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194
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B.M. Bates-Jensen and J. Cheng
Can We Measure Quality of Pressure Ulcer Care
by Evaluating Quality Indicators? Do Quality Indicators
Refl ect Care Quality?
Quality of care may not be directly measured using quality indicators. Process
measures are better more direct measures of quality of care as they provide data on
actual care delivery. There is not necessarily a direct relationship between care
delivery or process measures and quality indicators. This is most noticeable in using
the MDS-derived quality indicators in NHs. For example, Rapp and colleagues [ 68 ]
found that NHs with low prevalence of pressure ulcers did not self report more
guideline-recommended interventions compared to those with high prevalence of
pressure ulcers. When using direct observation as compared to self-report data or
medical record data, the questionable relationship between quality indicators and
care delivery is more pronounced.
Bates-Jensen and colleagues studied NHs in the highest and lowest quartile
for the MDS pressure ulcer quality indicator to evaluate if facilities with lower pressure ulcer quality indicator scores provided better pressure ulcer care [ 69 ]. Care
processes were measured from medical record data, direct observation, and use of
wireless movement monitors to quantify repositioning activity. They found no differences between high and low pressure ulcer quality indicator NHs for most pressure ulcer care processes with the exception of more frequent use of pressure
reducing support surfaces in the high pressure ulcer quality indicator NHs. Of interest,
repositioning for residents unable to self-reposition was not routinely performed at
2-hour intervals based on the movement monitor data despite medical record documentation that indicated 2-hour repositioning was occurring for nearly all residents.
They concluded the MDS pressure ulcer quality indicator was not an accurate measure of the quality of pressure ulcer care delivery [ 69 ]. These fi ndings are similar for
other related quality indicators. NHs identifi ed as performing in the upper quartile of
the MDS bedfast quality indicator had a higher proportion of bedfast residents and
more residents at risk for physical decline, direct observation verifi ed this fi nding. No
differences were shown between NHs with high MDS bedfast quality indicator
scores and those NHs with low MDS bedfast quality indicator scores. Signifi cant
differences between the two groups of NHs existed based on direct observation
of time residents spent in bed. In addition residents who required moderate to complete assistance for transfer or bed mobility were 4.4 times more likely to be
observed in bed more than 50 % of the time; those who could not stand and bear
weight were 5.4 times more likely to be found in bed more than 50 % of the time
compared to those who could. Residents in high bedfast homes who required physical assistance or were totally dependent were 3.5 times more likely to be found in
bed compared to their counterparts in lower performing NHs [ 54 ].
11 Quality of Care
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195
Can We Improve Quality of Pressure Ulcer Care?
While there are number of quality improvement organizations as described previously, the CMS contracts with regional and state quality improvement organizations
(QIOs) to review medical care and implement improvements to quality of care for
all Medicare benefi ciaries across health care settings [ 70 ]. QIOs have been instru-
mental in evaluating the quality of care related to pressure ulcers especially in the
NH setting. In fact, improving pressure ulcer care has been part of the past ten statements of work (the language for the CMS QIO contracts) [ 70 ]. In most cases, a
collaborative approach is used where organizational leaders and direct care staff
learn from each other as they progress through quality improvement plan–do–
study–act processes and then progress is measured by evaluating pressure ulcer
outcomes such as prevalence and incidence. Several investigators have used similar
approaches with success. Horn and colleagues [ 71 ] conducted an observational
study of 11 NHs that implemented a standardized certifi ed nurse assistant (CNAs)
documentation tool that incorporated best-practice information found that the high
risk pressure ulcer quality measure (a prevalence measure that includes admissions
with pressure ulcers and pressure ulcers that develop after admission) decreased
33 % from baseline, while the incidence of pressure ulcers decreased from 12.1 to
4.6 % after tool implementation. The success of the Horn and colleagues study
demonstrates the effect of and need for standardized documentation and communication across all NHs that is easily collected by front line staff (e.g., CNAs) and
easily interpreted by management to implement change processes [ 71 ].
