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Use of a Diagnosis-Driven Heel Pressure Injury Algorithm.

A pressure injury is a localized injury to the skin and/or underlying tissue, usually over a bony prominence or under a medical or other device. Pressure injuries result from pressure alone or in combination with shear (National Pressure Ulcer Advisory Panel [NPUAP], 2016). More than 2.5 million patients in the United States develop pressure injuries each year. Pressure injuries are associated with severe emotional, financial, and medical consequences. In addition, more than 60,000 patient deaths are attributed to pressure injuries each year (Agency for Healthcare Research and Quality [AHRQ], 2014). Black (2012) reported $3.5 billion spent annually for treatment of pressure ulcers based on $8,730 per case among 394,699 U.S. medical insurance claims. Finally, more than 17,000 lawsuits each year are related to pressure injuries, making them the second most common claim for wrongful death. Average legal compensation per pressure injury case is almost $1 million (AHRQ, 2014). After the Centers for Medicare & Medicaid Services halted payment for stage 3 or 4 pressure injuries that occur during hospitalization, AHRQ noted additional attention to prevention.

Heels are the second most common location for pressure injuries and the primary site of deep tissue injury (41%) (Black, 2012). In a cross-sectional survey of 104,266 patients, Black found the prevalence of heel pressure injuries to be 18.2%. Heel pressure injuries (HPIs) can result in infection, amputations, increased hospital length of stay (LOS), lengthened rehabilitation, and death. HPI healing times often are prolonged, taking several months to over a year in many cases (Wounds UK, 2013).

HPIs occur as a result of prolonged, high local pressures over a small contact area (NPUAP, 2014). The unique anatomy of the heel greatly increases its vulnerability to pressure injury. As the largest bone of the foot, the calcaneus is relatively wide for its skin surface area, points toward the external surface, and is surrounded by only 18 mm of subcutaneous tissue (Arao, Shimada, Hagisawa, & Ferguson-Pell, 2013; Wounds UK, 2013). This concentrated pressure can lead to compromised blood flow, localized tissue necrosis, and ulceration. When the patient slides down in the bed or the heels are dragged across the external surface, the heel is exposed additionally to shear that can cause destruction of the deeper tissue layers (Black, 2012). Tissue compromised by maceration, friction, dryness, or altered distal perfusion is particularly vulnerable to pressure injury (NPUAP, 2014).

Project Site and Reason for Change

The catalyst for change was increasing heel pressure injury rates, even as the institutional prevalence of pressure injury decreased. In 2013, 18 HPIs and 5 heel device-related pressure injuries occurred at the project site. These occurrences were attributed to the absence of standard HPI prevention practice. The facility also had four redundant heel protection devices, complicating clinical nurses' selection of appropriate devices. Pre-implementation cost associated with the four separate heel devices was $19,970, without considering costs related to complications of care.


Of sources identified in the literature review, 31 related directly to co-morbid conditions associated with HPIs in hospitalized adult patients. These were assessed using Melnyk and Fineout-Overholt's (2011) criteria and standardized appraisal forms. Based on these criteria, the stronger the evidence, the higher the likelihood it is valid and relevant for a particular clinical situation. All levels of relevant evidence were incorporated, including expert opinion, and consisted of Level I (4 sources), Level III (11), Level IV (8), and Level VII (8).

Data were analyzed with all conditions categorized on an Excel spreadsheet in order of representation in the literature. Eleven unique at-risk populations were identified: patients age 70 or older; and patients with leg immobility, diabetes mellitus, peripheral arterial or peripheral vascular disease, neurological conditions, malnutrition, edema, or obesity. Additional at-risk groups included patients with current or previous HPIs, smokers, and persons undergoing joint arthroplasty. They were identified as the initial assessment component of the HPI prevention algorithm. The HPI prevention algorithm was created by the project leader as a two-step process. First, 11 unique populations (see Figure 1) were used to identify patients at risk for HPIs. If a patient had any of the at-risk diagnoses, the nurse would move to the next step in assessment. This used duration of leg immobility to determine appropriate heel protection intervention. At the project site, pillow offloading was used for leg immobility of 24 hours or less. If leg immobility was expected to last 24-48 hours and pillow offloading could be maintained, a multi-layer prophylactic soft-silicone dressing was indicated. If the patient's legs were expected to be immobile for 48 hours or more, the nurse was instructed to consider applying an offloading boot. This approach allowed the nurse to use his or her clinical reasoning to determine if offloading boots were appropriate for the patient. Because the project site also had a vascular boot available, an alternate path was added to the algorithm to ensure patients with vascular compromise received that product.

