CAPTION: A stock photo of a pressure sore on a patient's buttock.

A common-cause analysis of 17 serious (stage 3, 4 or unstageable) pressure ulcers occurring between April and December 2007 at University of Minnesota Medical Center, Fairview revealed lack of documentation, knowledge and resources as common themes, says Christy Green-Swarthout, Fairview quality consultant.

Medical center staff conducted the analysis after Fairview reported to the state eight serious pressure ulcers as part of the most recent adverse health events reporting cycle. The number is up from four the previous year.

"Staff awareness and education will be key to prevention," says Green-Swarthout. "Skin-care champions will present best practices, and we're encouraging peer-to-peer awareness."

Physicians play a key role in preventing pressure ulcers, according to Lea Hietala, RN, CWOCN:

• Document pressure ulcers present on admission.

• Document hospital-acquired pressure ulcers if they occur.

• Order monitoring of treatment devices known to cause pressure ulcers, such as braces, casts, TEDs or NG tubes.

• Document when and why a patient is unable to reposition, and re-evaluate positioning limitations

routinely.

• Order consults from wound, ostomy and continence nurses (WOCNs) for staging and treating pressure ulcers.

"Physicians also can impact nutritional status and pain control," notes Marijane Hauer, RN, CWOCN. "Feeding a patient sooner rather than later, following nutritional consult recommendations and controlling patients' pain so they are willing to be repositioned are all key to pressure ulcer prevention."

Serious pressure ulcers represent one of the most common adverse health events, constituting 34 percent of events statewide for the last reporting period. Reported pressure ulcers likely will increase during the current reporting cycle because the Minnesota Department of Health has expanded the category to include unstageable ulcers. An unstageable ulcer is a full-thickness skin injury with necrotic tissue throughout the base. Eight of the 17 pressure ulcers studied were unstageable.

For more information, contact Green-Swarthout, 612-273-6311, cgreen2@fairview.org, or Hietala, 612-273-1906, lhietal1@fairview.org.

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