Several investigators have looked at pressure ulcer outcome measures after quality improvement programs [ 72 – 76 ]. Rantz and colleagues evaluated Medicaid-
certifi ed facilities in Missouri deemed “at risk” for quality that voluntarily enrolled
in a quality improvement program which included staff education, clinical site
visits, guidance on evidence-based guidelines, and assessment tools [ 73 ]. Rates of
pressure ulcer prevalence and pressure ulcer prevalence among high risk residents
improved by 21 % and 26 %, respectively, after implementation of the quality
improvement program. Limitations of this study included self-selection of NHs into
the quality improvement program, based on prevalence data, which does not control
for case-mix or variation over time. This limitation is similar for many of the QIO
or collaborative-based intervention studies as in most cases the NHs self-select into
the program.
Some investigators have looked at use of technology as a method of improving pressure ulcer quality. Baier and colleagues [
(Setting Targets Achieving Results-STAR) that tracks and provides feedback on six
quality measures; the tool collects longitudinal data, provides information to help select
annual quality indicator performance targets, and tracks improvement over time. NHs
using the STAR tool were grouped into ambitious and less ambitious categories
based on percent of improvement over time on the pressure ulcer quality measure.
On average, NHs with ambitious targets were 9 times more likely to improve on the
pressure ulcer quality measure than those with less ambitious targets [
74 ] evaluated NHs using a Web-based tool
74 ]. Similarly
196
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B.M. Bates-Jensen and J. Cheng
Sharkey and colleagues [ 75 ] evaluated NHs in Washington DC that implemented an
On-Time quality indicator tool, which provides clinical decision making tools, strategies for tool use, and guided facilitation for frontline NH staff. NHs were categorized
into three levels of implementation for analysis. Those NHs with high levels of
implementation (and better outcomes) were associated with greater team participation
in workgroup calls (especially from top leadership), presence of an internal champion,
and team willingness to trial and redesign process improvements [ 75 ].
Other investigators have examined the relationships between quality and staffi ng.
Temkin-Greener and colleagues [ 76 ] explored the relationship between NHs work
environment and risk of pressure ulcers and incontinence. Residents in NHs who
had higher staff cohesion (the extent to which staff are perceived to have common
goals, values, and strong group identity) had signifi cantly lower odds of pressure
ulcers and incontinence. There was no association between consistent assignments
or prevalence of formally organized teams with pressure ulcers and incontinence.
Interestingly, a 1 percent higher prevalence of self-managed teams resulted in a
2.3 % decrease in the odds of having a pressure ulcer, leveling off at 12 %, though
team dynamics did not affect incontinence [ 76 ].
In most cases, multipronged and multidisciplinary pressure ulcer prevention
approaches have also led to improvements in pressure ulcer prevalence and incidence rates in acute care and LTACHs as well as NHs [ 77 , 78 ]. Most studies evaluat-
ing pressure ulcer prevention interventions evaluate recurring components of pressure
ulcer prevention programs including pressure redistribution (repositioning and use of
support surfaces), nutritional assessment and support, incontinence management, skin
hygiene, inspection, and assessment [ 77 , 78 ]. These programs are implemented using
a wide variety of approaches [ 79 – 101 ] including: clinical performance monitoring and
feedback [ 79 – 83 , 85 , 90 , 92 , 98 ], skin care champions [ 80 , 83 , 84 , 86 , 89 , 90 , 93 – 95 ],
educational support materials [ 83 – 88 , 90 , 92 , 93 , 95 – 97 ] (including stickers [ 82 , 83 ,
85 , 89 ], turn clocks [ 79 ] pocket guides [ 83 , 85 , 88 ], newsletters [ 84 , 85 , 95 ], posters
[ 85 , 88 ], theme songs [ 79 , 80 , 83 ], and penlights [ 98 ]), protocol development [ 80 , 82 ,
83 , 86 , 88 , 90 , 94 , 99 , 100 ], risk assessment [ 79 , 81 – 83 , 86 , 88 , 89 , 91 , 95 , 96 , 100 ,
101 ], staff education [ 79 – 82 , 84 – 91 , 93 – 101 ], bed support surfaces [ 83 , 86 , 88 , 90 ,
91 , 95 , 96 , 100 , 101 ], and use of skin teams [ 80 , 83 , 84 , 86 , 89 , 90 , 93 , 95 ]. Outcomes
reported in these studies include both prevalence and incidence. Very few studies
measured care processes [ 92 – 95 , 97 ] which may further delineate why an interven-
tion is successful. The diffi culties with most of these studies are no comparison
groups, few process measurements, and no measure of sustainability of programs
with continued improvement in pressure ulcer quality indicators but they do provide
persuasive evidence that pressure ulcer care can be improved.
