2011 Review

Thanks to all who have supported the efforts of the National Decubitus Foundation during 2011.  The year began with the NDF presentation at the 12th NPUAP Biennial Conference in Las Vegas, with financial support from the Christopher and Dana Reeve Foundation.  There we were able to inform many of the leaders in bedsore prevention of the NDF Prevention Protocol, and to distribute many copies of the NDF prevention study.  The highlight for me was meeting Barbara Braden PhD, author of the Braden Scale, and hearing her agree that many hospitals have been able to drive their incidence rates to near zero by implementing the findings of the NDF study.

The best news of the year came from the National Database of Nursing Quality Indicators, sponsored by the American Nursing Association.  For the first time since the survey started in 1998 it showed a meaningful reduction in hospital-acquired pressure ulcer incidence.  Whereas the incidence for 2004 and 2006-2007 held steady a t 6.4%, 2010 showed a drop to 3.8% (2.7% excluding Stage 1 ulcers).

In April Medicare published, over American Hospital Association objections, the first hospital-specific patient safety data, including serious pressure ulcers, to be released nationally. Low-G Technologies announced a promising new mattress overlay based on a material used successfully for years to relieve pressure for fighter pilots on extended missions.

In a call to the office of Senator Bob Gordon, co-sponsor of the bill requiring New Jersey nursing homes to change all mattresses to pressure redistrbution types by April 2012, we learned that there has been no major resistance from nursing homes and that compliance with the law is expected.  We followed that by sending letters to chairs of senate health committees in all 49 other states informing them of the New Jersey law and urging them to do likewise.

In October a story in the Sacramento Bee described the backing of the California Hospital Association (CHA) for the efforts of several of its member hospitals that, in effect, implemented the NDF Prevention Protocol.  Several hospitals had greatly reduced pressure ulcer incidence by assessing risk for all admitted patients, and placing those at risk on special pressure redistribution mattresses.  During 2012 we will inform all state hospital associations of this action by the CHA, and urge them to adopt a similar policy position.

California Hospital Association Endorses NDF Prevention Protocol

The Califonia Hospital Association has undertaken a major initiative - Advancing Safe Patient Care.  As a part of that initiative, whether they realize it or not, the CHA has endorsed the methodology of the NDF Prevention Protocol.  As a key example of the reduction in pressure ulcer incidence being achieved, they cite the Sutter Health network of hospitals as having reduced pressure ulcer incidence by 86 percent:

"Enhanced screening practices that identify and respond to the needs of 'at-risk' patients"

"A $10 million investment in special pressure relieving mattresses and surfaces for all patient beds, including those in ER's and operating rooms, dagnostic imaging and patient transport gurneys."

These are the two essential elements of the NDF Prevention Protocol.  It is exciting to realize that this progress by the CHA provides us with a dramatic opportunity to contact hospital associations in every state to educate them about the progress being made in California.

Why Progress is Slow

A press release today by researchers at the University of Toronto expresses what many of us have realized for a long time.  It is very difficult to light a fire that gets the attention of the media when it comes to pressure ulcers:

'This slow uptake of quality improvements in pressure ulcer care in Ontario may be connected to the condition's low profile relative to other diseases. "It's one of those diseases that's kind of silent," said Prof. Murray Krahn, principal investigator on the study who is a Professor in the Department of Medicine and the Faculty of Pharmacy at U of T, and Director of THETA.

"Unlike HIV or breast cancer, there are no advocacy groups marching for pressure ulcers. The patients are seniors with co-morbidities and low mobility in long-term care," said Krahn.  Compounding the condition's visibility problem is that it doesn't belong to a particular clinical group. Patients are cared for by nurses, surgeons, infectious disease specialists, general practitioners and internists, so no one group is well-positioned to champion the cause effectively'.

It continues to amaze that the necessary investment in pressure redistribution surfaces would save hospitals a considerable amount, yet most have not made that investment.

Kinetic Concepts Inc. Sold for $5 Billion

KCI is the only manufacturer of the air-fluidized bed other than Hill-Rom that we know of.  About a week ago KCI was sold for 5 billion dollars.  KCI is the manufacturer of the AtmosAir support surface, one of those identified on the NDF website as having been proven effective in preventing pressure ulcers when used in conjunction with the NDF Prevention Protocol.  Hopefully the value of this sale indicates that a strong market for effective support surfaces is expected. 

