A bedsore, more properly known as pressure ulcer, is an area of skin and tissue that has become damaged. Pressure ulcers usually happen when a person is in a sitting or lying position for an extended period of time without shifting his or her weight. The continuous pressure against the skin causes a decreased blood supply to that part of the body. Without a normal blood supply, that part of the body cannot survive and the affected tissue dies.
In spite of progress in technology the occurrence of pressure ulcers remains unacceptably high. Using supporting surfaces, repositioning patients, moisturizing a patient’s skin, and optimizing a patient’s nutritional status are considered appropriate strategies to prevent pressure ulcers. According to the European Pressure Advisory Panel, “protein and calorie supplementation, along with the use of arginine, vitamins and trace elements with antioxidant effects appear to have a positive effect on healing.”
Unfortunately, according to the Nutrition Screening Initiative an estimated 40% to 60% of hospitalized older adults, 40% to 85% of nursing home residents, and 20% to 60% of home care patients are malnourished or at risk of malnutrition.
A study in the April 2007 issue of American Journal of Nursing examines the incidence and high cost of pressure ulcers and presents the results of an implemented protocol to reduce the occurrence of this widespread problem.
The study notes that “of more than 27 million deaths reported in the United States, pressure ulcers were listed as a cause of in 114,380, or 0.4%, of those deaths; in 21,365 (18.7%) of these, they were the primary (or underlying) cause of death.” That is equivalent over 300 deaths occurring each day in the United States where a bedsore is considered one of the causes.
The National Pressure Ulcer Advisory Panel (NPUAP) determined that the incidence of pressure ulcers in acute care settings ranged from 0.4% to 38%. In 1998, “the mean hospital cost per patient for treating a pressure ulcer was $15,760.”
Despite the seriousness of this problem hospitals and other healthcare settings are still plagued with high rates of pressure ulcers. Although guidelines and protocols for pressure ulcer prevention have been developed, “many physicians and nurses report feeling that they lack education regarding pressure ulcer management, suggesting that guidelines are not reaching their intended audience.”
Clinical nurse specialists (CNS) instituted a Pressure Ulcer Prevention Protocol Interventions, or PUPPI, at the Ohio State University Medical Center in Columbus Ohio. The protocol is a nursing initiative that involves assessing risk and nutritional status, providing skin care, documenting, and giving referrals as needed.
Pressure ulcer treatment protocols have shown a decrease in incidence “by almost 90% in nursing homes and almost 25% in critically ill patients.” Implementation of pressure ulcer management at one large teaching hospital showed a 55% decrease in pressure ulcer incidence after 2 years.
The PUPPI was instituted starting in September of 2004. The staff was provided with information and a number of tools to implement the protocol. As this was a new venture that required change and involved extra work, there was an additional effort to provide education, mentoring, and support.
The first quarter after implementation the pressure ulcer prevalence decreased from a benchmark of 12.65% to 4.11% for all ulcers and from 6.84% to 2.05% for hospital acquired pressure ulcers.
According to the study’s lead author, Kimberly Catania, rates continue to be lower at 5.59% for all pressure ulcers and 2.10% for hospital acquired pressure ulcers in November of 2006, and 8.53% for all pressure ulcers and 3.10% for hospital acquired pressure ulcers in February of 2007.
The study concludes, “While the unit CNSs have championed this process and continue to monitor the program, it has been the nursing staff who have embraced evidence-based nursing practice and brought it to the bedside by adopting the initiative into daily practice. They have become proactive rather than reactive regarding skin care issues. Their improved communication and critical thinking have had a significant impact on patient care and quality and outcomes.”
If you wish to find out more about the PUPPI program please contact Kimberly Catania at
Source: American Journal of Nursing, April 2007