Hospital-acquired pressure ulcers (HAPU) or bedsores e also called pressure sores or pressure ulcers e are injuries to skin and underlying tissues that result from prolonged pressure on the skin. Bedsores most often develop on skin that covers bony areas of the body, such as the heel, ankles, hips or buttocks. People most at risk of bedsores are those with a medical condition that limits their ability to change positions, requires them to use a wheelchair or confines them to a bed for prolonged periods. Bedsores can develop quickly and are often difficult to treat. Several care strategies can help prevent some bedsores and promote healing.

1. Project Zero Towards Nursing Never Events - Reduction of
Hospital Acquired Pressure Ulcers

2. Apollo Medicine 2012 September
Volume 9, Number 3; pp. 282e286
Article on Quality
Project zero towards nursing never events - reduction of hospital
acquired pressure ulcers
Gaurav Loriaa,b,*, Jammala Saritha Margaretc
ABSTRACT
Hospital-acquired pressure ulcers (HAPU) or bedsores e also called pressure sores or pressure ulcers e are
injuries to skin and underlying tissues that result from prolonged pressure on the skin. Bedsores most often develop
on skin that covers bony areas of the body, such as the heel, ankles, hips or buttocks.
People most at risk of bedsores are those with a medical condition that limits their ability to change positions, requires
them to use a wheelchair or confines them to a bed for prolonged periods.
Bedsores can develop quickly and are often difficult to treat. Several care strategies can help prevent some bedsores
and promote healing.
Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved.
Keywords: Bed sores, Clinical pathways, Back care, Bundles
EPIDEMIOLOGY
Pressure ulcers are lesions caused by unrelieved pressure
that results in damage to the underlying tissue. Generally,
these are the result of soft tissue compression between
a bony prominence and an external surface for a prolonged
period of time. The consequences of pressure-induced skin
injury range from non-blanchable erythema of intact skin to
deep ulcers extending to the bone. The ulcer imposes
a significant burden not only on the patient, but the entire
health care system.
It is universally considered nursing’s greatest challenges
and is among the most costly, most prevalent and most
widely endorsed of all nursing sensitive quality measures.
THE PRESSURE ULCER THAT TOOK DOWN
SUPERMAN
It is now fairly known that it was in fact a pressure ulcer
that took the life of Christopher Reeve e the Superman.
a
Nearly 9 years following his spinal cord injury, he developed a wound that became severely infected. He died in
October 2004 following a cardiac arrest at the age of 52
(Fig. 1).
THE STUDY
Red flag
Pressure ulcers increased to 29 (number of patients) in
August 2011 from an average of 7 per month.
Grade 1 ulcers were not even identified for some time
and they turned into grade 2.
Inadequate hand offs related to pressure ulcers.
Lack of nursing care due to lack of knowledge about
pressure ulcers.
Skin care was documented but not given/inadequately
given on the ground.
Coordinator Quality, bNational Head Quality, cExecutive Quality, Apollo Hospitals, Hyderabad, India.
Corresponding author. email: gaurav_l@apollohospitals.com
Received: 18.6.2012; Accepted: 29.6.2012; Available online: 14.7.2012
Copyright Ó 2012, Indraprastha Medical Corporation Ltd. All rights reserved.
*
http://dx.doi.org/10.1016/j.apme.2012.06.007

3. Project zero towards nursing never events
Article on Quality
Fig. 1 Common pressure ulcer points.
PLAN
A
C
T
PDCA Cycle for
HAPUs
D
O
CHECK
Fig. 2 PDCA cycle.
283

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Apollo Medicine 2012 September; Vol. 9, No. 3
Loria and Margaret
Fig. 3 Cause & effect diagram for HAPUs.
Aim: to reduce the hospital-acquired pressure ulcers to
near zero & sustain the same.
Objectives: initial skin assessments, timely care, set
processes & protocols.
Priority aims:
d Decrease
the incidence of pressure ulcer
development
d
d
d
d
Assess all patients for risk of developing a pressure
ulcer
Skin assessment/inspection of patients’ from headto-toe
Patient-specific pressure ulcer prevention care plan
documentation in the medical record
Patient & family education for prevention & care
of pressure ulcers.
Process: PDCA methodology (Fig. 2) was adopted and
a cause and effect diagram (Fig. 3) for the increased number
of bedsores was designed.
The team sought to deliberately identify the challenges
and imperatives to the prevention of pressure ulcers.
Indeed, the team spoke to many doctors and nurses over
and over again and listed down the initiatives.
d
Optimal assessments e ensuring accurate staging
(interdisciplinary approach)
d
Simplify urgent interventions
d
Provide a 360 approach to patient care/prevention
of pressure ulcers
Implementation: pressure ulcer bundles, HAPU clinical
pathway, Braden scale, pressure ulcer prevention (PUP)
team, back care protocols.
Pressure ulcer prevention tool included:
d
Complete head-to-toe assessment of the patient
d
Risk assessment using Braden scale
d
Order Nutritional Consult
d
Turn and position patients every 2 h
d
Use moisturizers.
Key tasks: daily monitoring rounds, immediate
reporting of any HAPU to the HAPU team.
Team: quality systems, nursing, infection control team,
Microbiologists, intensivists.
Pilot: one month.

5. Project zero towards nursing never events
Article on Quality
285
Fig. 4 Pressure ulcer prevention pathway.
METHODOLOGY CALCULATIONS
Inclusions
Numerator statement
All in-patients.
Number of patients developing pressure ulcers/bedsores
after 24 h of admission into the hospital.
Exclusions
Patients admitted with pressure ulcers/bedsores and all outpatients.

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Apollo Medicine 2012 September; Vol. 9, No. 3
Loria and Margaret
Benefits: timely patient assessments, set processes
protocols, team formation.
CONFLICTS OF INTEREST
All authors have none to declare.
FURTHER READING
Fig. 5 Trend of pressure ulcers over a period of time.
The prevalence of HAPU is operationally defined as
the number of patients with HAPUs divided by numbers
of patients observed.
Data collection analysis: HAPU team, pressure ulcer
prevention audit tool, monthly analysis presentation to
the HAPU team.
Initiatives:
Daily rounds by the ICN, ANS, back care Nurse.
HAPU team to assigned areas.
Pressure ulcer prevention chart in each file.
Braden scale as a part of daily assessments in the nursing
assessment form.
Non compliances reported to the Nursing Director as
well as the Microbiologist on a daily basis (Fig. 4).
Sustenance: continuous audits, trainings, data analysis.
The trend: (Fig. 5).
PERCENTAGE COMPLIANCE:
Prior: No standards protocols in place. 50% skin care was
found.
Target: 99% compliance to skin care 1 case per 1000
hospital discharges.
Achieved: 100% compliance zero cases per 1000
hospital discharges were found without a single HAPU.
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