Risk Management
Preventing heel pressure ulcers: Economic
and legal implications
By Courtney H. Lyder, ND, GNP, FAAN
ospital-acquired pressure ulcers (HAPUs)
are a challenging concern for nurse administrators. Not only are pressure ulcers
painful for patients, but they can also be
painfully costly for hospitals. The introduction in 2008 of the Centers for Medicare and Medicaid Services (CMS) policy for
nonpayment of Stages III and IV HAPUs places
an additional burden on nursing administration
to aggressively prevent these ulcers from developing.1 Heel pressure ulcers are the second most
common pressure ulcer location, yet there’s little research focused on the prevention of these
ulcers.2 This article reviews the current literature
related to preventing HAPUs and provides
guidance on the critical role of nurse managers
to decrease the incidence of heel ulcers.
H
Incidence, mortality, and costs
The National Pressure Ulcer Advisory Panel
(NPUAP) has noted pressure ulcer incidence
ranges from 0.4% to 38% in hospitals, from
2.2% to 23.9% in skilled nursing facilities, and
from 0% to 17% for home health agencies.3 Interestingly, the NPUAP 10-year retrospective
review (1990 to 2000) of published data on pressure ulcers found that heel ulcers rose from the
Pressure ulcers often lead to pain,
loss of function, infection, extended
length of stay, and increased
hospital costs.
sixth most common anatomical location to the
second most common anatomical location, followed only by sacral pressure ulcers. Moreover,
every year approximately 60,000 patients die from
complications of pressure ulcers.4 The significant
16 November 2011 Nursing Management
increase in incidence warrants greater focus on
the prevention of heel pressure ulcers.
The cost associated with caring for patients
with pressure ulcers varies greatly, depending
on the economic models that are used. For instance, do the models include only material
costs or do they also include nursing and ancillary staff time associated with providing care?
Pressure ulcers are the second most common
cause of hospital readmissions, with treatment
costs ranging from $20,000 to $70,000 per
wound.5 In addition, the costs of treating the
associated complications of pressure ulcers
during a single hospital stay often exceed
$200,000 per patient (this occurs in select cases
in which the ulcer isn’t recognized initially and
complications from the wound develop).6 Consequently, the costs related to pressure ulcers
place a tremendous financial burden on the
healthcare system.
An assessment of cost-of-illness of pressure ulcers in the Netherlands ranged from a low of $362
million to a high of $2.8 billion, which accounted
for approximately 1% of the total Dutch healthcare budget.7 An analysis by the CMS found that
the average charge per stay for a patient with a
Stage III or Stage IV pressure ulcer was $43,180.4
The CMS also determined that 257,412 beneficiaries admitted to hospitals developed Stage III and
Stage IV pressure ulcers, for a total CMS payout
to hospitals of over $11 billion.8 It should be noted
that only one-third of all hospitalized patients are
Medicare beneficiaries, thus the true cost of managing pressure ulcers in hospitals remains elusive.
States that publicly report their adverse events can
further shed light on the potential costs at the state
level. For example, comparing California with
Maryland related to pressure ulcer development
in 2008 indicates that California hospitals would
have lost more ability to bill at $47,000,000 (1,668
cases at $28,272) compared with Maryland’s
$17,652,455 (1,009 cases at $17,495).9 These figures
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Risk Management
clearly indicate that pressure ulcers
can present a serious financial dilemma for hospitals.
Litigation associated with pressure
ulcers continues to rise in hospitals.
One U.S. retrospective study investigating jury awards in pressure
ulcer cases found financial awards
ranging from $5,000 to $82,000,000,
with a median award of approximately $250,000.10 Given the potential revenue that can be garnered
through such law suits in the United
States, attorneys are now placing ads
on billboards, newspapers, and even
on TV seeking pressure ulcer cases.
So, what’s the bottom line? A lack
of wound-care knowledge can have
a significant negative impact on
both healthcare providers and institutions alike.
Pressure ulcers often lead to pain,
loss of function, infection, extended
length of stay, and increased hospital
costs. Both the CMS and several private health insurance companies
have stopped paying for Stage III
and Stage IV HAPUs.11 Thankfully,
most HAPUs are preventable. These
actions by the government and private insurance companies have forced
hospitals to develop more aggressive
programs related to pressure ulcer
prevention. The fact that the CMS is
no longer paying for HAPUs also
places the onus on hospital personnel to prove that the pressure ulcer
was unavoidable. Thus, considerable
attention to prevention is warranted,
especially with regard to heels, a vulnerable area for hospitalized patients.
