Pressure Ulcers and Prevention Among Acute Care Hospitals in the United States

The Joint Commission Journal on Quality and Patient Safety Adverse Events

Pressure Ulcers and Prevention Among Acute Care Hospitals in the United States Sandra Bergquist-Beringer, PhD, RN, CWCN; Lei Dong, MS; Jianghua He, PhD; Nancy Dunton, PhD, FAAN

H

ospital-acquired pressure ulcers are a known problem in acute care facilities and the focus of national policy and patient safety initiatives within the United States. Pressure ulcers reduce patient quality of life,1 are associated with higher in-hospital mortality,2,3 and contributed $1.99 billion in excess health care costs for Medicare patients between 2007 and 2009.4 Efforts to prevent pressure ulcers have intensified during the past decade through programs such as the Institute for Healthcare Improvement’s (IHI) 5 Million Lives Campaign to protect patients from harm5; the selection of pressure ulcers as a National Patient Safety Goal by The Joint Commission (for long term care)6; the implementation of the Centers for Medicare & Medicaid (CMS) nonpayment policy for hospital-acquired conditions, including stage III and IV pressure ulcers7; and the inclusion of pressure ulcers in the Partnership for Patients initiative to improve the safety of hospital care.8 Updated clinical practice guidelines on pressure ulcer prevention from the National Pressure Ulcer Advisory Panel (NPUAP)/European Pressure Ulcer Advisory Panel and the Wound, Ostomy and Continence Nurses Society were also published.9,10 These guidelines provide evidence-based recommendations for practice that include a skin and pressure ulcer risk assessment on admission, regular reassessment of pressure ulcer risk, and interventions to minimize patient risk, such as regular skin assessment, support surface use, routine repositioning, nutritional support, and skin moisture management. More recently, “Multicomponent interventions to reduce pressure ulcers” was 1 of the 10 patient safety strategies strongly encouraged, on the basis the evidence, “for adoption now.”11 The literature contains myriad studies on pressure ulcer prevention, many of which describe the implementation of interventions to prevent pressure ulcers in acute care facilities. Three recent reviews found that the majority of these studies reported a positive effect of the intervention(s) on pressure ulcer outcomes such as lower pressure ulcer incidence or nosocomial pressure ulcer rates.12–14 However, most were single-hospital studies. Fur404

Article-at-a-Glance Background: Most pressure ulcers can be prevented with

evidence-based practice. Many studies describe the implementation of a pressure ulcer prevention program but few report the effect on outcomes across acute care facilities. Methods: Data on hospital-acquired pressure ulcers and prevention from the National Database of Nursing Quality Indicators® 2010 Pressure Ulcer Surveys were linked to hospital characteristics and nurse staffing measures within the data set. The sample consisted of 1,419 hospitals from across the United States and 710,626 patients who had been surveyed for pressure ulcers in adult critical care, step-down, medical, surgical, and medical/surgical units. Hierarchical logistic regression analysis was performed to identify study variables associated with hospital-acquired pressure ulcers among patients at risk for these ulcers. Results: The rate of hospital-acquired pressure ulcers was 3.6% across all surveyed patients and 7.9% among those at risk. Patients who received a skin and pressure ulcer risk assessment on admission were less likely to develop a pressure ulcer. Additional study variables associated with lower hospital-acquired pressure ulcer rates included a recent reassessment of pressure ulcer risk, higher Braden Scale scores, a recent skin assessment, routine repositioning, and Magnet or Magnet-applicant designation. Variables associated with a higher likelihood of hospital-acquired pressure ulcers included nutritional support, moisture management, larger hospital size, and academic medical center status. Conclusions: Results provide empirical support for pressure ulcer prevention guideline recommendations on skin assessment, pressure ulcer risk assessment, and routine repositioning, but the 7.9% rate of hospital-acquired pressure ulcers among at-risk patients suggests room for improvement in pressure ulcer prevention practice.

September 2013 Volume 39 Number 9 Copyright 2013 © The Joint Commission

The Joint Commission Journal on Quality and Patient Safety ther, the relationship between each intervention in a multifaceted prevention program and the outcome were not examined.12 Few of the studies measured the effect on care processes12–14 such as the percentage of patients who received a skin assessment within 24 hours of admission. Nor were these effects uniformly reported,13 limiting comparison across studies. Moreover, nurse staffing and other organizational characteristics that might influence the success of the prevention interventions were not evaluated.13 The National Database of Nursing Quality Indicators® (NDNQI®) is the largest nursing quality registry in the United States15 from which pressure ulcer prevention performance and its influence on pressure ulcer outcomes can be examined.* The database was established by the American Nurses Association in 1998 with twin goals: (1) to provide participating hospitals with unit-based data and comparative information on patient outcome indicators, including pressure ulcers, for use in quality improvement activities; and (2) to develop a data repository for research related to the impact of nurse staffing on these outcomes.16,17 Participation in the NDNQI is voluntary and supported by membership fees. As of January 2013, the NDNQI received data from 1,909 hospitals in the United States and 17 hospitals outside the United States.18 For this study, only hospitals in the United States are considered. Development of the NDNQI was based on Donabedian’s quality framework,19 which posits that the structure and processes of care influence patient outcomes.20 The NDNQI began collecting data on pressure ulcer processes of care in 2000–2001 with select items on pressure ulcer risk assessment. Additional process-of-care measures were added in 2003, 2007, and 2009, and existing items were revised. The full set of process measures now includes eight items on pressure ulcer risk assessment and six items on pressure ulcer prevention interventions. Importantly, the NDNQI database contains uniform information on patient pressure ulcer risk and prevention interventions from numerous nursing units, which can be linked to structural measures within the data set, such as hospital bed size and nurse staffing, and to pressure ulcer outcomes. The purpose of this study was (1) to examine the frequency of pressure ulcer risk assessment and prevention interventions among patients at risk for pressure ulcers in NDNQI–participating hospitals, and (2) to identify patient pressure ulcer risk assessment and prevention interventions, hospital characteristics, and nurse staffing measures associated with hospital-acquired * The NDNQI is a program of the American Nurses Association’s (ANA) National Center for Nursing Quality. The program is being administered on ANA’s behalf by the University of Kansas School of Nursing.