pressure ulcers
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sion rates, and hospital charges
Incidence and prevalence of
Hospital lengths of stay, readmis-
Infections
Morbidity and mortality
(continued)
Table 11.3 Selected pressure ulcer clinical practice guidelines
Classifi cation of pressure ulcers
Assessment and monitoring of healing
Assessment of the individual
Pressure ulcer assessment
Methods for monitoring healing
Providing adequate nutritional support
Evaluation/Treatment/Management
Organization (National Guideline
Clearinghouse reference #) Guideline Outcomes
NPUAP EPUAP (2009)
(NGC 8204)
Pain assessment and management
Education of individuals, family, and healthcare providers in pain management
Support surfaces and positioning for treatment of pressure ulcers
Positioning while in bed and in a chair
Interventions for critically ill individuals, spinal cord-injured individuals, bariatric individuals
Wound cleansing
Debridement
Dressings (e.g., hydrocolloid, transparent fi lm, hydrogel, alginate)
Assessment and treatment of infection
Biophysical agents in pressure ulcer management (e.g., electrical stimulation, electromagnetic
agents, phototherapy, acoustic energy, hydrotherapy)
Biological dressings (insuffi cient evidence to recommend)
Growth factors (insuffi cient evidence to recommend)
Surgery for pressure ulcers
Pressure ulcer management in individuals receiving palliative car, including patient and risk
assessment, pressure redistribution, nutrition and hydration
Control of wound odor
pressure ulcers
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readmission rates, and hospital
charges
Incidence and prevalence of
Hospital lengths of stay,
Infections
Morbidity and mortality
Establishing a risk assessment policy
Risk assessment
Table 11.3 (continued)
Organization (National Guideline
Clearinghouse reference #) Guideline Outcomes
NPUAP, EPUAP (2009)
(NGC 8145)
Educating staff in risk assessment
Documentation of risk assessment
Use of structured approach to risk assessment (e.g., use of Braden and other standard scales)
Consideration of factors involved in pressure ulcer development:
Nutritional indicators
Factors affecting perfusion and oxygenation
Skin moisture
Advanced age
Skin assessment
Friction and shear risks (Subscale Braden Scale)
Sensory perception (Subscale Braden Scale)
General health status
Development of pressure ulcer prevention plan
Prevention
Ensuring comprehensive skin assessment policy is in place
Educating staff in skin assessment
Performing regular skin assessments, noting areas of heat, edema, induration
Skin care, including use of emollients and avoidance of massage, friction, and excessive moisture
Nutrition for pressure ulcer prevention
Nutritional screening and assessment
Providing nutritional support
Offering high-protein mixed oral nutritional supplements and/or tube feeding
Administering oral nutritional supplements (ONS) and/or tube feeding (TF)
Repositioning for the prevention of pressure ulcers
Technique in bed and in seated positions
Frequency of repositioning
Documentation of repositioning
Education and training of all involved in care
pressure ulcers
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preventing the development of
Incidence and prevalence of
Effi cacy of intervention for
pressure ulcers, and facilitating
wound healing
patients at risk and pressure
ulcer healing
Validity of tools used to assess
Morbidity
Cost
(continued)
Use of support surfaces
Appropriateness and functionality of the support surfaces
Use of high-specifi cation foam mattresses
Alternating-pressure active support overlays and replacement mattresses
Heel and elbow protection devices
Pressure-redistributing seat cushion
Organization (National Guideline
Clearinghouse reference #) Guideline Outcomes
Natural sheepskin pads
Special considerations for patients in the operating room
Risk assessment of individuals undergoing surgery
Using pressure-redistributing mattresses on the operating table
Positioning of the patient
Paying attention to pressure redistribution prior to and after surgery
Evaluation/Risk assessment
Assessment of individual risk for developing pressure ulcers using risk assessment tools
Assessment of other intrinsic/extrinsic risk factors
Assessment of skin
Assessment of nutritional status
Assessment for history of prior ulcer and/or presence of current ulcer, previous treatments,
or surgical interventions