Thoughts on NDF Website

The New Jersey law requiring all nursing homes to replace all mattresses with pressure redistribution types represents the greatest hope for ending the scourge of bedsores in our lifetime.  I am thinking of redoing the NDF website (decubitus.org) to concentrate on this factor, to convince other states to follow New Jersey's lead, to explain why the requirement must be extended to hospitals, and to raise funds to finance a campaign to educate the legislatures of 49 states.

Promising New Mattress Overlay

We have recently been contacted by Low-G Technologies, LLC.  They have developed a mattress overlay that has now undergone over 40,000 patient days of use without any hint of a pressure ulcer.  We will watch the progress of this product carefully.  This may be an ideal support suface for incorporation into the NDF Prevention Protocol.

Medicare Publishes List of Worst Performing Hospitals

Medicare has just released the listing of hospitals ranked by their commission of medical errors, including pressure ulcers.  This is an opportunity for the NDF to introduce the worst performers to the NDF Prevention Protocol, and to promise followup on future performance.

Back from Las Vegas

We spent this past weekend in Las Vegas at the NPUAP 12th Biennial Conference.  The NDF had been invited to make a poster presentation. Over 500 medical professionals were in attendance, and a large proportion of those visited our poster and learned about the NDF Prevention Protocol.  About 70 attendees picked up a copy of our 2008 study, published in Advances in Skin & Wound Care, that laid the basis for the protocol.  The NDF presentation will be posted on the website, www.decubitus.org, shortly.

One presentation from the stage provided some very encouraging news.  The National Database of Nursing Quality Indicators, sponsored by the American Nursing Association, for the first time showed a meaningful reduction in hospital-acquired pressure ulcer (HAPU) incidence.  Whereas the incidence for 2004 and 2006-207 held steady at 6.4%,  2010 showed a drop to 3.8% (2.7% excluding Stage 1 ulcers).  The slides from this lecture and all of the other lectures can be viewed at  http://npuap.org/conferences.htm.  

We spoke with the bed manufacturers that displayed at the conference, and verified that many hospitals are investing in pressure reduction support surfaces for prevention purposes, thereby saving large amounts in rental costs.  Other presentations, including one by Dr. Barbara Braden, indicated that on the order of 90% of hospitals are now assessing risk using the Braden Scale within the first 24 hours.  Therefore we feel certain that the very welcome reduction in HAPU is due to the fact that some hospitals have adopted the NDF Prevention Protocol whether they realize it or not.

Require Hospitals to Provide Safe Mattresses

There is now so much evidence that effective pressure reduction support surfaces result in greatly reduced pressure ulcer incidence rates that there can be no question that hospitals must not be allowed to cause bedsores by using inferior mattresses.  All states should pass laws similar to New Jersey's requiring safe mattresses in nursing homes and hospitals. Education is a major focus of the NDF, and we must concentrate on educating state legislators about pressure ulcers and how they can take action to solve the problem.

IHI Mentor Program

The Institute for Healthcare Improvement maintains a Mentor Hospital Registry.  It can be reached from ihi.org by clicking on Programs, then Canpaign, then Mentor Registry.  Twelve hospitals are listed under Pressure Ulcer Prevention, each of which has made great strides in reducing pressure ulcers, some to zero. All twelve list names of mentors along with phone numbers and email addresses.   Nearly all mention purchase of new pressure-reducing surfaces as a factor in their success.  I sent each an email asking what support surfaces they had purchased.  Several responded, and the most mentioned surface was the HillRom VersaCare.

One of the slides for my NPUAP presentation lists hospitals that have achieved a zero level of pressure ulcer incidence, or close to it, with the heading, "If They Can Do It....."

Additional Sources

Today I located some wonderful references.  First of all, a 2008 paper by Amit Gefen, PhD, finds that a pressure ulcer can be initiated in as short a time as one hour.  This provides support to the essential element of the NDF Prevention Protocol that the at-risk patient must be placed on a pressure reducing surface immediately.

The Institute for Healthcare Improvement (IHI.org) under their Programs section has a listing of hospitals that have made significant reductions in hospital-caused PU incidence, and that are willing to serve as mentors to other hospitals.  All of them list new support surfaces as an essential element.  I plan to ask each which support surface they procured.

Most Hopeful Development

The most hopeful development since the "never event" finding by Medicare has been the New Jersey law requiring all nursing homes to replace all beds with pressure redistribution mattresses. Our focus for the foreseeable future should be on educating the other 49 states about what New Jersey has done and asking, "why don't you take the steps needed to stop allowing bedsores?"