Every two hours, Olympics-style theme music is piped over the audio system at OSF St. Francis Medical Center in Peoria, Ill., signaling to hospital staff that it's time to perform a vital task: repositioning patients in their beds to avoid wear and tear on sensitive skin. Hospitals around the country are scrambling to put new programs in place to prevent pressure ulcers, commonly known as bedsores, after the federal Centers for Medicare and Medicaid Services announced last month that as of October 2008, it will no longer reimburse hospitals for treating eight "reasonably preventable" conditions.

Pressure ulcers are among the most prevalent, costly and dangerous on the list: In addition to interfering with recovery, lengthening hospital stays and causing extreme pain and discomfort, pressure ulcers can increase the risk of infection, with nearly 60,000 deaths annually from hospital-acquired pressure ulcers.

Nursing homes and long-term-care facilities have made strides of their own in prevention, motivated in part by the costs of litigation for failure to prevent pressure ulcers. But in acute-care hospitals, where patients stay for much shorter periods, prevention has been sporadic. Acute-care hospitals treat about 2.5 million pressure ulcers each year, and as many as 15% of hospitalized patients may have pressure ulcers at any one time, according to the Institute for Healthcare Improvement. Estimates for the cost of treating all pressure ulcers in the U.S. range up to $11 billion annually.

To combat this, hospitals are pushing screenings of all incoming patients from head to toe for skin issues that could lead to pressure ulcers. They are using visual examinations, ultrasound and other technologies that can help identify skin with tissue damage. In some cases, they are photographing areas of a patient's skin to document how it changes from day to day.

Taking the Pressure Off:
An Atmos Air pressure-relieving mattress from
Kinetic Concepts--used to help prevent pressure ulcers.

Hospitals are also buying special beds with high-tech air mattresses that minimize or redistribute pressure. And they are adhering to strict monitoring schedules that include shifting patients every two hours, frequently cleaning and moisturizing soiled or sensitive skin, and making sure that at-risk patients have enough protein and other nutrients in their diet to help the healing process.

Pressure ulcers are caused when skin lesions form near prominent bony parts of the body from unrelieved pressure when patients stay in one position for too long. Starting with skin redness or a blister, sores can progress to a deep crater that damages muscles, tendons and bone, requiring surgery and increasing the risk of complications such as the bloodstream infection sepsis. The late actor Christopher Reeve was being treated for an infection associated with a pressure ulcer when he died of cardiac arrest.
In elderly or disabled patients, sores can begin forming in as little as two to six hours, but pressure ulcers also can develop in much younger and healthier patients on the skin of the tailbone, back, buttocks, heels, back of the head, or elbows. Poor nutrition or dehydration can weaken the skin and make it more vulnerable.

In February, the National Pressure Advisory Panel (npuap.org) updated its definition of the original four "stages" used to diagnose pressure ulcers, and added two new stages on deep-tissue injury and unstageable pressure ulcers. Advisory panels in both the U.S. and Europe are updating guidelines in several languages through a joint project (pressureulcerguidelines.org). A number of quality groups, including the nonprofit Institute for Healthcare Improvement, and VHA Inc., an alliance of 2,400 not-for-profit hospitals in the U.S., are working with hospitals on the new prevention programs, using lessons learned from OSF St. Francis and others that have sharply reduced or even eliminated pressure ulcers.

To be sure, patients often arrive at the hospital with pre-existing skin lesions, and researchers say some ulcers may simply be unavoidable in patients with severe disabilities or compromised immune systems. Generally, however, experts agree that bedsores are a classic example of preventable harm: Despite strong evidence of effective strategies for prevention, guidelines are frequently ignored or overlooked.

Part of the problem is a nationwide nursing shortage that makes for a more harried and chaotic hospital environment. But there has also been no real incentive for prevention programs, since Medicare and private insurers typically pay for complications that arise once a patient is in the hospital.

That is changing with the advent of Medicare's new payment policy, which some private insurers are considering following. In addition to pressure ulcers, the preventable conditions for which Medicare will no longer reimburse hospitals include injuries from patient falls, urinary-tract infections, vascular-catheter-associated infections and mediastinitis, an infection following heart surgery. Also included are so-called never events, meaning they never should happen: objects left in the body during surgery, air embolisms and blood incompatibility. Medicare plans to add three additional conditions next year.