Preventing heel pressure ulcers
There’s a lack of research related
to the efficacy of heel protectors to
prevent heel pressure ulcers. One
of the earliest studies in 1991 investigating the effectiveness of heel
protectors to decrease interface
pressure on the heels found that if
the patient was on a support surface (low air loss, foam mattress
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overlay, or air flotation mattress),
the use of heel protectors didn’t
necessarily reduce interface pressure on the heels while the patient
was lying supine.12 It should be
noted that the sample size was
very small (N = 7). Another study
investigating the efficacy of six heel
pressure reducing devices didn’t
find significant differences in inter-
Panel International Treatment Clinical Practice Guidelines nurse managers should:
(a) ensure that the heels are free
from the surface of the bed.
(b) use heel protection devices that
elevate the heel completely (offload
them) in such a way as to distribute
the weight of the leg along the calf
without putting pressure on the
Nurse managers should consider the pricing associated
with the various heel protection devices that are under
consideration.
face pressure of the heels; however,
the cost variance was $100.13 This
suggests that in the absence of efficacy data, nurse managers should
consider the pricing associated
with the various heel protection
devices that are under consideration. A major limitation of this
study was the use of 40 healthy
volunteers. More recent studies
have found that the use of heel
protectors can significantly reduce
the incidence of HAPUs.14
Numerous guidelines exist regarding the overall prevention of pressure ulcers. However, few focus on
the nurse manager’s responsibility
in ensuring aggressive heel protection. One of the most important preventive measures is decreasing mechanical load. High pressure over bony
prominences (heels) for a short period
of time and low pressure over bony
prominences for a long period of
time are equally damaging. In order
to lessen the patient’s risk of heel
pressure ulcer development, it’s
important to reduce both the time
and the amount of pressure to
which the patient is exposed. As
recommended by the NPUAP/
European Pressure Ulcer Advisory
Achilles tendon (the knee should be
in slight flexion).
(c) use a pillow under the calves so
heels are elevated (floating).15
The recommended guidance for
(b) and (c) are based on expert
opinions. A review of the literature
suggests that there’s a scarcity of
clinical data, including randomized
controlled trials and cost-effectiveness
studies regarding optimal heel protectors.
Despite the paucity of studies,
heel protectors should be considered
for optimal prevention of heel ulcers.
Clinical considerations in selecting
an optimal heel protector device
should include:
• whether the device elevates the heel
off the underlying support surface
while protecting the foot drop and
rotation of the leg
• the ability to decrease friction/shear
• whether the device allows the
patient to be ambulated
• the ability to be cleaned
• the ability to remain in place while
the patient may be moving the leg
• decreasing heat to the heels
• cost.
Perhaps no other population is
more vulnerable to heel ulcers than
Nursing Management November 2011 17
Risk Management
those admitted to ICUs. These patients are often hemodynamically
unstable, have multiple comorbid
conditions, have poor nutrition,
and are immobile. An excellent
five-step universal heel pressure
ulcer prevention algorithm has
been developed by Drs. Cuddigan,
Ayello, and Black as a quick and
simple method for managing this
providers and institutions can easily
be exposed to litigation: “83-year-old
male was admitted to hospital with history of congestive heart failure, right
cerebral vascular accident, early-stage
dementia, and urinary and fecal incontinence. A pressure ulcer risk assessment scale was completed indicating
that the patient was at mild risk for
pressure ulcers. The patient was
It remains critical for the nurse manager to ensure
that a plan to protect the heels of hospitalized
patients is a priority.
challenge for the most vulnerable
populations. Implementing this
universal guideline may significantly decrease the overall presence of heel ulcers in CCUs.
Documentation
The assumption that pressure ulcers
result from poor care of the nursing
and/or medical staff has led to a
flood of litigation. Heel pressure
ulcers can develop independent of
good nursing care and/or medical
care. These lawsuits often lead to
significant financial outlays by
healthcare providers and/or institutions. A retrospective study investigating the lawsuit judgment in
cases of patients developing pressure ulcers on admission to hospitals found that a significant number
of medicolegal cases of pressure
ulcer development could have easily been avoided with little expense
to the healthcare institution. Thus,
if the healthcare institution had provided systematic and comprehensive preventive measures, it could
have potentially avoided many
costly lawsuits.