Evaluation and Action Plan

The HPI prevention algorithm was implemented hospital-wide as standard, expected practice. A series of SBAR (Situation, Background, Assessment, Recommendation) communications preceded implementation to describe the replaced products (including images), goals of the change, and explanations of how to apply each part of the new algorithm. The process was evaluated for adherence and patient/cost outcomes after 6 months.

Results and Limitations

The diagnosis-driven HPI prevention algorithm was instituted in March 2014 and resulted in a significant reduction in HPIs and heel device-related pressure injuries. One HPI and no heel device-related pressure injuries occurred in the post-implementation period, representing a 95.6% reduction in HPIs (n=18) and heel device-related pressure injuries (n=5). The single HPI was a stage 1 pressure injury in a patient with independent and normal bilateral lower-extremity mobility, thus not meeting inclusion criteria for prophylactic dressings or boots. A root cause analysis of this HPI found the injury occurred secondary to the patient's preference for crossing his legs in bed, and it was identified as an outlier. The resulting 100% reduction was associated with $200,790 in avoided cost (based on $8,730 per ulcer) (Griffin, Dean, Cayce, & Modrcin, 2015).

The replacement of four heel offloading devices with one effective offloading boot resulted in cost savings and elimination of waste. Post-implementation use and associated heel offloading device costs decreased by 28.7% based on an annualized boot usage of $15,522. The cost associated with purchasing the heel offloading devices was just 11.6% of projected initial investment of over $120,000. Offloading boot use was managed effectively with a cost-effective, evidence-based multi-layer soft-silicone heel border dressing (Mepilex[R] Border Heel, Molnlycke Health Care, Norcross, GA), which was already available at the study site.

Additional research is needed to delineate appropriate application beyond the acute care setting and for other at-risk populations, as well as using other prophylactic products or offloading devices. Although standardizing HPI prevention practice resulted in positive outcomes at the study site in the initial months, research is needed to determine the long-term effectiveness of this tool as well as how additional conditions may affect the risk for HPI development. Finally, scarce high-level evidence within 5 years before the project suggested additional research is needed for HPI prevention.

Lessons Learned/ Nursing Implications

Pressure injury prevention is an essential nursing intervention. Successful HPI prevention requires the nurse to understand the etiology of HPI and be able to identify at-risk patients. Nursing assessment at admission and throughout hospitalization is the foundation of this process. Coupled with standardization of evidence-based practice, this process can improve the nurse's ability to implement appropriate strategies to prevent HPI. Use of heel protective devices also can reduce the potential for heel breakdown. Nursing assessment, basic nursing care such as repositioning or offloading the extremity, and appropriate use of evidence-based protection devices can prevent HPI.

The clinical implications of a successful HPI prevention protocol include decreased morbidity and mortality, prevention of pain and discomfort, cost savings related to decreased LOS and treatment costs, decreased staff time, and avoidance of penalties associated with hospital-acquired conditions (Black, 2012; McGinnis, Greenwood, Nelson, & Nixon, 2014). The challenge is to develop guidelines that adequately identify at-risk patients, streamline nursing care processes, and promote cost-effective care. These guidelines must incorporate evidence-based practices and products to help the nurse proceed to produce optimal patient outcomes while avoiding harm.

Use of an algorithm proved to be effective for streamlining HPI prevention practice among clinical nurses at the study site. This tool allowed clinical nurses to use basic patient information to identify vulnerable persons, alleviating the need for extensive, time-consuming medical record reviews. Concurrent use of readily available medical information in conjunction with a simplified assessment process can facilitate timely, appropriate use of HPI prevention resources.