Last year, there were 322,946 cases of pressure ulcers as a "secondary diagnosis" (in addition to the primary reason the patient entered the hospital) reported in Medicare patients. The cost of treating a severe pressure ulcer with complications that require surgery can be as high as $70,000, studies show.

Critics of Medicare's new rules say unreimbursed costs for pressure-ulcer treatment will simply be passed along in higher medical charges for everyone. But Medicare counters that the new policy will give hospitals a strong incentive to screen patients who may be at risk. If hospitals can document that the skin ulcer was present at admission, it will pay for treatment.
Owensboro Medical Health System in Kentucky began a program in 2000 that included putting pictures of clouds on the doors of at-risk patients to remind nurses to reposition them in their beds every two hours. But a study in 2003 found it hadn't made a dent in reducing pressure ulcers. Joni Sims, a nurse and director of medical/surgical services, says nurses weren't all adhering to the turn schedules, and some patients who were at risk didn't get the cloud symbols. The hospital switched to turn clocks in each patient's room with a clearly marked schedule for turning patients every two hours; it also provided nurses' assistants with pagers to remind them of turn times.

Byron Morris, a nurse at Owensboro, says that the assistants help by repositioning patients if the nurse is busy. The paging system "can be unnerving, but it's all worth it in the end," he adds. "A little prevention goes a long way."

The hospital had also been using inflatable air mattresses that patients would take home at discharge, charging the bedding to patients' hospital bills. But after a pilot program showed a sharp reduction in pressure ulcers in two units that used pressure-relieving mattresses, the hospital spent $246,000 to buy 312 AtmosAir mattresses, supplied by San Antonio-based Kinetic Concepts Inc., as permanent medical equipment for the hospital.

Owensboro has reduced the incidence of skin breakdown at the hospital to 3% of patients from 24% in 2000, preventing an estimated 474 pressure ulcers from March 2003 to March 2007. That comes to a savings of as much as $1.9 million on treatment costs, and $97,457 in supply costs, "not to mention the harm to patients we've prevented," says Ms. Sims. Last month, the hospital initiated a policy requiring that all patients undergo a "four-eyed body check" on admission, with two nurses checking patients from head to toe; patients can refuse, but the refusal will be documented in the medical record.

AtmosAir mattress has a system of valves that allows air to move between cushions to adjust to the patient weight and minimize pressure. Hospitals can rent or purchase the mattresses, which cost about $1,000 each. Lynne Sly, president of Kinetic Concepts' therapeutic surfaces division, says families and caregivers can help by asking if hospitals are following prevention programs and by asking for special beds. "If an elderly patient who is 90 pounds and thin-skinned is admitted to the hospital, the family or caregiver should be asking what alternatives they have," Ms. Sly advises.

Collaborative efforts among groups of hospitals also show promise. A two-year effort sponsored by the New Jersey Hospital Association with 150 hospitals, nursing homes and home-care agencies had reduced the incidence of new pressure ulcers by 70% as of last month. Participants adhered to guidelines that included performing a complete skin assessment within eight hours of admission, evaluating patients' nutritional status and repositioning patients frequently.

Aline Holmes, the association's senior vice president of clinical affairs, says in some cases, hospitals found that patients in operating rooms weren't positioned carefully or placed on surfaces with adequate padding. And in other cases, frail, elderly patients were being held in emergency rooms for a long period of time on thin mattresses that exacerbated conditions in already-frail skin.

Hospitals are using different strategies to motivate their staff to follow prevention protocols. Genesis Medical Center in Davenport, La., developed a program with the acronym TOE -- for Turn, Overlay and Elevate: Turn the patient to prevent bedsores, overlay beds and chairs with special covers to prevent long contact, and elevate bony prominences such as heels to prevent long contact with surfaces.

OSF St. Francis developed an SOS team -- an acronym for Save Our Skin -- on each patient-care unit. In addition to the Olympic theme song played over the audio system, nurses and technicians get a page every two hours with the message "please turn your patients now." The hospital says it reduced the rate of pressure ulcers from a baseline of 9.4% in 2002 to 1.5% in December 2006, where it remains. 

Source: Wall Street Journal, 5 September 2007