Pressure ulcers: keys to prevention.

Success comes with formal procedures for assessment and monitoring

The statistics are grim: As many as 60% of residents admitted to nursing homes have pressure ulcers upon admission. The annual treatment cost has been estimated as high as $7 billion, and the life-threatening complications that arise from pressure sores account for 60,000 deaths in the United States every year.

But the news isn't all bad. The cost -- both human and monetary -- can be reduced significantly with appropriate preventive measures by: identifying residents at risk for skin breakdown, continually assessing changes in skin status, and ensuring that standards of care for prevention, early intervention, and treatment are implemented.

Incontinence, both urinary and fecal, is the greatest single risk factor for skin breakdown among nursing home residents, especially in light of new regulations that limit the chronic use of indwelling catheters. Immobility poses a risk almost as significant. Nutritional status also affects skin condition, and factors such as medications may indirectly contribute to skin breakdown by worsening incontinence or immobility.

Those residents at risk for skin breakdown should be identified during the admission process with a comprehensive risk assessment performed on every resident, regardless of acuity level. The assessment is best performed by the nurse who admits the resident - and doing so requires no special training beyond good, basic nursing skills.

The Agency for Health Care Policy and Research (AHCPR) strongly suggests the use of a risk assessment tool in the initial nursing physical examination. There are a number of such tools available from national publications, books, and even wound care product manufacturers. It is true that no single tool is appropriate for all long-term care facilities, and that the AHCPR has in fact questioned the validity of the tools that have yet to be extensively tested. Nevertheless, these devices can be invaluable in providing a user-friendly format for identifying residents at risk, evaluating baseline skin status, reporting subsequent changes, and documenting skin condition to ensure reimbursement for preventive or therapeutic products. The trick is to find the tool that most closely approximates what you're looking for and then to customize the information to meet the specific needs of your facility. The tool should be simple to use and should take only minutes to complete.

The tool used by Manor HealthCare Corp. consists of a dual-view outline of the body and a list of parameters that impact on skin condition: general physical condition, mental status, activity, mobility, incontinence, nutritional status, and existing breakdown. Each parameter has several descriptors with their own point values. For example, the descriptors for general physical condition are good (0 points), fair (1), and poor (2).

The admitting nurse indicates any areas of breakdown on the outline, circles the appropriate descriptor for each parameter, and adds the points for a total score. Comparing that score with a predetermined minimum risk score indicates that resident's level of risk.

Customizing the tool required a few changes based on the standards used in the Manor HealthCare Corp. homes. The first of those changes was to provide specific definitions for the highly subjective, somewhat nebulous descriptors such as "good, fair, and poor." Placing these definitions, which were adapted from the Hemphill Scale, on the back of the form, provided much more specific, uniform descriptions that eliminated any concern about differing interpretations.

Other descriptors were rewritten entirely. The revised descriptors for existing breakdown, for example, are highly specific and leave little room for misinterpretation: none (0 points), skin condition (an abnormal finding on the skin surface not related to pressure sores) (4), partial-thickness wound (8), full-thickness wound (8), stage 1 pressure ulcer (4), stage 2, 3 and 4 (8).

Perhaps the most important change was in the minimum score required to deem a resident at risk. Many tools require scores as high as 20, which leaves a large number of residents without the benefit of preventive care. Manor HealthCare Corp. has found that a minimum score of 8 serves the greatest number of residents. The Pressure Ulcer Risk Assessment Tool is completed on admission, readmission, level of care changes, and quarterly with each MDS update.

The Team Concept

Once the assessment is complete, appropriate preventive or therapeutic steps can be taken. Residents at risk for developing pressure ulcers, for example, will qualify for a mattress overlay or specialty bed. Also, those who stand to benefit from a bed cushion should be provided with a similar cushion designed for chairs.

Areas of the body affected by incontinence should be treated with some type of ointment barrier. Other preventive measures include a turning and positioning schedule, elevating the heels off the bed and involving the dietitian to assess the resident's nutritional needs.

The generic treatment for existing breakdown consists of various forms of pressure reduction or relief. Residents with a stage 3 or 4 pressure ulcer on the trunk of the body may qualify for a specialty bed under Medicare Part A. Meanwhile, all facilities should have easy access to overlays and to optimal topical wound care products such as wound cleansers, gauzes, hydrogels, etc.

Once the baseline skin status has been documented and the appropriate measures initiated, skin status must be monitored on a regular basis. To this end, Manor HealthCare Corp. has developed skin care teams. The director of nursing (or designee) and treatment nurse monitor the entire facility, and a charge nurse and nursing assistant from each unit join the team for rounds. The dietitian, physical therapist and occupational therapist are on-consult to round with the team.

Each week, the team rounds on all residents with stage 3, stage 4, and full-thickness wounds to make certain that wound status is improving. The team also rounds on all new admissions within the week of admission. This is done to make certain that all reddened areas or areas of existing breakdown have been documented appropriately. The team also looks for any changes that may have occurred during that week. If the skin is intact, the team may not need to see that resident again unless a change in status is reported.

Commitment to Education

Of course, assessment tools and team concepts are only as effective as the skills of those implementing the programs. In many cases, the nursing home staff's knowledge of skin status assessment, and especially wound care, must be updated on an ongoing basis. It is certain that, without the administration's commitment to staff education, the residents won't receive the quality care they deserve.

The nursing staff should be encouraged to take advantage of the many continuing education opportunities available today with respect to wound care: membership in professional organizations, lectures, seminars, books, workbooks, and videos exist in considerable numbers these days.

Moreover, a set of guidelines for treatment of pressure ulcers will be available from the AHCPR in the near future. The guidelines deal with prediction and prevention of skin breakdown, identifying residents at risk, reassessment and documentation. Moreover, a set of guidelines dealing with wound care products will be available from AHCPR in the near future. Watch for these.

Cathy Thomas-Hess, RN, BSN, CETN, is the ET Nurse Consultant for Manor HealthCare Corp., Silver Spring, MD. She speaks regularly in various national forums and her articles on wound care have appeared in national publications. Ms. Hess is also author/narrator of the video/workbook Fundamentals of Successful Wound Healing: An Educational Approach for the Quality Caregiver.