pressure ulcers. The study also describes the rate of hospital-acquired pressure ulcers for first through fourth quarters in 2010 to extend our report of 2010 rates published in the NPUAP 2012 monograph Pressure Ulcers: Prevalence, Incidence, and Implications for the Future,21 which was limited to the first and second quarters.

Methods STUDY DESIGN This was a retrospective study using first- through fourthquarter 2010 data on patient pressure ulcers and prevention, hospital characteristics, and nurse staffing from NDNQI–participating hospitals in the United States. The year 2010 was selected for analysis because this was the last year for which full data were available at the time of extraction.

DATA ON PRESSURE ULCERS NDNQI data on patient pressure ulcers included the number and category/stage of hospital-acquired pressure ulcers, assessment of pressure ulcer risk, and interventions to prevent pressure ulcers. The data for these measures were gathered quarterly by trained nursing staff located at each NDNQI hospital during a cross-sectional survey (NDNQI Pressure Ulcer Survey) that was performed on a single day. Categorization and Staging of Identified Pressure Ulcers. The skin of patients on each participating unit was visually examined during the NDNQI Pressure Ulcer Survey. Pressure ulcers detected were categorized/staged using NPUAP criteria,9 then classified as hospital-acquired or community-acquired. A pressure ulcer was determined to be hospital-acquired when review of the patient’s medical record revealed no documentation of the pressure ulcer on admission to the facility. To improve the accuracy of data on hospital-acquired pressure ulcers, NDNQI guidelines stipulate that nursing staff be trained in pressure ulcer identification and staging prior to survey procedures.22 An educational program was developed by the NDNQI to facilitate this training and released online. Modules within the educational program are updated routinely and freely available to anyone for review.23 Reliability studies on NDNQI pressure ulcer data found that nurses had moderate to near perfect reliability in pressure ulcer identification and staging.24,25 Participating hospitals are also encouraged to confirm acceptable interreliability of pressure ulcer identification and staging among their survey team members at least annually. Pressure Ulcer Risk and Prevention. Specific measures of pressure ulcer risk assessment included patient skin assessment on admission (yes/no), patient pressure ulcer risk assessment on ad-

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The Joint Commission Journal on Quality and Patient Safety mission (yes/no), time since the last pressure ulcer risk assessment, which is an estimate of the frequency of pressure ulcer risk reassessments, and the total Braden Scale26 score on last assessment. These data were captured by chart review during the NDNQI Pressure Ulcer Survey. Time since the last risk assessment was dichotomized for the analysis (> 0 hours to 24 hours or > 24 hours to 1 week) on the basis of the IHI recommendation that hospitalized patients be reassessed for pressure ulcer risk as least daily.5 Measures of prevention interventions consisted of daily skin assessment, pressure-redistribution surface use, routine repositioning, nutritional support, and moisture management. Routine repositioning was defined as the time interval for patient repositioning/turning identified in the patient plan of care or in unit policy for at-risk patients. Nutritional support referred to the provision of oral, parenteral, or enteral nutrition as recommended by clinical practice guidelines for pressure ulcer prevention.9,10 Moisture management was defined as actions performed to protect patient skin from excessive moisture or dryness. Intervention use during the 24-hour period before the NDNQI Pressure Ulcer Survey was determined from review of documentation in the patient record. The response options for these intervention measures are unique to the NDNQI and include “yes” and “no,” as well as “documented contraindication,” “unnecessary for patient,” and “patient refused,” which were added to improve the validity of the yes/no responses and quantify situations that may make the pressure ulcer unavoidable.

DATA ON HOSPITAL CHARACTERISTICS AND NURSE STAFFING Data on hospital characteristics and nurse staffing were studied because effective pressure ulcer prevention is influenced by the organizational culture and operational practices that promote these practices.27 NDNQI data on hospital characteristics included hospital size, which was defined as the total number of staffed beds in the hospital; Magnet status; and teaching status. Magnet status recognizes hospitals that achieved Magnet designation by the American Nurses Credentialing Center relative to applicants for this designation and non-Magnet hospitals. Hospitals self-classify as an academic medical center if the facility is the primary clinical site for a school of medicine, a teaching hospital if the facility has medical interns or residents, or a nonteaching hospital.22 Measures of nurse staffing included registered nurse (RN) hours per patient day and RN skill mix, which was defined as the percentage of total nursing hours provided by RNs.

