Hospital Acquired Conditions

Reliable Care for Patients at Risk of Hospital Acquired Pressure Ulcers

By Tim Gee (Principal, Medical Connectivity Consulting)


Quality health care delivery has never been more achievable. Our knowledge of human physiology, diagnosing and treating disease is comprehensive. The armamentarium of diagnostic tools, therapeutic modalities and patient monitoring capabilities is considerable. So why do adverse and sentinel events continue to plague health care delivery?

Any human endeavor is imperfect, in both knowledge and execution. Some imperfections in health care delivery are based on limited knowledge of biology and disease or poorly designed systems of care delivery. Overcoming these limitations entails the application of the scientific method to the systems of diagnosing and treating disease.

The patient care environment itself often hinders executing best practices for health care delivery. The prevalence of pressure ulcers, in most cases an easily preventable adverse event, typifies the frequent challenges facing health care providers and their patients. Many routine patient care tasks are critical to patient safety and positive patient outcomes. Examples of such routine tasks include patient turns, which prevent pressure ulcers, medication administration that avoids multiple adverse events, and respiratory circuit flushing that avoids ventilator-acquired pneumonia. Increased mortality and morbidity often result from missed, incomplete or interrupted routine patient care tasks.

An estimated 2.5 million patients are treated for pressure ulcers in acute care facilities each year. The estimated cost of managing a single full-thickness pressure ulcer is as high as $70,000, and the total cost for treating pressure ulcers in the United States is estimated at $11 billion annually.1 In 2008, the Centers for Medicare and Medicaid Services (CMS) classified pressure ulcers as a preventable Hospital Acquired Condition (HAC) that will no longer be reimbursed by current insurance guidelines, forcing the costs of treating hospital acquired pressure ulcers on to provider organizations.

According to CMS and the Centers for Disease Control (CDC), pressure ulcers are the most prevalent preventable hospital acquired condition. Yet one key to prevention of pressure ulcers is simplicity itself: turn and reposition at-risk patients at routine time frames to reduce pressure. The persistent challenge presented by pressure ulcers is a consequence of challenges inherent to patient care areas where patients are diagnosed and treated.

Patient Care Environment

Factors contributing to make the patient care environment hazardous start with the unpredictable nature of patients and the struggle to both ensure routine tasks are completed and respond to unforeseen or difficult to anticipate occurrences. Unlike the orderly and predictable manufacture of widgets, patients can be anything but predictable. Patients often exhibit their own unique combination of symptoms, response to therapy, progress and setbacks on their path to discharge. This patient variability contributes to an interrupt driven patient care environment where tasks – often complex and high risk – are completed with difficulty, if at all.2

Effective pressure ulcer prevention is often compromised by emergent demands and frequent interruptions that can drive this critical but routine preventive activity to the bottom of a work list where it can remain uncompleted. Current best practice (identifying at-risk patients and turning them every two hours) has proven to be marginally effective and difficult to sustain because consistent implementation is difficult to achieve.

Technology has significantly improved diagnostic capabilities and therapeutic outcomes by way of new and improved medical devices. Likewise, information technologies have been applied to patient care environment workflow issues to improve outcomes and reduce length of stay. Unfortunately, research has shown that the application of technology does not transform the interrupt driven nature of care delivery3 – if such a thing is even possible.

To date, efforts to ensure that patient turns and a myriad of other routine but important patient care activities are reliably completed have depended on poorly applied technology4 or manual “best practice” efforts driven by management. Progress towards reducing the incidence of pressure ulcers has been inadequate. Likewise, efforts to eliminate the occurrence of pressure ulcers using technology to transform the clinical environment into something more predictable where routine tasks can be reliably completed has failed. While the causes, prevention and cures for pressure ulcers are known, what is needed is a technology solution that actually works in spite of the challenges presented by typical clinical environments.

Conventional Notification Methods

Point of care activities can be divided into routine “as activities allow” and interruptions resulting from emergent situations or interactions with patients, family or staff. Routine activities may be scheduled for completion at specified times or as part of a work list of activities to be completed in a shift. Interruptions regularly result in failures to successfully complete required routine tasks every shift.5

Activities in response to emergent situations should be done as soon as possible. Alarms, alerts and similar indicators are intended to interrupt routine “as activities allow” types of tasks in response to critical situations. By their nature, emergent situations cannot be scheduled, nor can their frequency be determined in advance.

Tasks undertaken “as time allows” are often routine tasks driven by work lists derived from electronic medical records (EMRs) and other systems. Examples include recording vital signs, medication administration, coordinating patient care, patient turns and more. Added to this mix of emergent and routine tasks are communications required for discharge planning, physician communications and patient education. Much of this communication occurs in real time, meaning that time must be taken from other activities.

A predominate method of notifying caregivers of emergent situations is the use of alerts and alarms generated by medical devices and communications devices. Conventional alerts and alarms annunciate at the onset of an alarm condition such as when an alarm parameter is exceeded. These alarms may be silenced at the device, or sometimes remotely, for a predetermined period of time. Typically alarm conditions must be eliminated to cancel or terminate an alarm. Alerts and alarms are intended to notify caregivers of emergent or unanticipated events.

Conventional work lists are intended to drive routine “as activities allow” tasks. Work lists may also be used to manage the completion of routine tasks within specific time frames, such as medication administration and patient turns, or to help assure routine tasks are simply completed by end of shift. With no active annunciation, work lists are poorly suited to ensure that unanticipated transient events do not result in incomplete routine tasks. Transient events can overwhelm caregivers, precluding caregivers from accomplishing routine tasks, and routine tasks interrupted by transient events may never be completed.

Activities such as turning patients to prevent pressure ulcers are time sensitive like emergent events, yet flexible similar to “as activities allow” events. Bed turns can be done early, on time, or perhaps occasionally even on a slightly delayed basis without reducing effectiveness.


Certain adverse events, such as pressure ulcers, fall into this category of preventive activity that is easily overlooked or forgotten in today’s busy interrupt-driven point of care environment. Years of education, awareness building and best practice development have done little to eliminate these preventable hospital acquired conditions. New technologies are available that can be applied in new and unique ways to better match a technical solution to the actual environment found at the point of care in acute care hospitals.


1. Lyder CH. Pressure ulcer prevention and management. JAMA. 2003;289(2):223–226.

2. Cornell P, Transforming Nursing Workflow, Part I, JONA, Vol. 40, No. 9, pp 366-373.

3. Cornell P, Transforming Nursing Workflow, Part 2, JONA, Vol. 40, No. 10, pp 432-439.

4. Koppel R, Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety, JAMIA, Vol. 15, No. 4, pp 408-423.

5. Tucker A L, Operational Failures

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