Hospital Wide Monitoring & Management
 According to Centers for Medicare & Medicaid (2010) more than 2.5
million people in the United States develop pressure ulcers annually.
 Pressure ulcers cause pain, increased health risks such as; serious
wound infections, mortality and increased health care utilization.
 In-hospital mortality was also higher for pressure ulcer-related
hospitalizations, death occurred in 11.6 percent of stays with pressures
ulcers noted as a secondary diagnosis, (AHRQ, 2008).
 The Centers for Medicare & Medicaid no longer provides
reimbursement to hospitals to care for a patient who has acquired a
pressure ulcer while under the hospital‘s care, (CMS, 2008).
Pressure ulcer prevention and prevalence presents an
important challenge in acute and long term acute care
hospitals. Pressure ulcer prevention requires an
interdisciplinary and system wide approach to care. To
accomplish this task; coordination between all disciplines, an
organizational process and operational practices are needed.
Therefore, pressure ulcer prevention and prevalence calls for
a system focus to make needed changes.
What is a Pressure Ulcer ?
• Any lesion caused by unrelieved pressure resulting in
damage of underlying tissue (AHCPR, 1994).
• A pressure ulcer is localized injury to the skin and/or
underlying tissue usually over a bony prominence, as a result
of pressure, or pressure in combination with shear and/or
friction (NPUAP, 2007).
The staging of pressure ulcers, as defined by national
guidelines (NPUAP), allow for common understandings for
healthcare professionals.
Stage I
Stage II
Stage III
Stage IV
Suspected Deep Tissue Injury (DTI)
 Immobility or limited mobility
 Bowel & bladder incontinence
 Shearing and friction injuries
 Malnutrition or debility
 Obesity
 History of pressure ulcers
 Dehydration
 Contractures
 Lack of compliance
 Use of diapers / excess skin moisture
• All patients are assessed for presence of pressure ulcers or
wounds during the admission skin assessment completed by
a Registered Nurse.
• If a pressure ulcer / wound is identified during the admission
assessment, it is categorized as “Community Acquired”.
• If a pressure ulcer is identified during a daily nursing
assessment but it was not identified & documented during the
admission assessment, it is categorized as “Hospital
• Based on the information entered by the registered nurse into
the computer system, the hospital’s pressure ulcer
prevalence percentage is calculated.
• Pressure Ulcers are classified according to the National
Pressure Ulcer Advisory Panel (NPUAP) guidelines.
• Incidence of pressure ulcers is one of the Quality Indicator
(QIs) reflecting hospital’s quality of care. Pressure ulcer
prevalence data is utilized to measure quality of care
delivered to the patients.
• All Registered Nurses conducting admission assessments are
not familiar with current NPUAP/CMS Pressure Ulcer Staging
• Registered Nurse’s lack of wound care knowledge and
training leads to inaccurate staging of pressure ulcers.
• Inaccurately staged ulcers, as well as ulcers not identified
during the admission assessment, produces inaccurate
prevalence data.
• Inaccurately staged ulcers can reflect high hospital acquired
pressure ulcer rates.
A survey was developed to identify knowledge of nurses about staging
of pressure ulcers. Each nurse completing the survey was required to
identify & stage the pressure ulcers by observing the images of the
ulcers. 50 Registered nurses were randomly selected to complete the
survey. The following nurses completed the survey:
32 Registered Nurses with Bachelor of Nursing Degree
5 Registered Nurses with Master of Nursing Degree
1 Registered Nurse with Doctorate Degree
7 Registered Nurses with Associate Degree
5 Registered Nurses with Diploma
• 70% Nurses identified & staged 2 (2/6) pressure ulcers
correctly. Stage I & Stage IV
• 14% Nurses identified & staged 1 (1/6) pressure ulcer
correctly. Stage IV
• 8% Nurses identified & staged 3 (3/6) Pressure ulcers
correctly. Stage I , Stage II & Stage IV
• 4 Certified Wound Care Nurses were also asked to complete
the survey and all 4 nurses identified & staged all 6 (6/6)
pressure ulcers correctly (100%)
• Regardless of experience and educational background, all
registered nurses do not have the competence and skill to
identify wounds of different etiology, nor pressure ulcers of
different stages.