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DATA ANALYSIS The analysis of the first through fourth quarter 2010 NDNQI data on pressure ulcers, hospital characteristics, and nurse staffing was limited to adult critical care, step-down, medical, surgical, and medical/surgical units (the studied units) for comparison with previous analysis.21 Most of the pressure ulcer data are submitted by these units, and at least 90% of the patients on each unit receive the level of care appropriate to the unit type by definition in NDNQI guidelines for participation.22 Descriptive statistics were used to summarize the data on patient pressure ulcer risk assessment and prevention interventions, hospital characteristics, and nurse staffing. The rate of hospitalacquired pressure ulcers among all surveyed patients was defined as the proportion of patients with a hospital-acquired pressure ulcer in the studied units among all patients surveyed in these units. The rate of hospital-acquired pressure ulcers among patients at risk for pressure ulcers (at-risk patients) was defined as the proportion of at-risk patients with a hospital-acquired pressure ulcer in the studied units among all at-risk patients surveyed in these units. Hierarchical logistic regression models were constructed with SAS 9.2 (SAS Institute, Inc., Cary, North Carolina) using the GLIMMIX procedure to estimate the odds ratio (OR), 95% confidence interval (CI), and statistical significance (p < .05) for a hospital-acquired pressure ulcer among at-risk patients (n = 282,500). Hierarchical logistic regression analysis takes into account the nested nature of patients within units and units within hospitals to generate inferences.28 Three models were constructed so that each subsequent model added a set of measures to those included in the previous model, as follows: ■ Model 1 included patient-level data on pressure ulcer risk assessment and prevention interventions. ■ Model 2 added hospital-level data on hospital size, Magnet status, and teaching status. ■ Model 3 added unit-level data on nurse staffing. Both RN hours per patient-day and RN skill mix were centered at their mean by unit type for the analysis to control for the possible confounding between nurse staffing measures and unit type.

Results DESCRIPTION OF THE SAMPLE Nearly one quarter of all hospitals in the United States29 participated in the NDNQI Pressure Ulcer Surveys during 2010 (N = 1,419 participating hospitals). Hospital distribution by size, teaching status, and Magnet status (Table 1, page 407) was similar to the first and second quarter 2010 results.21 Data from

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The Joint Commission Journal on Quality and Patient Safety Table 1. Hospital Characteristics and Nurse Staffing Measures* n

Hospital Characteristics (N = 1,419 Hospitals)

Percentage of 1,419 Hospitals

Hospital Size (# of staffed beds)† < 100

300

21.1

100–199

411

29.0

200–299

286

20.2

300–399

191

13.5

400–499

109

7.7

> 500

122

8.6

Academic medical center

149

10.5

Teaching

482

34.0

Non-teaching

788

55.5

Magnet

326

23.0

Magnet-applicant

255

18.0

Non-Magnet

838

59.1

RN Hours per Patient Day Mean (SD)

RN Skill Mix Mean Percentage (SD)

All units

8.48 (4.37)

74.1 (13.3)

Critical care units

15.33 (2.73)

90.4 (7.1)

Step-down units

7.73 (1.96)

74.2 (9.9)

Medical units

5.84 (1.69)

66.7 (10.1)

Surgical units

6.09 (1.44)

68.3 (9.5)

Medical/Surgical units

5.94 (1.55)

67.6 (10.0)

Type

Magnet Status†

Nurse Staffing Measures (N = 10,261 Nurses)

* RN Skill Mix, percentage of all nursing hours supplied by registered nurses; SD, standard deviation. †

Because of rounding, percentages may total > 100%.

10,405 hospital units were analyzed. Nursing hours on these units were largely supplied by RNs—up to 90.4% in critical care units. Mean RN hours per patient-day ranged from 5.84 in medical units to 15.33 in critical care units. A total of 710,626 patients were surveyed for pressure ulcers in the studied units. Like our previous findings,21 52.0% of the patients were female, and 63 years old on average (standard deviation [SD] = 17.65).

units (2.6%). Quarterly variations were also observed. The rate of hospital-acquired pressure ulcers was 4.0% in Quarter 1, 3.6% in Quarter 2, 3.5% in Quarter 3, and 3.5% in Quarter 4. The 25,928 patients with a hospital-acquired pressure ulcer had 36,758 pressure ulcers. The distribution of pressure ulcers by category/stage is shown in Table 2 (page 408).

