Saving residents, money - and facilities - with improved skin care.

An estimated quarter of all nursing home residents suffer from painful pressure ulcers with nearly $3.5 billion annually being spent on treatment.

Experts agree that most pressure ulcers could be prevented and that external forces will escalate the incidence of pressure ulcers if they're left unchecked. Included among these external forces are changing health care policies and resulting reimbursement reductions prompting earlier discharges from hospitals to the nursing home setting.

By the year 2000, the elderly population will have increased dramatically. Because of technical and medical advances, people are living longer and with more concomitant diseases, thus putting them at risk for complications of immobility, such as pressure ulcer development.

In response to an already crisis situation, nursing home administrators need to aggressively implement programs aimed at reducing the incidence of pressure ulcers in an effort to contain treatment costs, avoid regulatory intervention and improve residents' quality of life.

Recently, a 140-bed nursing home located in a large metropolitan area was found not to meet wound care standards and was on the verge of the state's ordering it closed. In a reactive, emergency move, the facility brought in a wound care consultant to develop and implement a corrective plan of action.

Typically, the facility's residents were at high risk for developing pressure ulcers - most were female, incontinent and had an average age of 83. The team of specialists discovered that the facility was lacking formalized skin care protocols, risk identification instruments, incontinence care products or documentation of skin breakdown occurrence.

The consultant drafted a customized program to address and solve the facility's problem. This consisted of a needs assessment, extended care plan development, and an intensive wound and skin care education program for the facility's staff. The plan also called for initial clinical supervision for the first 30 days and continued telephone support for eight months. Upon reviewing this plan, the state granted the facility a 90-day reprieve.

Following the assessment and assigning of pressure ulcer risk scores to residents, all staff involved in direct patient care were instructed on the principles of preventing and treating skin breakdown and in the use of specific skin care protocols. Since the emphasis of this program was prevention, it included all of the elements listed in the Agency for Health Care Policy and Research (AHCPR) guidelines for the Prediction and Prevention of Pressure Ulcers in Adults. AHCPR recommendations included the use of risk assessment tools and risk factors, principles of skin care and early treatment, considerations in mechanical loading and support surfaces, and general education.

In addition, the nursing home purchased pressure reduction surfaces and implemented its own protocols for wound care, skin care and pressure ulcer prevention. This implementation included inservices on prevention and treatment products by representatives of the companies whose products had been selected for use in the program.

Patients at risk of pressure ulcers or skin irritation due to exposure to feces and urine were introduced to a cleansing, moisturizing and protective cream regimen. The facility chose to use Smith & Nephew United's Triple Care[R] line of products and its Options for Wound Skin Management[SM] education program. The program provides a selection of products and techniques to help staff effectively achieve treatment objectives for early intervention.

High-density foam overlays were used as pressure reduction surfaces for residents who were rated high risk on the Skin Breakdown Risk Assessment Scale, a pressure ulcer risk assessment tool.

This effort produced results. Before implementation of the program, there were 39 facility-acquired pressure ulcers of varying severity. After three months, the number of pressure ulcers dropped to four, and the state, upon re-evaluating the facility, allowed it to remain open (Table 1). In comparing the costs of skin care and wound treatment prior to the implementation of the new protocols and after implementation of the new treatment program, the cost of treating pressure ulcers dropped from $2,091.18 per week to $73.95 per week in the final stage of the study (Table 2).

These results have been replicated. After the implementation of a similar pressure ulcer prevention program in another 120-bed nursing care facility - it had an original occurence rate of 24.5 percent - no more than five patients in any one month developed pressure ulcers during the first three months of the program. At 6- and 8-month analyses, new skin breakdowns had declined to 0%. A 19-month follow-up involved 108 residents; all were evaluated, and only one exhibited skin irritation and the subsequent development of an ulcer. Prior to implementing the pressure ulcer prevention program, the facility was projected to have had 52 pressure ulcer occurences at the end of eight months. Total cost savings approached one-quarter million dollars during an eight-month period - in just that one nursing home. (Published in Advances in Wound Care, May/June 1995.)

Table 2
COST OF TREATMENT

Pre-Program Implementation Cost - June

Wet-to-Dry Dressings
Dressing Changes BID

Product cost per treatment                       $1.10
Nursing time cost per treatment                  $2.73
(based on treatment time of 20 minutes)
Weekly cost for initial 39 wounds            $2,091.18

Post-Program Implementation Cost- December

Stage 2: Hydrocoloid
Stage 3-4: Hydrogel

Dressing changes 3x weekly

Product cost per treatment                       $2.20
Nursing time cost per treatment                  $2.73
(based on treatment time of 20 minutes)
Weekly cost for 5 wounds                        $73.95

Total Weekly Cost Savings = $2,017.23

Beyond the benefits of being allowed to remain open and significant cost savings now and in the future, the implementation of this effective pressure ulcer prevention program resulted in the improvement in patients' quality of life. Patients continue to maintain healthy skin integrity and most often are spared the experience of painful pressure ulcers. Those that are admitted with pressure ulcers or, in rare cases, develop them while in the nursing home receive the most effective wound care, and their wounds are healed efficiently.

It is obvious that patients who are in less discomfort as a result of better skin integrity and the reduction of the incidence of painful pressure ulcers are easier and more gratifying to treat. This results in a better working environment for all nursing home staff. Staff from nurses aides to DONs experience heightened job satisfaction as the quality of care they provide improves.

The implementation of a comprehensive pressure ulcer prevention program in nursing homes is a viable strategy to minimize the occurrence of pressure ulcers and, as a result, reduce treatment costs, improve quality of life for residents and staff and avoid possible intervention by a outside licensing body. These are good reasons to get started today.

For more information write Smith & Nephew United, P.O. Box 1970, Largo, FL 34649-1970 or call [phone].

(TripleCare[R] is a registered trademark of Smith & Nephew United, Inc.)

Mary Beth Regan, RN, MS, CNS is a Clinical Nurse Consultant for Smith & Nephew United, a worldwide health care group that develops, manufactures and markets a wide range of technically sophisticated products concentrated in the areas of skin care, wound management, orthopedics and consumer health.