By Lindsay D. Andronaco RN, BSN, CWCN, WOC, DAPWCA, FAACWS

Is your facility taking hospital-acquired pressure ulcers, or HAPUs, seriously? This has become a hot button issue for CMS over the last five years. I must say that I hear constant complaints about staffing issues and that is why the patient ended up with a HAPU. I can see how this may be one piece of the puzzle, but overall there are many other factors to why one gets a HAPU. From my experience as a wound care specialist and consultant, I feel that the reasoning for HAPUs is multifaceted.

Possible Causes of Hospital-Acquired Pressure Ulcers

End of life and multi-system organ failure, under-diagnosed palliative patients, tubes and drains, inadequate nutrition, poorly controlled blood sugars, under utilization of offloading materials and mattresses, improper use of absorbent products or creams, as well as failure to use devices like a Hoyer lift all can worsen or cause pressure ulcers.

The Importance of Proper Pressure Ulcer Documentation on Admission

In the case of describing a HAPU, the nurse on admission must document properly or it doesn't count. The patient could come in with a TIA and a stage III pressure ulcer, but everyone is worried about the TIA and no one documents the pressure ulcer. That then means that when the TIA is handled, perhaps day three, the RN then documents the stage III. It appeared that the stage III occurred in the hospital. Currently, stage III and IV pressure ulcers, if they happen during an admission, are not reimbursable at all and are reportable offenses to the state. Also, all too often there is a failure to document properly that the patient had a deep tissue injury (DTI) on admission or the nurse incorrectly staged it or even called it a bruise and not a DTI. This can also become an issue in documentation, reimbursement, and professional as well as hospital liability.

Overall, I cannot justify in my experience that HAPUs directly relate to understaffing and nursing burn out. I will say that nurses are pulled away from the bedside more often due to the changes in health care. A staff nurse has an EMR to constantly update, providers to call, discharge paperwork to do, and all too often are not at the bedside doing the physical care. The physical care may be done by the RN but a key role is played by the CNAs/MAs. The physical care may be giving baths, getting patients up to chairs, changing after an incontinence episode, positioning the patient, and doing a dressing change.

That being said, I feel that some solutions to this are having turning teams, a WOC nurse/consultant, SKIN/SWAT team, and doing real time problem solving/quality analysis are tools that you can use to help the team best care for the patient. Also, having the proper supplies at the ready for the staff and having the bedside staff being properly educated are just key components to preventing HAPUs.

About the Author
Lindsay (Prussman) Andronaco is board certified in wound care by the Wound Ostomy Continence Nursing Certification Board. She also is a Diplomate for the American Professional Wound Care Association. Her clinical focus is working with Diabetic Limb Salvage/Surgical/Plastic Reconstruction patients, though her interests and experience are varied and include surgical, urological and burn care, biotherapeutics and Kennedy Terminal Ulcer research. Lindsay is the 2011 recipient of the Dorland Health People's Award in the category of 'Wound Ostomy Continence nurse' and has been recognized in Case In Point Magazine as being one of the "Top People in Healthcare" for her "passionate leadership and an overall holistic approach to medicine."

Lindsay is board certified in wound care by the Wound Ostomy Continence Nursing Certification Board. She also is a Diplomate for the American Professional Wound Care Association. In 2011, Lindsay was honored with the Dorland Health People's Award in the category of 'Wound Ostomy Continence nurse.'

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.