RATE OF HOSPITAL-ACQUIRED PRESSURE ULCERS, HOSPITAL-ACQUIRED PRESSURE ULCER RATES AMONG PRESSURE ULCER RISK ASSESSMENT, AND PREVENTION ALL SURVEYED PATIENTS INTERVENTIONS AMONG PATIENTS AT RISK FOR The rate of hospital-acquired pressure ulcers among all sur- PRESSURE ULCERS veyed patients was 3.6% (n = 25,928 patients). Exclusion of known pressure ulcers under nonremovable dressings that could not be staged and mucosal pressure ulcers that should not be staged30 reduced this proportion by another 0.1%. Hospital-acquired pressure ulcers rates were highest in critical care units (8.1%) relative to step-down units (3.7%), medical units (3.1%), surgical units (2.4%), and medical/surgical

Nearly 40% of the 710,626 patients surveyed were determined to be at risk for pressure ulcers (n = 282,500 from 1,407 hospitals) on the basis of the last Braden Scale score (90.5%) or other clinical factors (9.5%). The overall rate of hospital-acquired pressure ulcers among at-risk patients was 7.9%. When known pressure ulcers under nonremovable dressings that could not be staged and mucosal pressure ulcers that should not be

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The Joint Commission Journal on Quality and Patient Safety Table 2. Distribution of Hospital-Acquired Pressure Ulcers by Category/Stage Among Patients in NDNQI–Participating Hospitals During 2010* All Surveyed Patients (% of 36,758 Pressure Ulcers)†

Patients at Pressure Ulcer Risk (% of 31,998 Pressure Ulcers)‡

Stage I

27.9

26.2

Stage II

41.8

42.2

Stage III

4.5

4.7

Stage IV

1.8

2.0

Unstageable

10.3

10.9

sDTI

12.1

12.4

Under nonremovable dressing, mucosal

1.6

1.6

Category/Stage

* sDTI, suspected deep tissue injury. †

The 25,928 patients with a hospital-acquired pressure ulcer had 36,758 pressure ulcers.

‡

The 22,295 patients with a hospital-acquired pressure ulcer had 31,998 pressure ulcers.

staged30 were removed from this count, the rate of hospital-acquired pressure ulcers was 7.7%. The 22,295 patients with a hospital-acquired pressure ulcer had 31,998 pressure ulcers. Their distribution by category/stage was similar to the distribution observed for all surveyed patients (Table 2). Most of the 282,500 patients who were at risk for pressure ulcers had received timely admission skin and pressure ulcer risk assessments, suggesting that these evaluations have been integrated into usual routines and practices. Specifically, 92.9% of at-risk patients received a skin assessment, and 92.6% of at-risk patients received a pressure ulcer risk assessment within 24 hours of admission. A similar 94.2% were reassessed for pressure ulcer risk during the 24-hour period before the NDNQI Pressure Ulcer Survey. The average Braden Scale score on last assessment was 15.24 (n = 255,928 patients with Braden Scale scores; SD = 2.82); the median score was 16. When classified by Braden Scale risk level,31 2.7% of the 255,928 patients in our study with Braden Scale scores had a score of 9 or less, indicating that they were at very high risk for pressure ulcers, 14.8% had a score of 10 to 12 (high risk); 20.0% had a score of 13 to 14 (moderate risk); 55.0% had a score of 15 to 18 (mild risk); and 7.5% had a score of 19 to 23 (no risk). The frequency of interventions to prevent pressure ulcers varied among at-risk patients. More precisely, 89.6% of at-risk patients received a skin assessment for pressure ulcers during the 24-hour period before the NDNQI Pressure Ulcer Survey; 1.2% did not (Table 3, page 409). For 117 patients (0.04%), this intervention was not performed because of a documented contraindication. However, contextual data to explain the contraindication were not available for study analysis. A pressure-redistribution surface was in use for 81.8% of at-risk pa408

tients. For 7,791 patients (2.8%), a pressure-redistribution surface was deemed unnecessary for the patient, implying that this intervention was considered for implementation but, on review of the patient’s risk factors, it was determined the intervention was not needed. Approximately 75% of at-risk patients (76.8%) were routinely repositioned during the 24-hour period before the NDNQI Pressure Ulcer Survey; however, activities to manage moisture were performed for just 64.8% of these patients. Only 56.3% of at-risk patients received nutritional support; 19.1% did not. The proportion of patients who refused one or more of these interventions was very small (0.1%–0.4%).

PRESSURE ULCER RISK ASSESSMENT AND PREVENTION INTERVENTIONS, HOSPITAL CHARACTERISTICS, AND NURSE STAFFING MEASURES ASSOCIATED WITH HOSPITAL-ACQUIRED PRESSURE ULCERS AMONG AT-RISK PATIENTS Hierarchical regression modeling of pressure ulcer risk assessment and prevention interventions associated with hospital-acquired pressure ulcers (Model 1) revealed that patients who received a skin assessment on admission (OR = 0.73, CI = 0.65 to 0.83) or a pressure ulcer risk assessment on admission (OR = 0.80, CI = 0.72 to 0.90), or were reassessed for pressure ulcer risk during the 24 hours before the NDNQI Pressure Ulcer Survey (OR = 0.85, CI = 0.80 to 0.90) were less likely to develop a pressure ulcer (Table 4, page 410). The odds of a hospital-acquired pressure ulcer decreased 12% for each 1-point increase in the total Braden Scale score (OR = 0.88, CI = 0.88 to 0.89). Daily skin assessment (OR = 0.81, CI = 0.71 to 0.91) and routine repositioning (OR = 0.85, CI = 0.81 to 0.90) were also associated with lower likelihood of hospital-acquired pressure