Assessment for potential complications associated with pressure ulcers
Measures to minimize shear-related injury
Measures to redistribute pressure
Prevention/Management/Treatment
WOCN (2010) (NGC 7973)
Use of skin protectant
Nutritional management
Use of a low-air loss or air-fl uidized surface
Bowel/bladder management program
Implement strategies to optimize healing
Wound management
Use of antibiotics (e.g., topical, systemic)
Debridement of devitalized tissue
Adjunctive therapies as indicated
Evaluation of need for operative repair
Evaluation and management of pain
Patient/caregiver education
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ulcer_treatment_protocol__
review_and_comment_/
pressure_ulcer_treatment__
healthcare facilities
http://www.icsi.org/pressure_
Prevalence of pressure ulcers in
Effectiveness of treatment
protocol__.html
Evaluation/Prevention/Risk assessment
Assessment and daily reevaluation of all patients for the risk of pressure ulcer development (use
Organization (National Guideline
Clearinghouse reference #) Guideline Outcomes
ICSI (2012)
Table 11.3 (continued)
(NGC 8962)
of Braden Scale or Braden Q scale)
Documentation of the risk assessment
pressure, support surfaces, managing moisture, maintaining adequate nutrition/hydration)
Prevention plan and documentation
Initiation of pressure ulcer prevention plan (minimizing/eliminating friction, minimizing
Educating patients and caregivers
Skin inspection and documentation
Management/Treatment
Comprehensive assessment including wound evaluation and documentation
Review of history and physical, with emphasis on pressure ulcer
Wound description/staging
Review of etiology of pressure
Assessment of nutritional status
Monitoring the wound for signs of infection
Assessment of psychosocial needs
Pressure ulcer treatment
stimulation)
Establishing the treatment goal
Moist wound healing
Cleansing the wound
Choosing appropriate topical wound care products
Wound debridement
Consideration of adjunct therapy (including negative pressure wound therapy, electrical
Pain management
Management of nutrition (specifi c nutrient goals, vitamin and mineral supplement)
Surgical consultation
Patient and staff education
Discharge plan or transfer of care
Documentation of all items in patient’s medical record
prevalence and incidence
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healing time, pain, odor, and
infections
ulcers healed by 4–20 weeks of
care
recurrence
Risk-adjusted pressure ulcer
Risk-adjusted pressure ulcer
Risk-adjusted percent of pressure
Risk-adjusted pressure ulcer
tion with pressure ulcer care
and outcomes
per pressure ulcer healed)
(e.g., per 100 pressure
ulcer-free days)
Patient and professional satisfac-
Cost effectiveness of healing (e.g.,
Cost-effectiveness of prevention
pressure ulcers in long-term
care settings
assessment tools for pressure
ulcers
Prevalence and incidence of
Reliability and validity of risk
Effi cacy of intervention measures
Time to healing
(continued)
Braden scale)
Evaluation/Risk assessment/Screening
Initial and continuous pressure ulcer risk assessment using valid, reliable scales (including
Nutritional assessment with a validated measure
Document medical and surgical history
Organization (National Guideline
Clearinghouse reference #) Guideline Outcomes
AAWC (2010)
(NGC 8120)
Assessment of psychosocial conditions and quality of life
Environmental assessment
Physical examination including wound assessment
Diagnostic tests
Prevention/Rehabilitation
Skin inspection and maintenance
Hydration and nutrition plan of care
Rehabilitative and restorative programs
Positioning standards of care to manage pressure ulcers
Off-loading equipment including chairs, intensive care, and operating rooms
Interdisciplinary team approach
Education
Management/Treatment
Remove/alleviate all causes of pressure ulcer damage
Debride, cleanse, and dress the wound
Advanced or adjuvant interventions
Surgical interventions
Documentation of response
Palliative care
Recognition/Assessment
AMDA (2008)
that may affect ulcer healing, history of pressure ulcers, impaired or decreased mobility, and
others using risk assessment instruments (e.g., the Braden Scale for Predicting Pressure Sores,
the Norton Score)
(staging) of the pressure ulcer
Examination of the patient’s skin thoroughly to identify pressure ulcers
Assessment for risk factors for developing pressure ulcers such as comorbid conditions, drugs