• Only registered nurses who receive specialized training in
wound care and have experience in wound management and
staging pressure ulcers are qualified to properly stage
pressure ulcers.
• Staff registered nurses to complete client’s skin assessment during
the hospital admission process and every 24 hours.
• If any skin issues identified other than intact or normal skin, a
consult for wound care nurses would be placed.
• Wound care nurses will be responsible for identification and
management of wounds, staging of pressure ulcers and initiating
additional consults for further work up, if necessary such as;
Dermatology, Podiatry, Vascular Surgery, General Surgery etc.
• Hospital’s Pressure Ulcer Prevalence percentage to be calculated
from the assessment note completed by the certified wound care
According to National Commission For Certifying Agency
(NCCA) and the Accreditation Board for Specialty Nursing
Certification (ABSNC), Wound Care Nursing is a nursing
specialty, and the certification is the validation of knowledge,
skills and expertise, which protects the public from unsafe and
incompetent providers and distinguishes the healthcare facility
for utilizing nurses expert in the management of wounds.
Certified Wound care nurses are key health care team members who:
• Accurately assess / stage patients wounds and provide critical
• Implement cost-effective, evidence-based plan of care and develop
strategies to prevent complications.
• Collaborate with physicians in managing patients with wounds.
• Provide education to medical, nursing and ancillary staff.
• Educate and advocate for patients and their families.
According to wound care certification board (WOCNCB),
entry level Wound Care Nurse must possess following
qualification in order to sit for certification exam:
• Registered Nursing License
• Bachelor’s Degree in Nursing
• 1500 Clinical Hours in Wound Care
• Completion of a Wound Care Training Program
• According to some studies certified wound nurses provide
safe and high quality care to patients and have a significant
impact on the quality of care.
• A secondary analysis from 652 hospitals showed that a
10% increase of certified baccalaureate nurses decreased
the odds of inpatient 30-day mortality by 2% (KendallGallager,2011).
• A test of 460 Registered Nurses showed certified wound
nurses scored significantly higher on a Pressure Ulcer
Knowledge Test than non-certified RNs or RNs certified in
other specialties (Zulkowski et al., 2007).
• A retrospective analysis (Bolton et al., 2004) revealed that
78.5 percent of those patients treated by a board certified
wound care nurse healed in comparison to the 36.3 percent
of those treated by non-certified nurses.
• Based on data collected and review of various studies, it is
concluded that patients have improved outcomes when certified
wound care nurses are involved in the assessment and treatment of
their wounds from admission to discharge.
• A change in current practice is required to ensure all patients with
pressure ulcers and other wounds are seen by certified wound care
nurses, for accurate classification, staging, recommending
treatments and monitoring progress of all wounds. In addition,This
practice will ensure that patients are receiving the best possible care
that will lead to improved patient outcomes.
Agency for Health Care Policy and Research (AHCPR), U.S. Department of Health
and Human Services, December 1994. Treating pressure sores. Consumer Version
Clinical Practice Guideline Number 15
Agency for Healthcare Research and Quality (2008) National healthcare quality &
disparities report. (www.ahrq.gov)
Bolton, L., McNees, P., Van Rijswijk, L., De Leon, J., Lyder, C., Koba, L., (2004).
Wound Healing Outcomes Using Standardized Assessment and Care in Clinical
Practice. Journal Wound.Ostomy Continence Nursing, 31, 65-71.
Centers for Medicaide and medicare services (2008) Hospital program regulations.
Kendall‐Gallagher, D., Blegen, M. (2009). Competence and Certification of
Registered Nurses and Safety of Patients in Intensive Care Units. American Journal
of Critical Care. 2009 Mar; 18(2):106‐116.
National Pressure Ulcer Advisory Panel (NPUAP) (2007). Pressure Ulcer Staging
System Updated. http://www.npuap.org/pr2.htm
Wound, ostomy, and continence certification board (WOCNCB). www.wocncb.org
Zulkowski, K., Ayello E., Wexler, S. (2007). Certification & Education: Do They
Affect Pressure Ulcer Knowledge in Nursing. Advance Skin Wound Care. 2007
Jan; 20(1):34‐8.

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