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The Joint Commission Journal on Quality and Patient Safety Table 3. Pressure Ulcer Prevention Interventions Among At-Risk Patients at Risk for Pressure Ulcers (N = 282,500) Frequency by Response Option (%) Type of Prevention Intervention

Yes

No

Documented Contraindication

Daily skin assessment*

253,045 (89.6)

3,527 (1.2)

117 (0.04)

Pressure-redistribution surface use†

231,209 (81.8)

22,690 (8.0)

272 (0.1)

Routine

repositioning‡

Unnecessary for Patient

Patient Refused

7,791 (2.8)

292 (0.1)

216,972 (76.8)

23,032 (8.2)

653 (0.2)

19,277 (6.8)

989 (0.4)

Nutritional support§

159,033 (56.3)

53,979 (19.1)

3,983 (1.4)

31,524 (11.2)

521 (0.2)

Moisture management||

183,154 (64.8)

28,457 (10.1)

316 (0.1)

32,367 (11.5)

181 (0.1)

* Missing data on 25,811 patients (9.1%). † Missing ‡

data on 20,246 patients (7.2%).

Missing data on 21,577 patients (7.6%).

§

Missing data on 33,460 patients (11.8%).

||

Missing data on 38,025 patients (13.5%).

ulcers. Interestingly, patients for whom pressure-redistribution surface use, routine repositioning, nutritional support, or moisture management were deemed unnecessary had lower hospitalacquired pressure ulcer rates, suggesting that nurses appropriately identified needless interventions. Prevention interventions significantly associated with higher hospital-acquired pressure ulcer rates included nutritional support (OR = 1.59, CI = 1.52 to 1.66) and moisture management (OR = 1.09, CI = 1.03 to 1.15). Patients for whom daily skin assessment was contraindicated (OR = 2.60, CI = 1.50 to 4.49) and those who refused repositioning (OR = 1.76, CI = 1.43 to 2.15) were also more likely to have a hospital-acquired pressure ulcer. The odds of a hospital-acquired pressure ulcer for pressure ulcer risk assessment and prevention interventions remained remarkably stable when hospital characteristics (Model 2) and nurse staffing measures (Model 3) were added to the regression analysis. In the fully adjusted model (Model 3), the likelihood of pressure ulcer development was significantly higher among larger hospitals (OR = 1.08, CI = 1.06 to 1.09) and academic medical centers relative to nonteaching hospitals (OR = 1.25, CI = 1.18 to 1.31). In contrast, the likelihood of hospital-acquired pressure ulcers was significantly lower in Magnet hospitals (OR = 0.68, CI = 0.65 to 0.71) and those applying for Magnet status (OR = 0.73, CI = 0.70 to 0.77) when compared with non-Magnet hospitals. RN hours per patient-day and RN skill mix were not associated with hospital-acquired pressure ulcers after controlling for all other variables in the model.

Discussion In this study, we investigated the rate of hospital-acquired pres-

sure ulcers for the first through fourth quarters in 2010 and the frequency of pressure ulcer risk assessment and prevention interventions in a large sample of NDNQI–participating hospitals from across the United States and examined their relationships, including nurse staffing measures. Our reported hospital-acquired pressure ulcer rate of 3.6% among all surveyed patients in adult critical care, step-down, medical, surgical, and medical/surgical units is lower than the 3.8% for the first and second quarters of 2010 and the 6.5% rate for 2006–2007 (fourth and first quarters) found in previous analysis of NDNQI data from these unit types.21 Seasonal variations in hospital-acquired pressure ulcers with higher first-quarter rates were also observed and likely explain the difference between the 3.6% rate for all four quarters in 2010 and the 3.8% rate for the first and second quarter only. Seasonality in hospital-acquired pressure ulcer rates was also reported by He et al.,32 with winter months (January–March) being highest and summer months (July–September) being lowest during 2004–2008. Although the magnitude of these fluctuations diminished after 2008 as hospitalacquired pressure ulcers decreased, the first-quarter rates during 2009–2011 remained higher than the other quarters for reasons that have yet to be elucidated but may be related to seasonal variations in patient volume and acuity relative to nurse staffing levels.32 The overall downward trend in facility-acquired pressure ulcers since 2006–2007 was noted in other large database studies that compared these rates over time. Data from the 2006–2009 International Pressure Ulcer Prevalence Surveys showed that facility-acquired pressure ulcer rates among hospitals in the United States decreased from 6.4% in 2006 and 2007 to 5.0% in 2009.33,34 Among acute care facilities participating in the Collab-

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The Joint Commission Journal on Quality and Patient Safety Table 4. Pressure Ulcer Risk Assessment and Prevention Interventions, Hospital Measures, and Nurse Staffing Measures Associated with Hospital-Acquired Pressure Ulcers Among At-Risk Patients in NDNQI–Participating Hospitals*

