Is pressure ulcer prevention alive and well? Maintaining skin integrity calls for periodic review of practices and protocols as recommended.

Prevention of pressure ulcers is a constant process for long-term care facilities, but vitally important to preserve residents' health and avoid major deficiencies. A prophylactic approach should include three steps: identifying high-risk residents, implementing a prevention plan, and auditing the prevention plan. Armed with this protocol, how can we accomplish prevention? Nursing leaders must empower staff into action.

Identifying High-Risk Residents

Mental status, activity, mobility, nutritional status, and incontinence are all factors that have a direct influence on the risk of a resident developing a pressure ulcer. Use of a recognized risk assessment tool--such as the Norton and Braden scales--is mandated for all residents on admission. Assess on admission and once a week for four weeks, and then quarterly, or with any change in a resident's status. (1)

Communicate with the resident if his or her mental status allows for participation in the plan and with the resident's physician and/or certified registered nurse practitioner, family member(s), nursing, social worker, dietitian, physical therapist, social worker, discharge planner, and staff caring for the patient, such as geriatric nursing assistants. Communication with the resident (if possible) and family cannot be emphasized enough.

Educate staff on risk assessment and the definitions of friction and shearing with examples of how these occur. Staff should have a solid understanding of comorbidities that place residents at increased risk, such as diabetes, immunosuppression, cardiac and pulmonary issues, smoking or a history of smoking, multiple sclerosis, neurological conditions, weight loss, low albumin, anemia, obesity, and contractures. A prevention plan should be implemented immediately. Documentation of this assessment is essential, and every person responsible for charting should know where to locate this information.

Implementing the Prevention Plan

Define staff members' duties to implement prevention goals, including pressure relief, maintenance of clean intact skin, monitoring of nutritional status, patient movement, and patient family education.

Pressure relief. This is still the "biggie." Pressure-relieving devices can come in many forms: specialty beds, mattress replacements, overlays, and assistive devices. Choosing the correct device and implementation are pertinent in prevention. A support surface should provide adequate pressure relief or reduction for residents according to their risk level.

The facility prevention plan should include a way for staff to reconcile the resident's risk level with appropriate actions sanctioned by the facility. The plan's steps should be clear and concise and meet regulatory guidelines. When staff understand the connection between the risk score and needed response, they will be more likely to act. Chairs, wheelchairs, and heel protection need to be included in your pressure-relief device plan. Staff may place a wonderful mattress on a resident's bed, yet the resident sits in a sling-seat wheelchair without a cushion for several hours each day. All surfaces on which the resident spends time must be part of the plan. For example, in one facility, staff taught and encouraged a resident to carry his chair cushion to the outdoor patio to use.

A turning and positioning schedule (TAPS) is not out of style. Heel flotation, whether by an assistive device or pillows, must be part of any plan. Clearly, a facility physical therapy department is a tremendous resource. If available, a physiatrist--often a part of this department--can significantly help stroke patients and residents with contractures. Document each step of pressure relief: mattress type (including date applied), TAPS, physical therapy involvement, and resident and family education.

Skin inspection. Inspect the skin daily and at any episode of incontinence, looking for redness or skin breakdown. In addition to the incontinent area, examine and reexamine any area over a bony prominence when turning and positioning. Skin loses moisture as the aging process occurs; therefore, gentle cleansing and moisturizing is necessary. The incontinent area may require an additional barrier ointment for protection, depending on facility protocol and the type of incontinence briefs used. Do not forget to examine incontinent residents who sit in chairs for any period. Document all skin inspections.

Nutritional status. The patient's nutritional status is a critical factor in the risk for developing pressure ulcers. The best resource is the facility's dietitian, who will provide guidance, recommendations, documentation of the nutritional plan deemed best for the resident, and reevaluation of the plan's effectiveness.

