Hospital-acquired pressure ulcers (HAPUs) are a national concern due to patient morbidity, treatment cost, and reimbursement issues. Stages III and IV pressure ulcers (PUs) that occur during hospitalization are among the conditions considered preventable by the Centers for Medicare and Medicaid Services (CMS). Harborview Medical Center (HMC), located in Seattle, WA, is a Level 1 trauma/burn center and safety net hospital serving diverse populations. HMC is committed to providing excellence in care including optimal skin care and PU prevention to people from all walks of life. At HMC a new system for monitoring daily PU incidence, completing monthly multidisciplinary intensive reviews on HAPUs, and application of an algorithm used to determine if HAPUs were avoidable was developed and implemented. This system has assisted HMC in addressing PU tracking, prevention, compliance with regulatory mandates and has improved skinrelated outcomes.

More than 400 million adults worldwide were classified by the World Health Organization (WHO) as obese in 2005, with a projected increase to 700 million by 2015. 1 Obesity is the fastest growing chronic condition in the United States, affecting greater than 30% of the adult population. 2 For the age group of 40-59 year olds, the obesity prevalence is over 40%. 3 Minority women are disproportionately affected, with greater than 50% of non-Hispanic black women and Mexican-American women ages 40-59 being obese. 4 In critical care, these statistics are replicated, with almost one-third of intensive care unit (ICU) patients being obese. 5,6 Obese patients are more likely to have increased lengths of stay, higher morbidity, and increased likelihood of discharge to nursing home facilities. [6][7][8][9] Obese patients also pose a unique challenge for preventing skin breakdown, healing wounds, and preventing complications of surgery and prolonged immobility. Yet little research to date has been done to study the effects of obesity on skin integrity and wound healing in this patient population.Many challenges are presented with care of the obese patient in the intensive care unit. Difficulties with mobilization and re-positioning, unpredictability of pharmacokinetic effects, 7 and lack of appropriate diagnostic equipment to monitor hypotension, hypoxia, and hypoperfusion put these patients at increased risk for skin breakdown and wound healing problems. There are many associated diseases that go along with being overweight and obese. 3These co-morbidities -especially diabetes, hypertension, cardiovascular disease, and pulmonary dysfunction -not only make obese patients sicker when they come to the ICU, they also may make them more prone to skin breakdown and wound healing complications while they are there. 6 Critical care patients who are overweight or obese are at much higher risk of systemic inflammatory response syndrome (SIRS) leading to multiple organ dysfunction syndrome (MODS). 5,10,11 Hypotension, hypoxia, and hypoperfusion are endpoints of MODS that decrease tissue perfusion and increase a patient's risk of skin breakdown. Newell and colleagues (2007) stratified risk of pressure ulcer development in critically ill patients by body mass index (BMI) and found that risk for pressure ulcer compared with patients of normal BMI was more than 1.5 times greater for patients with BMI 30 to 39.9, and almost threefold greater for patients with BMI greater than or equal to 40. Factors that influence skin breakdown, such as sedation, use of paralytics, fluid overload, fever, incontinence, and mechanical trauma are especially important to assess in the obese critical care patient.

Purpose The purpose of this cohort study was to evaluate the effect of a 1 year intervention of an electronic medical record wound care template on the completeness of wound care documentation and medical coding compared to a similar time interval for the fiscal year preceding the intervention. Methods From October 1, 2006 to September 30, 2007, a “good wound care” intervention was implemented at a rural VA facility to prevent amputations in veterans with diabetes and foot ulcers. The study protocol included a template with foot ulcer variables embedded in the electronic medical record to facilitate data collection, support clinical decision making, and improve ordering and medical coding. Results The intervention group showed significant differences in complete documentation of good wound care compared to the historic control group (χ2= 15.99, p < 0.001); complete documentation of coding for diagnoses and procedures (χ2= 30.23, p < 0.001); and for complete documentation of both good wound care and coding for diagnoses and procedures (χ2= 14.96, p <0.001). Conclusions An electronic wound care template improved documentation of evidence-based interventions and facilitated coding for wound complexity and procedures.