Measures Risk and Prevention Interventions Skin assessment on admission Risk assessment on admission Risk reassessment in last 24 hours Last Braden Scale score Daily skin assessment Yes Documented contraindication Pressure-redistribution surface use Yes Documented contraindication Unnecessary for patient Patient refused Routine repositioning Yes Documented contraindication Unnecessary for patient Patient refused Nutritional support Yes Documented contraindication Unnecessary for patient Patient refused Moisture management Yes Documented contraindication Unnecessary for patient Patient refused Hospital Characteristics Bed size (no. of staffed beds) Teaching status Academic medical center Teaching hospital Magnet status Magnet Magnet-applicant Nurse Staffing Measures RN hours per patient-day RN skill mix

Model 1. Risk and Model 2. Risk and Prevention Prevention Interventions, and Interventions† Hospital Characteristics‡ Odds 95% CI P Value|| Odds 95% CI P Value||

Model 3. Risk and Prevention Interventions, Hospital Characteristics, and Nurse Staffing§ Odds 95% CI P Value||

0.73 0.80 0.85 0.88

(0.65–0.83) (0.72–0.90) (0.80–0.90) (0.88–0.89)

< .001 < .001 < .001 < .001

0.75 0.82 0.88 0.88

(0.67–0.85) (0.73–0.91) (0.83–0.94) (0.88–0.89)

< .001 < .001 < .001 < 001

0.76 0.82 0.87 0.88

(0.67–0.87) (0.73–0.92) (0.81–0.92) (0.88–0.89)

< .001 <. 001 < .001 < .001

0.81 2.60

(0.71–0.91) (1.50–4.49)

< .001 < .001

0.83 2.68

(0.73–0.94) (1.55–4.63)

.003 < .001

0.82 2.84

(0.72–0.94) (1.64–4.95)

.003 < .001

1.01 0.91 0.48 1.25

(0.95–1.07) (0.54–1.55) (0.40–0.57) (0.81–1.93)

.79 .74 < .001 .31

0.99 0.87 0.48 1.29

(0.93–1.05) (0.51–1.47) (0.40–0.57) (0.84–1.98)

.76 .59 < .001 .25

1.00 0.87 0.46 1.30

(0.94–1.07) (0.50–1.50) (0.39–0.55) (0.82–2.06)

. 97 .61 < .001 .27

0.85 0.79 0.67 1.76

(0.81–0.90) (0.57–1.08) (0.60–0.74) (1.43–2.15)

< .001 .14 < .001 < .001

0.87 0.79 0.67 1.79

(0.82–0.92) (0.57–1.09) (0.61–0.74) (1.46–2.19)

< .001 .15 < .001 < .001

0.86 0.80 0.69 1.78

(0.81–0.92) (0.57–1.11) (0.62–0.77) (1.43–2.20)

<. 001 .18 < .001 < .001

1.59 0.86 0.84 1.04

(1.52–1.66) (0.75–1.00) (0.78–0.91) (0.74–1.48)

< .001 .05 < .001 .81

1.56 0.83 0.84 1.04

(1.50–1.64) (0.72–0.95) (0.77–0.90) (0.73–1.48)

< .001 .009 < .001 .83

1.58 0.81 0.84 1.15

(1.51–1.66) (0.70–0.95) (0.78–0.91) (0.80–1.65)

< .001 .007 < .001 .45

1.09 0.86 0.72 0.74

(1.03–1.15) (0.52–1.43) (0.66–0.78) (0.39–1.41)

.004 .57 < .001 .36

1.07 0.85 0.73 0.73

(1.02–1.14) (0.52–1.41) (0.67–0.79) (0.38–1.39)

.01 .54 < .001 .34

1.06 0.97 0.73 0.74

(1.00–1.13) (0.57–1.66) (0.67–0.80) (0.38–1.46)

.04 .91 < .001 .39

1.07

(1.06–1.09)

< .001

1.08

(1.06–1.09)

< .001

1.26 1.02

(1.20–1.33) (0.98–1.06)

< .001 .39

1.25 1.01

(1.18–1.31) (0.97–1.05)

< .001 .57

0.69 0.77

(0.66–0.72) (0.74–0.80)

< .001 < .001

0.68 0.73

(0.65–0.71) (0.70–0.77)

< .001 < .001

1.01 1.21

(0.99–1.02) (0.98–1.50)

.34 .08

* The National Database of Nursing Quality Indicators® (NDNQI®) CI, confidence interval; RN skill mix, percentage of all nursing hours supplied by registered nurses. † n = 212,823 patients, 17,356 patients with a hospital-acquired pressure ulcer. ‡ n = 212,823 patients, 17,356 patients with a hospital-acquired pressure ulcer. § n = 192,109 patients, 15,487 patients with a hospital-acquired pressure ulcer. || p < .05 = statistical significance.

