Pressure Ulcer and Risk Assessment Report

Background: The existing practice to track pressure ulcers at an Urban University Medical Center was for staff to complete an unusual occurrence report if a patient developed a pressure ulcer while in the hospital. The report was submitted to the Risk Management Department and the Unit Director. The Wound and Ostomy Team did not track the number of patients with pressure ulcers or patients at risk for developing a pressure ulcer. The scope of the pressure ulcer problem was unknown aside from quarterly prevalence data.

Objective: To identify daily, the number of patients with pressure ulcers and those at risk for the developing a pressure ulcer.

Methods: The electronic medical record was utilized to generate a daily report of patients with pressure ulcers and those at risk of developing a pressure ulcer. The information included in the pressure ulcer and risk assessment report was: the first time and date the ulcer was recorded, patient name, age, medical record number, length of stay, stage of pressure ulcer when first recorded, last recorded stage of pressure ulcer, site/laterality of ulcer, admit date, hours in operating room, albumin, final assessment date, last Braden score recorded, the Braden subcategories identified were used to identify risk if they fell below 2 for all categories with the exception of moisture which is below 3.

Results: The report is generated daily. The report is utilized in a variety of ways by multiple disciplines including Physical Therapy, Dietary, Risk Management, Coding, Discharge Planning, Department of Professional Development, and the Wound and Ostomy Service.

Conclusions: The database has been used to trend and analyze data on wound types and locations. The report has elucidated the need for staff education on pressure ulcer staging. There have been enhancements made to the electronic medical record to improve, ease and standardize documentation.