HPIs are costly and among the most challenging to heal (McGinnis et al., 2014). Pressure injuries on the heel are the second most common pressure injury overall and the most commonly occurring pressure injury in the perioperative setting. As McGinnis and colleagues noted, HPIs are associated with serious complications such as osteomyelitis, septicemia, and limb amputation.

HPI prevention can be challenging without tools to identify at-risk patients. The HPI prevention algorithm currently is used at the project site to standardize HPI prevention practice. Although its initial intent was to guide identification of patients most at risk for HPIs as a foundation for cost-conscious, effective use of the available HPI prevention devices; the algorithm has become a guide for the decision making of clinical nurses performing lower-extremity assessment by facilitating consistent, effective offloading through use of appropriate pressure-relieving devices to decrease HPI rates.

Literature Summary

* Heel pressure injury (HPI) has an 18.2% prevalence and is associated with infection, amputations, increased hospital length of stay, lengthened rehabilitation, and death (Black, 2012; Wounds UK, 201 3).

* Heels are the second most common anatomical location for pressure injuries and the primary site of deep tissue injury (Black, 2012).

* Prevention is essential because hospitals are no longer reimbursed for stage 3 or 4 pressure injuries that occur during a patient's hospitalization (Agency for Healthcare Research and Quality, 2014).

CQI Model

Plan-Do-Study-Act (PDSA) (Institute for Healthcare Improvement, 2017)

Quality Indicator with Operational Definitions & Data Collection Methods

12 month pre- and post-implementation audit of hospital-acquired HPIs, heel device-related pressure injuries, and associated costs

Clinical Setting

286-bed academic medical center in the southeastern United States

Patient Population

Hospitalized adults age 18 or older

Program Objectives

* Reduce hospital-acquired pressure injuries and alleviate heel device-related pressure injuries.

* Standardize heel pressure injury prevention practice.

* Decrease costs associated with heel offloading devices by eliminating waste and duplication.


Agency for Healthcare Research and Quality (AHRQ). (2014). Preventing pressure ulcers in hospitals: A toolkit for improving quality of care. Retrieved from https:// hospital/pressureulcertoolkit/index.html

Arao, H., Shimada, T., Hagisawa, S., & Ferguson-Pell, M. (2013). Morphological characteristics of the human skin over posterior aspect of heel in the context of pressure ulcer development. Journal of Tissue Viability, 22(2), 42-51.

Black, J. (2012). Preventing pressure ulcers occurring on the heel. Wounds International, 3(3), 1-4.

Griffin, C.C., Dean, T., Cayce, J.M., & Modrcin, M.A. (2015). Pressure ulcer prevention: Effectiveness of heel off-loading methodologies. Open Journal of Nursing, 5, 909916. doi:0.4236/ojn.2015.510096

Institute for Healthcare Improvement. (2017). Plan-do-study-act (PDSA). Retrieved from http :// HowtoImprove/default.aspx

McGinnis, E., Greenwood, D.C., Nelson, A., & Nixon, A. (2014). A prospective cohort study of prognostic factors for the healing of heel pressure ulcers. Age and Ageing, 43(2), 267-271.

Melnyk, B.M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia, PA: Lippincott, Williams, & Wilkins.

National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance. (2014). Prevention and treatment of pressure ulcers: Clinical practice guideline. Perth, Australia: Cambridge Media.

National Pressure Ulcer Advisory Panel (NPUAP). (2016). National Pressure Ulcer Advisory Panel announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury [press release]. Washington, DC: Author.

Wounds UK. (2013). Quick guide heel ulcer management. Accessed from http:// 10960.pdf

Caption: FIGURE 1.

Heel Pressure Injury Prevention Algorithm
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Title Annotation:Continuous Quality Improvement
Author:Sullivan, Rhonda
Publication:MedSurg Nursing
Article Type:Report
Geographic Code:1USA
Date:Nov 1, 2017
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