Patient movement. Patient immobility is a major contributing factor to pressure ulcers; consult physical therapy for maximizing patient mobility. Restorative range of motion can be helpful, and TAPS is a part of this implementation. Patient attendance at activities on a pressure-reduced surface in a geri-chair or wheelchair can be part of the plan. Include documentation of each behavior.

Communication. Documentation of each and every step of your prevention plan is essential. Update each resident's plan regarding its effectiveness and changes needed to allow for an individualized process. Communicate to all involved, including the family--this cannot be emphasized enough. Educating the resident, if able to participate, and the family is a strong step toward completing the plan of care.

A Wound, Ostomy, and Continence Nurse can be a resource to your facility in selecting products, educating staff, and developing a prevention plan; find one in your area at www.wocn.org. Prevention is possible with teamwork, communication, monitoring, and evaluating progress.

Auditing the Prevention Plan

Collect data on the prevalence and incidence of pressure ulcers in your facility to evaluate the prevention plan. These data are a quantitative measure of success, help to establish a baseline, and provide ongoing monitoring to show improvement or lack thereof.

Each of the facility's departments should complete a thorough review of current policies and protocols related to pressure ulcers for accuracy and to ensure they are appropriate and based on current clinical standards. Review the pressure-relief devices policy or protocol yearly, as technology changes and new devices may become available.

Identify goals that the facility needs to meet, set the bar high, and develop simple audit tracking tools to evaluate the behavioral changes. For example, "staff will complete the risk assessment scores in 100% of the residents' charts and will review them on the 15th of each month," or "every resident with a certain risk assessment score will have the heels floated and will sit on a wheelchair cushion. Staff will document the results by observation."

Complete staff education with all those involved to ensure the knowledge level is the same--behavioral changes can occur only if staff know the pertinent information. The facility can individualize the education method. Consider self-learning packets, competency days (in which staff attend "hands-on" demonstrations and return demonstrations), traveling posters (educational posters displayed on a specific unit for a period and then moved to another unit), or one-on-one education days. Record the attendance and information provided; these can become helpful tools when later evaluating the program's effectiveness.

Schedule audits on a regular basis, and spontaneously audit to monitor behavioral changes. Audits should include a variety of methods for monitoring, observation, staff or resident interview, chart review, product availability, cost review, and completion of documentation forms. To track behavioral changes, choose realistic audit tools; if a tool is too complicated, staff will not complete the audit and will not report the incidence. Staff can modify or delete audit tools as needed. For example, if the facility has purchased pressure-relief wheelchair pads for all chairs, a tool to monitor the specific pad in the chair may not be necessary; staff may only need to record whether the pad is present.

Conclusion

Developing a prevention plan in long-term care is a constant process. The success or failure of the plan directly relates to the administration's view of its importance. If administration support is not available, staff will have a difficult time implementing and auditing any behavioral changes from the plan. Without implementing a prevention plan, death of the resident, litigation, and survey failure can result. Knowledge of the statistics and current data guides all of us in long-term care to work together to achieve the best outcome for our residents.

Donna McMullen, RN, CWOCN, and Carolyn Corazza, RN, CWOCN, are owners of E.T. Consultants, Inc. They provide hands-on clinical expertise and consultation in the care of patients with wounds, ostomies, fistulas, and incontinence problems. These services are provided through contractual agreements with home health, long-term care, acute care, and outpatient facilities. For more information, phone [phone]. To send your comments to the authors and editors, e-mail [e-mail].

References

1. Wound, Ostomy, and Continence Nurses Society (WOCN). Guideline for prevention and management of pressure ulcers. Glenview (III.): WOCN, 2003 (WOCN clinical practice guideline; no. 2).

2. National Pressure Ulcer Advisory Panel. Pressure ulcer stages revised by NPUAP. February 2007. Available at www.npuap.org/pr2.htm.

3. Gray M. Clinical Epidemiology: Essential concepts and principles. In Prevalence and Incidence: A Toolkit for Clinicians. Journal of Wound, Ostomy, Continence Nursing 2005;1-5.