The following case study highlights elements of how healthcare
placed on a standard mattress with a
4-inch solid foam overlay, turned every
2 hours while in bed and chair. On Day
2 of hospital admission, a nurse indicated an ‘erythematic’ area on left hip
and heel. She intervened by gently massaging the two erythematic areas with
lotion and turned the patient on the
right side. By Day 5, a Stage II pressure ulcer was noted on the left hip and
a Stage I pressure ulcer was noted on
the left heel. A hydrocolloid dressing
was placed on the Stage II pressure
ulcer, and nothing was ordered for the
Stage I pressure ulcer. The charts noted
that a wound nurse would be consulted.
By Day 8, a Stage III pressure ulcer
was noted on left hip and heel.”
This case highlights some common errors made by the hospital
staff. To identify the areas of concern, the patient was at extreme
high risk for pressure ulcers because he had multiple health conditions that made him immobile (congestive heart failure, right cerebral
vascular accident, early-stage dementia, and urinary and fecal incontinence). Moreover, the risk assessment tool placed him at mild
risk. This is an important factor, indicating that the tool may have
18 November 2011 Nursing Management
been utilized incorrectly. Furthermore, no pressure ulcer risk assessment tool has 100% sensitivity and
specificity.16 The patient was only
placed on a standard mattress with
a foam overlay. Given the patient’s
risk level, a dynamic surface (such
as an alternating air mattress) may
have been more appropriate. Further complicating this patient’s condition was the massaging of the erythematic area on the left hip and
heel. Research indicates that massaging a red spot may actually
deepen the devitalized area.17 Although a hydrocolloid dressing was
ordered for the Stage II pressure
ulcer, nothing was ordered for the
Stage I ulcer (such as offloading the
heel). There was no indication of a
heel protector being used. In this
case study, it was obvious that additional preventive measures
weren’t instituted that may have
avoided the pressure ulcers.
One major factor in decreasing the
exposure to litigation appears to
be the adequacy of documentation.
Comprehensive documentation is
also requisite for reimbursement of
services and products. Moreover, good
documentation justifies the medical
necessity of services and products.
Regulatory agencies independent of
healthcare providers require documentation to justify continuation of
pressure ulcer care. Good documentation should reflect the care required
in the prevention and/or treatment of
pressure ulcers.18 Essential documentation should include the following
related to heel pressure ulcers:
• daily skin assessment of the heels
• use of an offloading device (such
as heel protectors)
• moisture and heat controls on the
heels
• educating the patient and family
about the importance of protecting
the heels
• decreasing friction and shearing
forces on the heels
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Risk Management
• education of the patient and family
about the importance of heel protection.
Prevention is everything
The prevention of heel pressure ulcers is challenging. Although there
remains a scarcity of large-scale
clinical data related to the use of
heel protectors, there have been a
number of smaller-scale studies
conducted, the results of which
appear quite promising. One such
study demonstrated that utilizing
heel protectors and an evidencebased prevention protocol resulted
in zero heel ulcers among the intervention group.19 In a 555-patient
skilled nursing facility, another research study utilized a heel protector and a preventive protocol to reduce heel ulcers incidence by 95%.20
In the subsequent 11 months of this
study, the development of two heel
pressure ulcers was noted: one in a
patient who hadn’t been identified
as being at risk and a second in a
patient who had refused to wear the
protector during the day. Hence, the
heel ulcer rate during the 11-month
period was actually zero among patients who were identified as being
at risk and who were compliant
with the intervention.
Many clinical experts believe
that quality heel protectors should
be a part of any aggressive pressure
ulcer prevention program. It remains critical for the nurse manager to ensure that a plan to protect
the heels in hospitalized patients is
a priority. With the implementation
of the CMS hospital-acquired conditions policy, nurse managers are increasingly held accountable for aggressive prevention plans to reduce
the incidence of pressure ulcers.
Moreover, nurse managers must
ensure that the nursing staff is accurately and consistently documenting interventions to protect the heel,
thus reducing the hospital’s liability. If these measures are diligently
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followed and a heel pressure ulcer
still develops, the healthcare provider
can be relatively certain that the ulcer
was most likely unavoidable. NM
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Courtney H. Lyder is the dean of the UCLA
School of Nursing and the assistant director of UCLA Health System in Los Angeles,
Calif.
The author has disclosed that she has no
significant relationship with or financial
interest in any commercial companies
that pertain to this article.
DOI-10.1097/01.NUMA.0000406569.58343.0a
Nursing Management November 2011 19