Pressure ulcers are among the most common soft tissue injuries that occur in nursing homes and hospitals. They also cause pain and increase the risk of infection. The treatment of pressure ulcers often requires the person to be in bed on a special surface for long periods daily, which may result in feelings of social isolation and depression. In 2008, the Centers for Medicare & Medicaid Services (CMS) deemed pressure ulcers a “never event,” which meant they were considered preventable. The designation prompted CMS to exclude hospital-acquired pressure ulcers from reimbursement.

These events also spurred the creation of the Pennsylvania Restraint Reduction Initiative (PARRI). Under the auspices of Kendal Outreach, PARRI has been collaborating with nursing homes in Pennsylvania since August of 2008 on pressure ulcer prevention, mainly focusing on process and prevention.

Boosting Best Practices

Having compiled a collection of best practices from nursing homes that demonstrated success with pressure ulcer prevention, PARRI created in 2010 “A Practical Guide to Pressure Ulcer Prevention,” which includes process components, data collection tools, assessment tools, and prevention techniques.

In 2011, the concept of the Pennsylvania (PA) MAP-IT for Healthy Skin emerged after a year of planning and working with other entities in the state. MAP-IT stands for Manage, Assess, Plan, Implement, and Teach. An expert panel discussion led to identification of potential barriers as well as some key discoveries, which helped launch a successful program. There already existed an abundance of resource materials, evidence-based interventions, standards, and guidelines that were collected and made available for all MAP-IT participants and as a repository for the general public.

Education Key To Success

The cornerstone of the program has been, and continues to be, educational opportunities for staff providing all levels of care, with a particular focus on the education of frontline and direct care staff and their roles in preventing pressure ulcers.

A website ( has helped disseminate information, keep communication open, and accord additional educational opportunities for staff.

In April 2012, the MAP-IT initiative was officially launched. From this auspicious beginning, partnerships among health care organizations were established. Hospital, long term care, personal care, and home health care organizations with established associations were assembled into a continuum of care. Two continuums of care were recruited, with each consisting of one acute-care agency, skilled nursing homes, personal care homes, and home health care agencies.

The organizations in each continuum were identified by the discharge planners working in the acute setting, based on the post-acute referrals for care.

Identifying Process Weaknesses

The first step in the development of each continuum was to have the participating agencies complete an organizational needs assessment to help identify gaps and/or weaknesses in the current pressure ulcer prevention and treatment process in each participating organization.

Included was a checklist of pressure ulcer-related topics, which included screening for pressure ulcer risk, developing a pressure ulcer care plan, assessing and reassessing pressure ulcers, monitoring prevention of pressure ulcers, monitoring treatment of pressure ulcers, and assessing staff education and training

Pennsylvania’s MAP-IT for Healthy Skin adopted the Institute for Healthcare Improvement’s model of collaboration across the health care continuum, a process that gathers a group of health care workers, along with experts in the field, to enable better learning from each other. This system employs evidenced-based practices throughout the continuum and encourages consistent use of such practices in all care settings.

The PARRI team has provided in-services and individual consultation to participating organizations to fill gaps identified by the needs assessment. The PARRI education modules have been used by the MAP-IT organizations to educate their own staff, their clients, and family members.

Many of the modules have activities that help revitalize staff enthusiasm for pressure ulcer prevention.
Additional proficiency has continued to be gleaned through best practices that are shared among participating organization members.

Education has been a large part of this collaboration, using both experts and practitioners to emphasize best practices. The first topic of prevention to be targeted was the appropriate response for all direct care staff and nursing staff when a change in the skin color, texture, or temperature is discovered, aptly named the Red Alert Program.

The Skincare In-ServicePrior to the Red Alert Program, staff completed a survey to help determine future educational needs. Based on these survey results, PARRI staff developed a second in-service, known as the SKINCARE Bundle, based on the SKINCARE bundle from Penn Presbyterian Hospital (see sidebar, left).

