The complexities of the COVID-19 public health emergency required skilled nursing facility (SNF) operations to change dramatically and often to save the lives of the most vulnerable population. Through heroic efforts, SNFs transformed clinical systems of care, sometimes in less than a day, to win the war against the pandemic.

While operations and resources shifted to battle COVID-19, unintended consequences emerged—one being greater incidence of pressure injuries. Now that the pandemic is at a turning point, facilities can start to refocus and improve this trend. This article suggests ways to reorient efforts toward preventing and managing pressure injuries.

Maximize Role of Wound Nurse

Imagine if the infection preventionist’s sole responsibility were to treat residents who have an infection. This suggestion seems odd because it ignores the scope and breadth of what must be done to control and prevent infections for all residents. Yet when considering the wound nurse’s role, this person’s time is often consumed by completing daily dressing changes, at least five days a week, and the weekly comprehensive wound assessments.

While dressing changes and weekly wound assessments are critical tasks, there is a missed opportunity to utilize the wound nurse’s expertise and talents to champion skin integrity for all residents. Therefore, to refocus on pressure injury prevention, reset the wound nurse’s role.

Identify, Adjust Care Plan

The wound nurse can contribute to the goal of preventing pressure injuries in significant ways. One of the most imperative is by developing and implementing care delivery processes that consistently yield outcomes that support skin integrity.

For example, introducing and overseeing a process that consistently identifies residents’ risk for skin breakdown is vital to address these risks.

While most SNFs require the Braden risk assessment to be completed at regular intervals, the Braden is a tool to capture the risks; it is not the process. A nurse must first accurately assess the resident and then select the responses on the Braden that best correspond to their assessment.

This task may seem straightforward, but an audit of the Braden risk assessments could reveal variation in how the nurses assess and thus complete them. If so, the wound nurse can work with the nurses to improve their assessment skills to ensure the initial risk information can be relied upon.

Next, the wound nurse can ensure that information from the Braden is being utilized to develop an individualized care plan that comprehensively addresses the resident’s risk. Then, the wound nurse can support the implementation of care-planned interventions at the bedside by working with caregivers, offering just-in-time training, and being available to answer questions.

Lastly, the wound nurse can confirm that the interventions are effective at maintaining skin integrity or adjust the care plan accordingly.

A Data-driven Approach

Data should drive the determination of whether there is a problem and, if so, where to focus resources to improve processes. If these decisions regarding pressure injury prevention and management have been based solely on the count of pressure injuries, consider a reset that improves how the data are interpreted or give more context for decision making.

A change in the count of pressure injuries doesn’t necessarily mean something is good or bad. Rather, it’s an indicator to prompt questions and translate the data into usable information. The instability of the pressure injury count makes it difficult to glean meaning from the measure.

Using count data collected from week to week presents clinical leaders random ups and downs of trying to manage a number without considering why they are managing it. Starting with the right measurement of pressure injuries—one that correlates with the goals and acceptable threshold for performance—is the first step to using data in a meaningful way.

Calculate Injuries Monthly

A more stable and telling indicator of performance is to calculate the pressure injury rate each month, using occupied bed days. For example, if two facilities have 10 pressure injuries, but one facility has four times the census of the other, the count of 10 ignores that the facility with the higher census may be more successful at managing pressure injuries.

To calculate the pressure injury rate, follow these steps:

  1. Count the number of pressure injuries during the month.
  2. Determine the number of occupied bed days for the month. Use the same point in time each month so the calculation is consistent. The business office can provide these data.
  3. Divide the number of acquired pressure injuries by the number of occupied bed days.
  4. Multiply the results in step 3 by 1,000. This will yield the pressure injury rate per 1,000 occupied bed days, providing a stable rate that can be compared each month.

Establish Goals

This measurement can be used to establish an acceptable threshold (the minimum acceptable level of performance) and a goal (the level of performance that is desired). Sustainable improvement can take significant time to achieve, so consider achievability and the reality of the facility’s situation when setting goals and thresholds for pressure injury prevention and management.

To establish goals and thresholds:

  1. Examine pressure injury performance trends over time. This provides a realistic perspective of performance so that a facility avoids overreacting if a measure falls outside an acceptable range.
  2. Use a baseline. A baseline uses existing data to provide a starting point. If the performance trends indicate the average pressure injury rate is 10 percent, this is the baseline to consider how much improvement is realistic and to evaluate improvements or declines in performance over time.
  3. Benchmark performance. A benchmark serves as the standard to measure the facility’s performance against. State and national pressure injury quality measure data are sources to benchmark against.

Changes in the monthly pressure injury rate prompt leaders to ask questions and narrow down which processes are problematic. The following questions will help leaders uncover the details needed to identify the issues and respond accordingly:

What is the rate of admitted vs. acquired pressure injuries?

If the admitted rate is higher than acquired, shift focus to treatment processes. If the rate of acquired is higher, shift to prevention processes.

What are the healing rates for the stages?

If it takes prolonged periods to heal pressure injuries, especially stages 1 and 2, focus on treatment processes.

At what stage do we usually identify pressure injuries? Do we identify them early at stage 1, or are they caught at stages 2 and 3 instead?

If identification occurs in the later stages, focus on monitoring, identification, assessment, and reporting processes.

Is occurrence of acquired pressure injuries on multiple residents, or is there one resident with multiple pressure injuries that increases the rate dramatically?

If pressure injuries are on multiple residents, focus on prevention processes. If pressure injuries are mostly related to one resident, focus on this resident’s care plan.

What is the most common location (for example, behind ears) for acquired pressure injuries?

Relate the location to prevention processes (for example, protect skin behind ears for all residents that use oxygen).

Alexis Roam, MSNSNFs have learned to be agile and adapt quickly. With this capacity for change, hitting reset is an opportunity to look toward the future to enhance operations and achieve even greater performance.

Alexis Roam, MSN, RN-BC, DNS-CT, QCP, is curriculum development specialist for the American Association of Post-Acute Care Nursing (AAPACN). She can be reached at