High acuity can mean high risk of pressure ulcers.

Freelance writer Katherine J. Paul is a frequent contributor to Contemporary Long Term Care. She is based In Hiram, Ohio.

PRESSURE ULCERS MAY BE CLOSELY LINKED IN MOST PEOPLE'S minds to traditional nursing homes, where incontinence and other factors put elderly residents at increased risk. But the challenges of preventing and treating such wounds mount in subacute care settings. Many patients are admitted to subacute facilities following long surgeries and critical care stays, which often set the stage for the development of pressure ulcers.

In fact, many of the people admitted to subacute units already suffer from the condition. "Among subacute patients, you're going to see more [pressure ulcers] because they are admitted with them, usually from an acute setting," says Frances Regan, RN, director of nursing for the Glengariff Health Care Center in Glen Cove, New York, a 262-bed facility with 81 subacute beds. "In the acute setting, you're going to get breakdowns, especially in intensive care where pressure ulcers are not the primary concern."

Making the problem even more urgent for subacute providers are the cost constraints of Medicare's new prospective payment for SNFs: Under the new system, it has become increasingly necessary to determine the true cost of treating pressure ulcers, and to reduce those costs by healing the condition more quickly--or preventing it in those patients not yet affected. "Make sure you have good screening tools, treatment protocols that include product selection, and a good program for monitoring the success of your wound care treatment program," advises Cindy Laggis, RN, vice president of program development for Mariner Post-Acute Network, an Atlanta-based operator of more than 400 skilled nursing facilities nationwide.

Mariner is currently developing a standard list of wound care products based on cost and effectiveness. The list will be used throughout the company's network of subacute facilities.

Adopting treatment and assessment guidelines is also key. There are none specific to subacute care, but providers can use clinical practice guidelines available from the federal Agency for Health Care Policy and Research (AHCPR). The guidelines, based on the best available scientific evidence on management of ulcers, were developed to help identify adults at risk of pressure ulcers, to define early interventions for prevention, and to manage pressure ulcers. "The guidelines are not setting-dependent," says Carrie Sussman, president of Sussman Physical Therapy and a former subacute unit director. (To order the free guidelines, call AHCPR at 800-358-9295 or send an e-mail request to [less than][e-mail][greater than].)

For the sake of cost control and quality of care, subacute providers should place considerable emphasis on assessment and follow-up. According to AHCPR, most pressure ulcers can be prevented, and Stage I pressure ulcers need not worsen under most circumstances.

Risk assessment is key to prevention, experts agree. To make the most of limited resources, providers should target resources to those at highest risk. Topping the list: quadriplegic patients, elderly patients with limited mobility, and critical care patients. "Aging is the number one factor affecting skin function, followed by hydration, medications, and nutrition," notes Laggis. Other risk factors include an altered mental status that affects the patient's ability to respond to pressure-related discomfort; immobility caused by injury, surgery, or a chronic health condition; moisture on the skin from incontinence; and friction and sheer pressure from agitation or uncontrolled body movement.

To help predict which patients are most likely to experience skin breakdown, use existing risk assessment tools, such as the Braden and Norton scales. In a study conducted by Stratis Health, a Minneapolis-based quality improvement organization, eight hospitals were shown to reduce the incidence of pressure ulcers by focusing on caregiver education--in particular the use of the Braden Scale to conduct daily skin inspections.

Some subacute providers fall down when it comes to consistency. It's important to assess a patient's risk not only upon admittance, but also on an ongoing basis. "Pressure ulcers can occur within a 24-hour period," says Laggis.

Daily evaluation and ongoing risk assessment is also essential if facilities are going to monitor the success of their wound care treatment program, notes Laggis. And being able to demonstrate success is a plus when searching for managed care contracts.