Wound Manage 2003;49:44-51.
13. Whittington K, Patrick M, Roberts JL. A national study of pressure ulcer prevalence
and incidence in acute care hospitals. J Wound Ostomy Continence Nurs
14. Butts PM, Wiggins WC, Blackburn RH, et al. Wounds that heal: a comprehensive
interdisciplinary wound care program. Presented at the 14th Annual Clinical
Symposium on Wound Care; September 30 to October 4, 1999; Denver, CO.
Poster 17.
15. Young ZF, Evans A, Davis J. Nosocomial pressure ulcer prevention: a successful project.
J Nurs Adm 2003;33:380-3.
16. Stewart S, Box-Panksepp JS. Preventing hospital-acquired pressure ulcers: a point
prevalence study. Ostomy Wound Manage 2004;50:46-51.
17. Xakellis GC Jr, Frantz RA, Lewis A, et al. Cost-effectiveness of an intensive pressure
ulcer prevention protocol in long-term care. Adv Wound Care 1998;11:22-9.
18. Black JM, NPUAP. Moving toward consensus on deep tissue injury and pressure ulcer
staging. Adv Skin Wound Care 2005;18:415-21.
19. Webster, JG. Prevention of Pressure Sores—Engineering and Clinical Aspects. New York,
NY: Adam Hilger; 1991:32.
Back to Top of Page


​Combating pressure injuries with innovative technology
August 15, 2017 by Julie Thurn, RN, BSN

If you have ever known someone with a pressure injury, commonly known as a pressure sore or pressure ulcer, you know how miserable they can be. As the director of skilled nursing facility clinical practice, I know many residents arriving from hospitals who are not yet ready to go home because they need rehabilitation or other skilled nursing services.

Pressure injuries affect 2.5 million residents, lead to 60,000 deaths and cost $9 to $11.6 billion per year in the U.S., according to the Agency for Healthcare Research and Quality. Moreover, pressure injuries are painful and detrimental to patient quality of life.

People who acquire pressure injuries face an average of five extra days in the hospital, according to the national Medicare Patient Safety Monitoring System Study. The study also shows 22 percent are readmitted to the hospital within 30 days of discharge.

Typically, pressure injuries are seen on a bony part of the body and are the result of not just pressure, but also friction; shear, when skin is pulled in one direction and tissue beneath is pulled in another; and microclimate, a combination of temperature and moisture. People who spend much of the day in bed or sitting are at increased risk of developing a pressure injury.

Anti-friction technology
One of our main objectives at Augustana Care is to reduce the incidence of pressure injuries and help residents heal faster should they acquire these injuries. Nurses can use a number of tools to treat pressure injuries, including one known as GlideWear. Augustana Care began collaborating with Tamarack Habilitation Technologies, the maker of GlideWear, almost three years ago.

Initially, Tamarack brought a friction management technology to us in the form of a specially-designed sock made with low-friction fabric. Their product line has grown to include socks, wheelchair cushion and headrest covers, undergarments and prosthetic liner patches. The products utilize a patented, dual-layer strategic friction management fabric technology. Friction is equal to 0.18, roughly the same as a car tire on slick ice at minus-40 degrees Fahrenheit.

Recently, our rehabilitation nurses used GlideWear for a woman whose hips, thighs, buttocks and chest had been burned in the shower. She could barely get out of bed and cried out in pain when she tried to sit up. She had to take pain medication every four hours just to be able to tolerate her situation.

The woman began wearing the shorts and, after a while, began coming out of her room and sitting in the dining room with others. Her need for pain medication decreased as well. Nurses told me that when she returned home, she sent a thank you note expressing gratitude for the help she received. I was very happy to learn her condition had improved.

Another gentleman who was quadriplegic came to us initially with nine pressure injuries. The Tamarack team created several custom-made pieces for him, which helped the wounds on his feet, sacrum and hip area heal faster than we expected.

Other tools to combat pressure injuries

At Augustana Care, we conduct a comprehensive skin evaluation using a measurement called the Braden scale, which assigns a numeric value to risk of skin damage. Physical and occupational therapists assist in assessing the risks residents face, and staff are trained to conduct assessments so they can spot problem areas quickly. I would highly recommend using the Braden scale to any healthcare workers who may be dealing with pressure injuries.

Following an individualized and comprehensive skin assessment, common risk reduction strategies include:

Positioning off at-risk areas
Keeping skin clean and dry
Refraining from vigorously massaging or rubbing areas at risk of pressure injury as friction can cause tissue damage and deterioration
Maintaining or restoring continence levels
Reducing excessive exposure to moisture for a specific area
Keeping the patient hydrated and the skin moisturized with emollients
We may ask our wound care team to follow the residents to see what exactly may be causing a pressure injury. An in-house dietician also looks at residents to determine nutritional status. In addition, we use pressure relief mattresses that alternate air pressure on the surface of beds in skilled nursing and rehabilitation areas.

The most important part when dealing with pressure injuries is prevention. Our efforts are focused on the healing process, and the comments and feedback we have received to date are telling us we are on the right track