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-
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."
Reducing Pressure Ulcer Incidence through Braden Scale Risk Assessment and Support Surface Use
ADVANCES IN SKIN & WOUND CARE
VOL. 21 NO. 7 WWW.WOUNDCAREJOURNAL.COM
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.
NOSOCOMIAL PRESSURE ULCER PREVALENCE RATE BEFORE AND AFTER PROGRAM IMPLEMENTATION
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.
META-ANALYSIS OF PRESSURE
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;
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.
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.