(NGC 6410)
Assessment of the patients overall physical and psychosocial health and characterization
ulcers
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Prevalence of new pressure ulcers
Prevalence of nonhealing pressure
and healing
Identifi cation of physiologic, functional, and psychosocial factors that can affect ulcer treatment
Organization (National Guideline
Clearinghouse reference #) Guideline Outcomes
Table 11.3 (continued)
treatment of causative factors and modifi able comorbid conditions, optimal nutritional support,
Identifi cation of priorities in managing the ulcer and the patient including identifi cation and
prevention and management of infection of the ulcer, and others
Treatment/Prevention
psychosocial support
appropriate positioning devices, support surfaces, and offl oading devices; maintaining the
lowest possible head elevation
silver dressing
Establishment of a realistic, individualized interdisciplinary care plan
Provision of general support for the patient including hydration, nutrition, pain management, and
Management of pressure by proper positioning, turning and transferring techniques; using
Management of infection using topical antibiotics (e.g., bacitracin–polymyxin) if indicated or
dressings
diabetes, heart failure, peripheral vascular disease) that may contribute to pressure ulcer risk
Debridement of necrotic tissue from the ulcer (autolytic, enzymatic, mechanical, surgical)
Covering and protecting the ulcer and surrounding skin using appropriate ulcer care products and
Management of comorbid conditions (e.g., anemia, chronic obstructive pulmonary disease,
cellulitis
adjunctive therapies (e.g., negative pressure wound therapy)
Monitoring
Monitoring and documentation of the patient’s progress and ulcer healing
Recognition and management of ulcer complications such as increasing necrosis, infection,
Reassessment of treatment and change in approaches if indicated; consideration of surgery and
Monitoring of the facility's management of pressure ulcers using specifi c indicators
Assessment of pressure ulcers
Risk assessment
Braden Risk Score
Stage I pressure ulcers in patients with darkly pigmented skin
HIGN (2008)
(NGC 6346)
tears
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Prevalence of skin tears
Prevalence of nonhealing skin
Prevention strategies
Braden Risk Score
Management of pressure ulcers
Risk assessment documentation
Care issues and interventions: mobilization, skin care, moisture, positioning, use of devices,
Organization (National Guideline
Clearinghouse reference #) Guideline Outcomes
nutrition, friction and shear
Assessment of skin tears
Risk assessment
Three group risk assessment tool
Payne-Martin classifi cation system
Prevention
Safe environment
Staff/caregiver education
Protect from self-injury and skin injury during routine care
Management/Treatment of skin tears
Assess size of wound
Cleaning wounds
Application and removal of dressings
Use of skin sealants, protective ointments, liquid barriers
NPUAP National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel. Pressure ulcer prevention recommendations. In: Prevention and treatment of pres-
sure ulcers: clinical practice guideline. Washington (DC): National Pressure Ulcer Advisory Panel; 2009
http://www.hartfordign.org from Ayello EA, Sibbald RG. Preventing pressure ulcers and skin tears. In: Capezuti E, Zwicker D,
WOCN Wound, Ostomy, and Continence Nurses Society. Guideline for prevention and management of pressure ulcers. Mount Laurel (NJ): Wound, Ostomy, and Continence
Nurses Society (WOCN); 2010 Jun 1. 96 p (WOCN clinical practice guideline; no. 2)
ICSI Institute for Clinical Systems Improvement. Pressure ulcer prevention and treatment protocol. Health care protocol. Bloomington (MN): Institute for Clinical Systems
Improvement (ICSI); 2012 Jan. 88
AAWC Association for the Advancement of Wound Care. Association for the Advancement of Wound Care guideline of pressure ulcer guidelines. Malvern (PA): Association
for the Advancement of Wound Care (AAWC); 2010. 14 p
AMDA American Medical Directors Association. Pressure ulcers in the long-term care setting. Columbia (MD): American Medical Directors Association (AMDA); 2008. 44 p
HIGN Hartford Institute for Geriatric Nursing.
Mezey M, Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York (NY): Springer Publishing Company; 2008 Jan. pp. 403–29
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