ANAHEIM –– Nephrology nurses monitoring the care of their hospitalized hemodialysis patients can use a specially designed protocol to reduce the risk of bed ulcers.

Mary Ann Sarantos, BHA, RN, CCRN, CDN, Amy Hubbard, BSN, RN, CNN, and David C. Smith, DNP, RN, ANP-BC of Scottsdale (Ariz.) Healthcare described the protocol in their abstract, “A nephrology nurse designed skin surveillance protocol to identify hospitalized hemodialysis patients at increased risk for hospital-acquired pressure ulcer formation,” at the 45th annual American Nephrology Nurses Association meeting here.

“A review of hospital-acquired pressure ulcer (HAPU) data for a community hospital system revealed that chronic kidney disease was a significant contributing factor for HAPU formation. This is consistent with findings that link changes in physical status typically seen in chronic kidney disease with pressure ulcer (PU) formation,” the authors wrote. “HAPUs are associated with untoward patient and financial outcomes. Additionally, HAPU formation is a CMS ‘never event’ and is also included among the National Database of Nursing Quality Indicators as a nursing-sensitive outcome.” A "never event" means that CMS will not pay for treatment if the condition could have been prevented.

In response to the hospital HAPU data, the Scottsdale Healthcare acute dialysis nursing staff developed an evidence-based protocol to determine patients at increased risk. All new admissions to the acute dialysis unit were given a full body skin exam by either a certified dialysis or certified nephrology nurse. Any existing alterations in skin integrity were documented in the patient record. The patients were also assessed for factors that placed them at increased risk for HAPU formation including friable skin, 1+ or greater generalized edema, limited mobility/unable to independently turn in bed, and altered mental status. Patients who were deemed to be at increased risk were referred to the Wound Care Consultation Service.

All referred patients were then placed on the pressure ulcer prevention protocol.

Results
A review of nine months of data with the protocol in place showed that 9% (56 of 613) of the hemodialysis patients were at increased risk and referred for aggressive HAPU prevention management. “This protocol benefits vulnerable hemodialysis patients who are at increased risk of HAPU formation,” the authors wrote.