Heel Pressure Ulcers: Identification and Prevention

Purpose:
In an effort to decrease heel pressure ulcers and improve patient outcomes, specific patients were identified to being at risk for heel pressure ulcers. This was inclusive of patients with a Braden score of 18 or less, whereby the “Skin Protocol” was initiated.

Relevance/Significance:
Hospital acquired pressure ulcers not only cause patients severe pain and discomfort, but also increase morbidity and mortality rates, length of stay, hospital costs and work-load of staff nurses. Pressure ulcer prevention requires early identification and rapid intervention.

Strategy and Implementation:
This nurse driven protocol included an identification band applied to the patient's wrist and skin barrier applied to the patient's heels. Heels were elevated with pillows every two hours, or as needed. Patients with a Braden score of 15 or less, utilized a decision tree to determine whether the patient should be provided with a heel-off loading device. If the patient was non-ambulatory, has a Braden score of 15 or less, and had at least two co-morbidities (Diabetes Mellitus, hemi paresis, unconscious, spinal cord injury/head injury, trauma, impaired perfusion, leg compartment syndrome, Multi System Organ Failure, leg/hip fractures, stroke, quadreparesis, age 65 or greater, decreased sensation, PVD, malnutrition, or CHF) the offloading device was utilized. A skin integrity questionnaire was completed upon commencement and at termination of the pilot to measure the education and engagement of the nursing staff.

Evaluation:
Through education of staff and identification of the high-risk population, along with the use of the “Skin Protocol” band and offloading devices when necessary, a decrease in heel pressure ulcers by 50% was expected and trending of data is ongoing. The questionnaire will be provided every six months for continual evaluation of the education and need for reinforcement of the “Skin Protocol”.

Implications for Practice:
The nurse driven protocol is an evidence-based approach that allows for nurses to make clinical decisions regarding the skin integrity of patients at high risk for heel pressure ulcers.