4. Brown G. Long-term outcomes of full-thickness pressure ulcers: Healing and mortality. Ostomy/Wound Management 2003;49(10):42-50.

5. Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: A systematic review. Journal of the American Medical Association 2006;296(8):974-84.

6. Kale S. Taking the pressure off: Patients, caregivers, and pressure ulcers. Healthy Skin; Medline Industries, 2007;4(1)25-7.

by Donna McMullen, RN, CWOCN, and Carolyn Corazza, RN, CWOCN

RELATED ARTICLE: Important Definitions

In February 2007, the National Pressure Ulcer Advisory Panel (NPUAP) newly defined a pressure ulcer as a "localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction." A number of contributing or confounding factors are also associated with pressure ulcers, including obesity, diabetes, cardiac issues, low albumin, low hematocrit and hemoglobin, neurological changes preventing mobility, and circulatory issues. The significance of these factors is yet to be elucidated. (2) The following are key terms related to pressure ulcers:

* Pressure relief is measured through the amount of pressure required to close the capillaries' blood flow to the skin.

* Pressure-relief devices constantly reduce the interface pressure to below capillary closing pressure (25-32 mmHg).

* Prevalence is the number of residents with a defined clinical condition within a particular time frame. (3)

* Incidence is a measurement of a clinical condition found in residents over a defined period. (3)

* High-risk patients, for the purpose of this article, are those with a Braden score of less than 15.

* Shearing and friction cause the skin to stretch, limiting circulation. This happens when staff drag a resident across the bed instead of lifting the resident with a drawsheet. Raising the head of the bed greater than 30 degrees can also contribute to shearing and friction.

RELATED ARTICLE: Pressure Ulcer Implications in Long-Term Care

* Physical. According to one reported study in 2003, long-term care residents with acquired full-thickness pressure ulcers had a six-month mortality rate of 77.3%. (4) Staff also see the change in the quality of life residents experience.

* Prevalence and Incidence. Prevalence of residents with pressure ulcers in long-term care is 2.3% to 28% and incidence is 2.2% to 23.9%. (5)

* Financial. The cost in 2006 to close a full-thickness pressure ulcer (stage IV) was $70,000. (5)

* Legal. Failure to prevent pressure ulcers can lead to litigation, with 87% of all pressure ulcer litigation derived from long-term care facilities. (5) In addition, state and federal surveyors cite facilities that are ineffective in prevention management. Lack of good communication between caregivers, families, and residents is one of the most common issues seen in medical negligence cases. (6)

Table. Prevention plan assessment criteria

Identifying High-Risk  Implementing the       Auditing the Prevention
Residents              Prevention Plan        Plan

Risk assessment tool   Team members           Collection of baseline
* Norton or Braden     * Roles and              data
  scales                 responsibilities     * Prevalence survey
* List of high-risk    * Competencies         * Review of policies/
  residents                                     protocols
Risk assessment tool   Identification of      Goal evaluation
  behaviors              goals                * Target met or not met
* Correlate with the   * Prevalence           * Behavior changes
  risk assessment      * Incidence            * Develop incidence
  tool score           * Targets set            monitoring tool
* MD orders written
  in chart
                       Pressure relief        Education of staff on
                       * Type of device         prevention plan
                       * Policy/protocol      * Competencies
                       * TAPS                 * Self-learning packets
                       Skin inspection        Audit tools
                       * Licensed and non-    * Chart audit
                         licensed             * Bedside audit
                       * Documentation tools  * Documentation tools
                                              * Random and/or
                                                spontaneous
                       Nutrition              Ongoing monitoring
                       * Policy/protocol      * Audit tool development
                       * Documentation tools  * Staff responsibility
                                              * Care plan updating
                       Patient movement
                       * Physical therapy's
                         role
                       * Devices involved
                       * Documentation tools
                       Communication
                       * Patient, MD, and
                         family
                       * Care plan
                         development
                       * Document
                         notification