Massachusetts Department of Developmental Services Risk Management Protocols

Subject: Pressure Ulcers (Decubitus Ulcers, Bed Sores)

What is it?
A pressure ulcer is a sore or wound that develops when a person is lying in one position for up to 2 hours or sitting in one position for up to 1 hour. The skin and muscle tissue gets squeezed between the bone and the surface of the chair or bed the person is on or even if their skin is being pressed on by oxygen tubing or eyeglasses. The pressure against the skin reduces the blood flow to the skin and underlying tissue stopping the flow of oxygen. This reduced blood flow causes the skin to redden, then open, causing a wound which can quickly become very deep and difficult to heal, causing great pain, bone infection and even sepsis.

Common Definitions:
•	Braden Scale: A system of measuring or predicting a person’s risk for development of a pressure ulcer.
•	Friction: Resistance to motion. Another cause of pressure ulcers. This can occur when the skin is dragged across a surface, such as when a person changes position or is moved or repositioned. If the skin is moist (wet brief) the friction is worst and can cause significant skin and tissue damage. This can also worsen existing pressure ulcers.
•	Repositioning: The act of placing a person in a different position or adjust or alter the position in order to relieve pressure on a part of the body. Persons should change position at least every two hours and more often if they are at risk for pressure ulcers.
•	Sepsis: Septicemia or a sepsis infection is a serious, life threatening condition that occurs when the body has an overwhelming immune response to an infection. When this happens, chemicals are released into the blood to fight the infection. Those chemicals then trigger widespread inflammation which leads to organ failure and blood clots. A person in a poor state of health can have a very difficult time recovering from sepsis.
•	Shear: This occurs when two surfaces move in opposite directions. For example, when a person slides down in their bed the tailbone moves down while the skin over the tailbone may stay in place. This pulls the skin in the opposite direction. This can cause tearing and damage to the skin. It can also worsen existing pressure ulcers. The person is usually at an angle when this occurs.
•	Skin Integrity:  The skin is healthy, undamaged and able to perform its basic functions. A skin integrity issue might mean that the skin is damaged, vulnerable to injury or unable to heal quickly.
•	Standard Precautions: A system of protective actions that assumes that all body substances may contain potentially infectious material.  It requires good hand washing technique and use of barriers such as gloves, gowns, masks and eye protection to prevent transmission based on source of infection.
•	Staging of Ulcerations: A process by which pressure ulcers are categorized according to their severity. There are 4 stages with Stage 1 being the least serious and an “Unstageable” condition meaning it is cannot be determined until further analysis and treatment occurs. 
•	Universal Precautions: A system of protective actions similar to Standard Precautions but which apply only to blood spills or body fluids.

Who is at risk?
Persons:
•	who are in poor health and/or chronic health conditions, especially diabetes and vascular disease
•	with paralysis, heavy sedation or who are in a coma
•	who are post-surgery or have recently had a mobility limiting medical procedure
•	with fragile skin, skin tears or chronic skin problems
•	who are elderly
•	with loss of feeling or sensation to a body part
•	with weight loss, especially during a prolonged illness
•	who are immobile or have limited mobility
•	with poor nutrition and/or hydration
•	with excessively dry or moist skin
•	with bowl or urinary incontinence
•	with exposure to shear and/or friction

How are pressure ulcers managed?
•	It is the expectation of the Department of Developmental Services (DDS) that pressure ulcers are managed in the individual’s environment(s) with as little disruption as possible to their routine.
•	Standard and/or Universal Precautions must be followed as it relates to management of the wound.
•	All individuals with risk factors for developing a pressure wound should be evaluated, using a standardized screening tool. If determined to be at risk, an individualized protocol should be created to manage the prevention and/or treatment of pressure ulcers.
•	An individualized protocol for the prevention and management of pressure ulcers must be created for any person determined to be at risk. 
•	All wound care is to be managed or overseen by a Certified Wound and Ostomy Nurse under the order of the Health Care Provider.
•	Information regarding the individual’s status relative to this issue is to be handled in the same manner as any medical information according to HIPAA regulations.
•	Notify the DDS Area Office Nurse, and other relevant programs, immediately, of a new diagnosis or change in diagnosis regarding this issue
•	All agencies should have a pressure ulcer management policy or guidelines for their staff and train their staff in its use.

Where and to Whom do these recommendations and protocols apply?
These guidelines apply to the care of any individual who has a pressure ulcer or is at risk for a pressure ulcer in all settings.  It applies to all staff.

Where can I find additional help?
•	DPH – www.mass.gov/dph
•	CDC – www.cdc.gov
•	NIH – www.nih.gov
•	DDS – www.mass.gov/dds