While the terminology has changed over the years from decubitis ulcer to bed sore to pressure ulcer and now pressure injury, hospital-acquired pressure injuries (HAPIs) that worsen during hospitalization are serious reportable patient safety events.
In addition to negative patient outcomes, according to the article "Economic Evaluations of Strategies to Prevent Hospital-Acquired Pressure Injuries" in Advances in Skin & Wound Care, the financial burden of HAPIs on the United States healthcare system was estimated between $6 and $15 billion per year in 2012.
There are many preventive strategies that have been implemented over the years for HAPIs. Frequent repositioning of patients and pressure redistribution surfaces (either alone or in combination) are the most common approaches. These methods alone, however, are often only partially effective and can be costly to implement.
The ability to gauge the likely benefits of the available preventive strategies and compare their cost-effectiveness is essential to making evidence-based decisions about the selection and implementation of preferred methods.
The authors of the article performed a review of the literature published between 2004 and 2015 that reported on the costs of HAPIs and economic evaluations of prevention strategies in acute care. Their goals were to identify what prevention strategies had an economic evaluation, assess the relative strengths and weaknesses of the evaluations performed to date, and determine what future economic evaluations should incorporate.
A combination of risk assessment, nutritional support, and repositioning resulted in cost savings, decrease in HAPI incidence, and reduction in deaths in one study from 2013. In another study, pressure redistribution surfaces, nutritional support, repositioning, and moisture/incontinence control resulted in significant cost savings and an increase in quality of life.
Pressure redistribution surfaces were the modality most commonly studied. These studies typically compared various types of pressure redistribution surfaces with an active control. In patients with spinal cord injuries, for example, requiring assistance with repositioning, a continuous computer-regulated mattress was found to be effective if nurses were not able to frequently reposition patients.
Mattress overlays were reported to be a cost-effective intervention compared with replacing mattresses, whereas another study indicated that alternating pressure mattresses offered an economic advantage compared with alternating pressure overlays.
An inflated static overlay was found to be less costly and as effective as either a microfluid static overlay or a low-air-loss dynamic mattress with pulsation. Pressure redistribution surfaces may be less costly than frequent repositioning programs.
Other single approaches to prevent HAPIs, such as dressings or nutritional support, also showed success. So, while there are some effective methods and devices used for preventing and treating pressure injuries, there is no magic bullet.
Another article in Advances in Skin & Wound Care features the results of a quality improvement project to reduce the number of hospital-acquired pressure injuries (HAPIs) by flagging extremely high-risk patients with a pink paper reminder system and implementing a pressure injury prevention order set.
The pink paper reminder system is a cost-neutral, simple approach to identify patients at highest risk of pressure injury development who meet specific criteria. The first step was to develop a risk assessment tool, the pink paper criteria. When a patient met the specified criteria, a pink piece of paper titled "SKIN AT RISK" in a large font was hung at the head of the patient's bed to reinforce preventive strategies. Next, a set of pressure injury preventive measures was ordered.
As a result, there was a 67% reduction in HAPI incidences following the initiation of the pink paper reminder system. Identifying and flagging patients who are at extremely high risk of pressure injuries and implementing an order set of pressure injury preventive measures dramatically reduced the rate of HAPIs per 1000 patient-days.
The available evidence from research shows that HAPIs are costly and prevention is preferable to treating them once they occur, as there are more than a few challenges to healing.
Any skin and wound nurses who'd like to share their HAPI successes and failures?