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The Joint Commission Journal on Quality and Patient Safety orative Alliance for Nursing Outcomes (CALNOC) data registry, hospital-acquired pressure ulcers decreased from 7.0% in 2006 and 6.2% in 2007 to 2.8% in 2009 and 1.8% in 2010.35 More recent evidence suggests that hospital-acquired pressure ulcers continue to decline.32,36 These findings likely reflect the effect of national initiatives to reduce pressure ulcer occurrence and the usefulness of routine monitoring for quality improvement purposes to lower these rates. The 1.8% rate of hospitalacquired pressure ulcers observed in CALNOC 2010 survey data was notably lower than the 3.6% rate for 2010 from NDNQI survey data and is probably due to differences in the participating hospitals. Most of the CALNOC study hospitals (97%) were located in California; only 14% were larger facilities with a daily census of 300 or more. In contrast, NDNQI–participating hospitals were from across the United States, and 29.8% had 300 staffed beds or higher. Significant regional variations in pressure ulcer rates were reported by Lyder et al.,3 with the highest incidence in the northeastern United States. We found that larger hospital size was associated with higher pressure ulcer rates. Most hospital-acquired pressure ulcers were stage I and stage II pressure ulcers. In contrast, stage III and stage IV pressure ulcers together accounted for 6.3% of all pressure ulcers; 22.4% of the pressure ulcers were unstageable and suspected deep tissue injury (sDTI). When totaled, the proportion of full-thickness pressure ulcers (stage III, stage IV, and unstageable ulcers) was 16.6%, and the proportion of stage III and stage IV ulcers, unstageable ulcers, and sDTI (full thickness pressure ulcers/injuries) was 28.7%. These results suggest that adverse event reports that include only stage III and stage IV pressure ulcers underestimate the overall rate of full-thickness tissue loss/injury from pressure by 62.0% to 78.0%. The 12.1% of sDTI was greater than the 7.0% to 10.9% previously reported21,37 and warrants further investigation. The rate of hospital-acquired pressure ulcers was substantially higher (7.9%) among patients at risk for pressure ulcers. By risk level, approximately one half of these patients were at mild risk (Braden Scale score, 15 to 18); another 20.0% were at moderate risk (Braden Scale score, 13 to 14). Maklebust and Magnan38 found that nurses had difficulty determining which preventive interventions should be deployed for patients with Braden Scale scores of 13 to 18. Consequently, patients at mild risk or moderate risk may be more vulnerable to pressure ulceration than their risk assessment indicates. Consideration of the individual risk factors (subscales) within the Braden Scale and related subscale scores was recommended for pressure ulcer prevention planning.39 Other studies, such as those conducted by Bry et al.40 and Lyder et al.,3 showed that patients with a hospital-acquired

pressure ulcer have multiple risk factors not captured in standard assessment tools. Collectively, these findings suggest that an evidenced-based program of pressure ulcer prevention tailored to patient risk factors, identified through review of pressure ulcer risk assessment tool subscale scores and other clinical factors, should be promptly implemented for all hospitalized patients determined to be at pressure ulcer risk. Only 56.3% to 89.6% of the at-risk patients received interventions to prevent pressure ulcers recommended by clinical practice guidelines,9,10 during the 24-hour period before the NDNQI Pressure Ulcer Survey. For another 2.8% to 11.5% of these patients, the intervention was deemed unnecessary. The 1.4% of at-risk patients with a documented contraindication to nutritional support was lower than expected because food or fluids are often withheld after midnight (NPO) in preparation for surgery or diagnostic procedures in the morning. Results suggest room for improvement in pressure ulcer prevention but should be interpreted with caution, given the 7.2% to 13.5% of missing data across interventions. Strategies to improve survey completion of the prevention intervention items should be employed, including more detailed instructions for selecting nutritional support response options. Hierarchical regression modeling revealed that patients who received a skin assessment on admission, a pressure ulcer risk assessment on admission, or a skin assessment within the 24-hour period before the survey, or were reassessed for pressure ulcer risk during this period, were less likely to acquire a pressure ulcer. Findings support clinical practice recommendations for skin and pressure ulcer risk assessments to prevent pressure ulcers.5,9,10 As with previous studies,41,42 higher Braden Scale scores were associated with lower pressure ulcers rates. Routine repositioning reduced the odds for hospital-acquired pressure ulcers by 14%, and this study is one of only a few studies that have confirmed this association.43–46 The regression analysis controlled for redistribution surface use, risk level (Braden Scale score), hospital characteristics, and nurse staffing measures, whereas previous investigations were smaller-sample studies that may not have accounted for these factors. Because data on repositioning frequency were not available for our analysis, future research should examine the relationship between the repositioning interval and hospital-acquired pressure ulcer occurrence. Although the number of at-risk patients who refused routine repositioning was small, the positive association with hospital-acquired pressure ulcers supports the need for patient and family education on pressure ulcer prevention and the consequences of noncompliance with the prevention program.47 We found no significant association between pressure-redis-

