Taking the Pressure Off by Getting to the Bottom of the Problem: The Value of Expert Validation During Pressure Ulcer Prevalence Surveys

Purpose:
The primary goal was to quantify Moisture Associated Skin Damage (MASD). A secondary goal was to determine the effect expert validation by a Certified Wound Care (CWC) Nurse had during Pressure Ulcer (PU) Prevalence Surveys on the Hospital Acquired PU (HAPU) rate at an academic medical center.

Relevance/Significance:
HAPUs are a nurse-sensitive indicator considered to be a measure of the quality of nursing care. Many organizations have created teams that perform survey assessments at prescribed intervals. Although generally led by a CWC Nurse, the assessment is often done by an RN with additional didactic training. The differential assessment of pressure ulcers versus other lesions such as MASD is complex and requires expertise. Further, the staging of pressure ulcers can be challenging for the non-expert.

Strategy and Implementation:
During patient consults, the CWC Nurse observed that many skin lesions were secondary to moisture and not pressure. The presence of moisture on the skin is a risk factor for PU development. Moisture from urine, stool or diaphoresis can lead to MASD, which is known to increase the risk of HAPU occurrence. More importantly, the CWC Nurse observed that RNs and providers were often classifying MASD as pressure ulcers. To quantify and further understand the issue, the presence of MASD was added as a finding on the data collection sheets during the monthly PU Prevalence Survey. In the first four months of data collection, the number of patients with identified MASD was low while the HAPU rate remained above target. To gain further insight, the CWC Nurse began validating all potential HAPUs and MASD. When the Skin Care Team identified a potential HAPU or MASD, they would page the CWC Nurse who would re-assess the patient to determine the differential diagnosis of the identified lesion.

Evaluation:
Validation provided quantification of MASD and actual HAPUs, as lesions were often misclassified. In the first 6 months, there was a 70% decrease in the HAPU rate. In comparing 15 months of mean pre- and post- validation data, a 207% decrease in the mean HAPU rate was noted. After consistently missing targets pre-validation, HAPU rates have been below target since expert validation began.

Implications for Practice:
The findings of PU Prevalence Surveys may need validation by an expert. This may provide more accurate data of the occurrence of HAPUs and other lesions, such as MASD. The validation process described has been implemented in an academic medical center and informs quality improvement initiatives.