The low-cost, replicable solution to reducing the risk of pressure ulcers

This week, we showcase how Rajagiri Hospital won GOLD for ‘Patient Safety’ at the 2021 HMA Awards, by putting in place initiatives which significantly minimised the risk of pressure ulcers in patients.

As one of the critical pillars of quality health care, ensuring patient safety and improving patient outcomes are among the key objectives of a hospital.

Achieving them, however, are often easier said than done, although there are several major contributors that can help, including educating caregivers on proper care techniques, reducing the patient’s average length of stay (ALOS), and minimising associated health risks by employing safe bedside practices.

At India’s Rajagiri Hospital, one of the key health problems affecting their patients was identified to be decubitus ulcers, commonly known as pressure ulcers.

Pressure ulcers are localised injuries to skin and underlying tissue resulting from prolonged pressure on the skin. It often occurs on skin covering bony regions like the occipital, scapular, elbows, sacrum and heels. Factors such as poor nutrition, increased moisture on skin, prolonged pressure and compromised sensory stimuli act as catalysts for pressure ulcers.

According to data from the National Centre for Biotechnology Information (NCBI), pressure ulcers rank third based on the cost of treatment, and its mortality risk is two to six times higher compared to other disease conditions, and is responsible for approximately 60,000 deaths annually.

As a tertiary care referral hospital, Rajagiri Hospital is often referred patients with community associated pressure ulcers for therapy and nursing care. Therefore, the primary responsibility and challenge for Rajagiri was to cure the pressure ulcer, in order to accelerate the healing process and shorten the length of stay of patients, thus increasing patient satisfaction and reducing hospital expenditure for the patient in the process.

In their awards submission to HMA, Rajagiri Hospital explained: “Since pressure ulcer management is a measure of nursing quality and patient’s health status, we decided to monitor and evaluate selected category of patients by using FOCUS (Find, organise, clarify, understand, and select) and PDCA (Plan, Do, Check, Act) Methodology.”

To that end, Rajagiri started a focus group – which included patients with Community Associated Pressure Ulcers at time of admission, as well as patients that were likely to develop Hospital Associated Pressure Ulcer (HAPU) during hospitalisation – to study and categorise the contributory factors impacting the prevalence of pressure ulcers.

Ultimately, the aim of Rajagiri Hospital’s project – which was helmed by a group of staff that named themselves Team SOROZAT – was to improve patients’ health safety in community based pressure ulcer cases, as well as the safety of patients who were vulnerable to developing pressure ulcers.

For starters, Rajagiri’s nursing leaders identified the cracks in their system, and devised routines to be introduced in the nursing regime to check for pressure ulcers.

This led to the nursing team developing the TRIGON Pressure Ulcer management concept of patient care, by introducing key interventions in risk assessment, patient identification and bedside nursing practice.

These interventions included:

  • As part of initial nursing assessment process, unit-wide training was initiated to prepare nurses to conduct risk assessment of pressure ulcers based on the Braden Scale.
  • To ensure all nurses in a unit were aware of vulnerable patients in their unit, a marking system was introduced on the nurses’ information board to facilitate easy identification.
  • A 30-degree tilt position has been proven to promote circulation, increase airflow, promote healing and prevent pressure ulcer. However, physically maintaining this position with regular pillows is difficult, and without proper support, this position is uncomfortable for the patient. Hence the Triangle Cushion was introduced to tilt and stabilise the patient’s position at a 30-degree angle, to prevent the after-effects of being confined to bed.
  • The SSKIN care bundle checklist was introduced in bedside nursing care of identified patients. Additionally, Tissue Viability nurses and members of Team SOROZAT would conduct daily skin assessments of identified patients.
  • Nurses were reminded to reposition patients every two hours, which led to the introduction of the Position clock, with an alarm and visual alerts outlining the patient positioning plan, including positioning frequency and type. Based on the Position clock, the unit leader could assess if the patient had been re-positioned correctly.
  • Nurses used the PUSH Tool to monitor changes in pressure ulcer to assess the effectiveness of treatment.

In addition to conducting daily skin assessments of vulnerable patients, members of Team SOROZAT also carried out training, audits, data collection, and evaluation of the outcomes from the interventions that were introduced to the nursing practice.

The project proved to be a resounding success for Rajagiri Hospital. “There was a remarkable improvement in the healing status of pressure ulcers in Community Associated Pressure Ulcer cases…the total healing status improved from 19% in 2019, to 72% in 2020,” Rajagiri revealed.

“The deterioration status of Pressure ulcers was brought down to 0 in 2020, as compared to 28 cases in 2019.

“In addition, there was a significant reduction in the length of stay of patients – from an average of 21 days in 2019, to just 10 days in 2020 after implementation. Feedback from the sample group of patients also indicated a 11% increase in the quality of nursing care in 2020.”

With the help of their innovative strategies, Rajagiri hospital was able to minimise the risk of pressure ulcer in patients undergoing extended hospitalisation, and was able to improve the healing in patients referred to Rajagiri hospital with CAPU.

These strategies helped to improve the patient’s health safety by reducing the risk of infections and thereby, contributed to reducing the average length of stay in the hospital.

The hospital concluded: “These interventions are replicable and easily scalable to other hospitals, irrespective of the clinical design, thanks to the low cost of implementation. In addition to the training of the nurses, the simple initiatives like position clock and Triangle Cushion help nurses in efficient execution of bedside nursing care.”


Nominations for HMA Awards 2022 are now open! This year, awards will be handed out in seven categories, including Patient Experience Improvement, Infection Control Excellence, Clinical Effectiveness Improvement, Most Advanced Healthcare Technology, and more. For more details, click here.