A recent Quality Improvement initiative introduced at the Veterans Administration Boise Medical Center found the Leaf Patient Monitoring System to be the first practical technology that improves both patient care and system efficiency by monitoring and coordinating patient turning. In the absence of comprehensive studies to determine who should be turned to prevent the development of life-threatening pressure ulcers, this new technology offers a significant leap forward in patient care because it enables clinicians to monitor patients at all risk levels and stop depending on easily misinterpreted medical guidelines that healthcare has relied on since the Braden Scale was introduced in 1987. Studies1,2 have repeatedly shown that patients perceived to be at lesser risk under the Braden Scale have, in fact, developed pressure ulcers that require significant care, including extended hospital stays.


The standard of treatment for pressure ulcers

It’s no exaggeration to say that the standard approach to pressure ulcer prevention has, for the last 156 years, been to turn patients every two hours. While that approach may have been practical in 1859 when the guidelines were first developed, staffing costs today make it impossible to meet the two-hour standard. The Braden Scale’s introduction was important because it provided guidelines for assessing risk and, as a result, identifying patients who need more intensive staff attention.

The Braden Scale, along with the Norton Scale commonly used in Europe, are tools to optimize staff deployment and workflow but were never studied in many of the clinical settings where they are being used, such as the intensive care units of hospitals. And these scales are deficient because, while they are based in science, they rely on the interpretations of individual clinicians to assess each patient’s risk. That explains why so many “lesser risk” patients develop pressure ulcers that lead to prolonged hospital stays.

The difficulty of accurately completing the scales and using them to develop appropriate, timely interventions poses a significant problem. In the U.S. alone, more than one million hospital patients will develop a pressure ulcer this year. Recent studies have shown that an estimated 3.5% to 4.5% of all hospitalized patients develop potentially preventable, hospital-acquired pressure ulcers.3 And those wounds can be deadly. The Department of Health and Human Services says that up to 60,000 people a year die from pressure ulcers.4


Pressure ulcers: Serious, costly problem

Stages of pressure ulcers
Stages of pressure ulcers

Pressure ulcers form when sustained pressure on a given area of the body causes tissue compression and impairs blood flow to affected areas. If surface pressure is not relieved, the resulting shortage of blood flow can lead to localized tissue damage and cell death. Pressure ulcers initially appear as areas of reddened or discolored skin but can quickly develop into large open wounds if interventions are not initiated.

Studies have shown that the development of a pressure ulcer independently increases the length of a patient’s hospital stay by 4-10 days. The extended time in the hospital, combined with the severity of the wound, makes pressure ulcers expensive to treat. For example, the cost of treating a pressure ulcer ranges from $2,000 to $20,000 per ulcer, depending on severity. The Society of Actuaries has calculated that the overall incremental cost of treating an average pressure ulcer is $10,700.5 Federal studies show the nation’s healthcare system spends at least $10 billion a year to treat hospital-acquired pressure ulcers.6 Since virtually all of the nation’s 5,700 hospitals have the problem, the average hospital spends more than $1.7 million to treat pressure ulcers each year. And much of that expense must be covered by the hospital. Because they are largely avoidable, the Centers for Medicare & Medicaid Services discontinued reimbursement for hospital-acquired pressure ulcer treatment in 2008, thus increasing the demand for early-stage prevention.


The advantage of wireless technology

The Leaf system we deployed helps to increase staff efficiency because it identifies the individual patients who specifically need to be turned, enabling nurses to focus their time and energy on patients who are at greatest risk of developing pressure ulcers. The side benefit is that the system also allows us to not disturb patients who are turning themselves and, therefore, are at lower risk.

Overall, the technology increases compliance with turn protocols. Some studies have found industrywide compliance with turn protocols to be as low as 15%. Studies of the efficacy of Leaf technology have found compliance to reach 90 percent when the sensors are used. And, the technology has helped institutions to improve staff productivity. The system ensures that patients experience adequate tissue decompression time between repositionings so that patients who turn themselves back to their favored side do not over-pressurize a body area.

By using the sensors on most or all patients, the Leaf System enables clinicians to overcome the problems that often result from misinterpretation of the Braden scale. And it certainly allows healthcare providers to optimize their clinical staff workflow by allowing them to focus their attention on those patients who need it most, while at the same time ensuring that no patient is neglected. This can help to eliminate pressure ulcers from the list of medical mistakes that commonly occur in American hospitals.

1. Jenkins ML, O’Neal E. Pressure ulcer prevalence and incidence in acute care. Adv Skin Wound Care. 2010;23(12):556-9.
2. Johnson J, Peterston D, Campbell B, Richardson R, Rutledge D. Hospital-acquired pressure ulcer prevalence – evaluating low-air loss beds. J Wound Ostomy Continence Nurse. 2011;38(1):55-60.
3. Hospital-acquired pressure ulcers: results from the national Medicare Patient Safety Monitoring System study. Lyder, et al. J Am Geriatr Soc. 2012 Sep;60(9):1603-8.
4. http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcertoolkit/putool1.html
5. Society of Actuaries’ Health Section. Economic Measurement of Medical Errors. Schaumburg, IL: Society of Actuaries; 2010.
6. Are We Ready for This Change? Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. April 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcertoolkit/putool1.html

Statement from Dr. Doucette re: financial interest: “I have no financial interest in Leaf Medical or any related company or technology, nor does any family member. My involvement consisted of a clinical trial in our hospital.”

Margaret Doucette
Margaret Doucette, MD is the Medical Director of the Center for Wound Healing and Hyperbaric Medicine clinics in Boise and Meridian, Idaho. She is also the Director of the PACT (prevention of amputation) and Wound Programs at the Boise VA Medical Center and is a Clinical Instructor through the University of Washington in Seattle, Washington. She received a DO from the University of Osteopathic Medicine and Health Sciences, Des Moines, IA, 1984, did her internship at Des Moines General Hospital, and her residency in Physical Medicine and Rehabilitation at the University of Minnesota, Minneapolis, MN.



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