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The Joint Commission Journal on Quality and Patient Safety tribution surface use and the rate of hospital-acquired pressure ulcers among patients at risk for pressure ulcers in adult critical care, step-down, medical, surgical, and medical/surgical units. Although heterogeneity in the support surface used may have confounded the relationship, Rich et al.48 reported similar results for powered and nonpowered support surface use in older patients with hip fracture. Among pediatric intensive care patients, however, and postoperative patients at high pressure ulcer risk, support surface use decreased pressure ulcer development.45,49 Several previous studies that have described the implementation of interventions to prevent pressure ulcers reported equipping all beds in a unit or the hospital with pressure-redistribution mattresses.50–53 If common practice, there may not have been enough variability in pressure-redistribution surface use to detect an association with hospital-acquired pressure ulcers. The positive relationship between nutritional support and hospital-acquired pressure ulcers and the positive relationship between moisture management and hospital-acquired pressure ulcers were not expected. These results likely reflect the crosssectional approach to data collection on prevention interventions that limited temporal inferences and may indicate that these interventions were implemented after the hospital-acquired pressure ulcer was discovered. Jankowski et al.52 found that timely access and appropriate use of barrier ointment, skin protection wipes, and moisturizers were persistent challenges to prevention program initiatives. The higher rate of pressure ulcers among at-risk patients in larger hospitals and academic medical centers likely reflects patient acuity within the institutions. Trauma and complexly ill patients are often transferred or directly admitted to these types of facilities because they are better equipped to care for sicker patients. The odds of having a hospital-acquired pressure ulcer were 32% lower for at-risk patients in Magnet hospitals and 27% lower for at-risk patients in Magnet-applicant hospitals relative to non-Magnet hospitals after adjusting for study covariates (Table 4, Model 3). These effect sizes are surprising large, considering that previous studies reported lower hospital-acquired pressure ulcer rates for only Magnet in-process hospitals (p < .05),54 modestly lower rates in Magnet hospitals (p < .10),55 or no significant difference between Magnet and non-Magnet hospitals in pressure ulcer rates.32,56 Notably, the earlier evidence was from Magnet hospitals that predated 2007 revisions to the Magnet model for greater focus on exemplary professional practice and the expectation for better patient outcomes.57 RN hours per patient-day and RN skill mix were not meaningfully associated with hospital-acquired pressure ulcers after controlling for all other variables in the model. In contrast, pre412

vious studies using NDNQI data on nurse staffing and pressure ulcer outcomes showed that an increase in RN hours per patientday was associated with higher hospital-acquired pressure ulcer rates and that an increase in RN skill mix was associated with lower rates.32,58 Differences between study results may be related to sampling and other methodological variations. Although our analysis adjusted for Braden Scale scores, which estimate patient risk for pressure ulcers, the findings may also reflect uncontrolled measures of patient acuity that attenuated the association to nonsignificance. Lake et al.59 showed that NDNQI hospitals cared for more complex Medicare patients than the average hospital.

LIMITATIONS Research to replicate this study in non-NDNQI–participating hospitals is needed, as the sample of hospitals were volunteer members of the NDNQI, and results may not generalize to all hospitals in the United States. Also, hospital-acquired pressure ulcers by state and United States region were not evaluated, limiting comparison with studies that report these rates. Magnet hospitals were overrepresented relative to their national distribution, as were large hospitals, although the proportion of smaller hospitals with less than 200 staffed beds participating in the NDNQI has grown over time.21 The regression analysis did not control for age, sex, or unit type, which are worthy variables but were not included in the modeling because all hospitalized patients should be assessed for pressure ulcer risk and all at-risk patients should receive prevention interventions. Furthermore, study methods limited the report to discussion of associations rather than causation.

Conclusions Findings from this study of NDNQI–participating hospitals in the United States identified a 3.6% first through fourth quarter 2010 rate of hospital-acquired pressure ulcers among all surveyed patients in adult critical care, step-down, medical, surgical, and medical/surgical units, which was lower than the 6.5% rate for 2006–2007 (fourth and first quarter) previously reported. Although recent evidence suggests that hospital-acquired pressure ulcers continue to decline, subsequent research should determine if the downward trend in these rates can be sustained. To the authors’ best knowledge, this is the first study to examine the association of pressure ulcer risk assessment and prevention interventions with hospital-acquired pressure ulcers across acute care facilities in the United States. Results provide empirical evidence for pressure ulcer prevention guideline recommendations on skin assessment, pressure ulcer risk assessment, and routine

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The Joint Commission Journal on Quality and Patient Safety repositioning to reduce pressure ulcer occurrence among hospitalized patients and support for Braden Scale use among these patients. Although the study’s results are encouraging, much work remains to reduce the rate of hospital-acquired pressure ulcers among at-risk patients, which was 7.9%. Strategies to improve the proportion of at-risk patients who receive pressure ulcer prevention interventions should be employed to reduce this rate. Future studies are needed to establish the temporal relationship between pressure ulcer prevention and hospital-acquired pressure ulcers, with attention to individual intervention use and the hospital characteristics and nurse staffing measures that may influence these relationships. J Sandra Bergquist-Beringer, PhD, RN, CWCN, is Associate Professor and NDNQI Pressure Ulcer Consultant, School of Nursing, University of Kansas Medical Center, Kansas City. Lei Dong, MS, is Senior Research Analyst, Department of Biostatistics, and Data Manager, Office of Scholarly, Academic & Research Mentoring, University of Kansas Medical Center. Jianghua He, PhD, is Associate Professor, Department of Biostatistics, University of Kansas Medical Center. Nancy Dunton, PhD, FAAN, is Research Professor and NDNQI Principal Investigator, School of Nursing, University of Kansas Medical Center. Please address correspondence to Sandra BergquistBeringer, [email protected].

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