Organizations were asked to incorporate this material into training for new staff and annual training or as needed.

Another level of education was added by offering continuum participants the Wound, Ostomy, and Continence Nurses Society’s new program for Wound Trained Associate (WTA). The WTA program is an online class that focuses on wound physiology, prevention, treatment, and care.

Abington Memorial Hospital (AMH) sponsored the program, which provides certified training to all levels of nursing staff, including certified nurse assistants, licensed practial nurses, and registered nurses.
The 40-hour training modules have been offered periodically to all MAP-IT members.

Dialogue, Communication Prioritized

Data collection began in July 2012, prior to the Red Alert program, and continues. Thus far, most organizations have benefited from the ongoing education, collaboration, and communication afforded by MAP-IT. A few organizations that have seen an increase in prevalence have been involved with additional training and education from the PARRI staff, with positive results.

Another measured outcome was increased satisfaction regarding communication across the continuum. Communication was initially identified as a barrier for both continua, since it is common to attribute pressure ulcers to care settings other than staff’s own.

Establishing relationships and allowing open, honest dialogue among continuum members has brought effective communication to the forefront, making it a priority for the first year.

Along those lines, communication guidelines were developed by both continua to stipulate information that moves among health care settings concerning the skin of patients. The combined recommended information was published as “Guidelines for Communicating Skin Condition Across the Continuum” and is available on the MAP-IT website (

A consequence of the guidelines being developed was building relationships of trust, mutual respect, and cooperation among the various organization representatives. For example, in the western continuum a wound, ostomy, and continence nurse from one organization offered to become the wound expert for a small nursing home that could not financially afford its own wound nurse.

This typifies the exchange of expertise and knowledge among members being established through this program. Mentoring on an unofficial level has also occurred among members. One member has retired but agreed to continue to attend the meetings and share her expertise and experiences with other members.
Relationships and network building have become common side effects of the continua.

Best Practices Identified

MAP-IT participants have identified some best practices of member organizations for pressure ulcer prevention and treatment. For example, PARRI staff recently interviewed an eastern continuum member, who shared his facility’s process for maintaining a pressure-ulcer-acquired incidence rate of less than 0.2 percent (see

PARRI staff also identified a MAP-IT organization that has decreased its incidence rate by 50 percent over five months.

In the eastern continuum, members are developing information about the skin for consumers that will be posted on YouTube to educate the general public about skin care and pressure ulcer prevention. In the western continuum, members are concerned that insufficient lighting was preventing them from visualizing the earliest manifestation of pressure ulcers. A proposed pilot study will explore ideal lighting across the various settings of the continuum of care.

Also, both continua are interested in additional education for nursing staff on the correct use of the Braden Risk Assessment for Predicting Pressure Ulcers.

The long-term goals for PA MAP-IT include identifying new continua of care interested in pressure ulcer prevention. To serve the needs of the underserved urban population, a third continuum has been identified and initiated in Philadelphia.

Another goal is to use the PA MAP-IT process to improve other quality measures that participants across the current continua choose. For example, PA MAP-IT for Safe Environments would encompass both fall management and restraint elimination and would be a good fit for both continua using the expertise the PARRI team can provide.

PA MAP-IT for Palliative Care would involve quality of care and a holistic approach to care at all levels of care and would enhance serious illness and end-of-life experiences for patients and their families, as well as staff involved in the care. As PA MAP-IT moves forward, the group anticipates that the relationships will continue to grow and contribute to seamless movement of patients within the health care continuum.
Education will continue to be at the forefront for participants. These processes, in turn, will improve care and efficiency in the participating systems, which will enhance the patients’ outcomes.

The MAP-IT process can be used as a model for other continua to develop an enhanced experience for patient and staff alike.

Linda Hnatow, RN, a regional director of the Pennsylvania Restraint Reduction Initiative, can be reached at or (610) 742-6416. Karen Russell, RN, a regional director of the Pennsylvania Restraint Reduction Initiative, can be reached at or (724) 864-3767.