Sounding Off on Pressure Relief: Two expert consultants sound the alarm for nursing homes confronting pressure relief dilemmas post-PPS. (Feature Article).

Whatever their problems, long-term care providers have suffered from no shortage of options for pressure relief. From foam core mattresses to the most complex low-air-loss rotational beds, a wide variety of support surface products has been available for years. What these providers have suffered from, since the advent of the Medicare Prospective Payment System (PPS) in 1997, is tighter reimbursement substantially narrowing those choices--and therein hangs the tale. Some providers are reducing their support surface investments to dangerous levels, according to consultants Glenda Motta, RN, MPH, ET, and Thomas Krouskop, PhD, PE. As liability suits for pressure sores begin to proliferate, both Motta and Dr. Krouskop have been caught up in legal defense-related consultations for besieged facilities. After reviewing these facilities' operations in detail, they've come away with a warning and some recommendations. They shared them in separate interviews with Nursing Homes/Long Term Care Management Editor Richard L. Peck.

Glenda Motta, RN, MPH, ET

Peck: What sort of trends have you seen in support surface utilization by nursing homes since PPS?

Motta: Facilities have swung from using expensive support surfaces, under Medicare Part A, to purchasing or using the cheapest alternative available, if anything at all. I know of facilities that are treating support surfaces as an avoidable expense, and resident outcomes are getting worse as a result. The way to fix this and avoid those obscene legal settlements is not tort reform, but to use support surfaces that work to prevent pressure ulcers.

Peck: Are facilities trying to make up for this by enhancing nursing services in some way?

Motta: As a former DON, I can say that doing things like turning a resident every hour or two often doesn't happen. Staff do what they can, but there are just too many responsibilities. Nursing staffs are well-intentioned and care plans are developed, but the necessary preventive steps often don't happen. This problem is only worsened by today's shortage of nursing assistants and licensed nurses.

As for the monetary penalties, while there was some talk from the Bush administration about modifying things, it looks now as though there's no relief in sight.

Peck: Given the difficulties that nursing facilities face, what might be a realistic approach to improving things?

Motta: First of all, I think facilities have to accept that prevention is highly cost-effective in our litigious society. They have to figure out a way to spread out the cost as broadly as possible over the resident population. You can't say, "If it's not reimbursed, we're not going to do it," because you might have to tell that to the judge, and that won't work.

Facilities should identify companies and suppliers who will work with them on this. Some are producing the best products to achieve good outcomes, and others are pushing cheap products just to stay in business. Facilities should know the difference. One company (Tempur Medical) guarantees outcomes with its program and products and received clearance from the Office of Inspector General in the Department of Health and Human Services (HHS) for its program.

Facilities must recognize that consistency results in positive outcomes. A plan that encompasses guidelines for support surface use, good nutrition and skin care, and addressing major risk factors, and applies them consistently, will achieve good results. Yes, they will have to spend money--but a lot less than the monetary fines imposed or the cost of a judgment for negligence or poor quality care.

Glenda Motta, RN, MPH, ET principal at GM Associates, Mitchellville, Maryland, can be reached at [phone].

Thomas Krouskop, PhD, PE

Peck: What trends have you seen in support surface utilization by nursing homes since PPS?

Dr. Krouskop: I understand that nursing homes are caught between a rock and a hard place on funding, and there aren't a lot of data to work with concerning support surfaces for the elderly; but facilities have let this place their operations at risk. When I ask them, for example, whether they have a protocol for monitoring products and replacing them when necessary, they say "not really." There are lots of foam core replacement mattresses available that will do as good a job as anything in the market, but many don't seem to be using them. And those who do use them don't pay attention to length of use and the need for replacement. After 24 to 30 months, foam mattresses begin to degrade in performance. There are simple ways to test for this- I've devised an easy-to-use instrument for this and I'd be happy to share the drawings with anyone who e-mails me- but right now I'm not seeing this done.

Peck: Is anyone talking to facilities about product longevity and the need for replacement?

Dr. Krouskop: I doubt it. What they are often told is that a product is "guaranteed" for workmanship and materials. What that really means is that the specific product is as good as any other of that type made by the company. It says nothing about performance. This is an issue for long-term care facilities because the medical foam market is a very small slice of the overall market of foam manufacturers, and hospital replacement mattresses use the same foam as household furniture, with the same life expectancy.

Peck: How is the wide variety of products available in this market either helping or worsening the situation?

Dr. Krouskop: Air-filled products, whatever else they might be, are all basically balloons. If set up appropriately, they are all pretty much equivalent in their ability to redistribute body weight and reduce pressure. Where the differences come in are, for example, particular add-ons that might make their use convenient for a particular facility or, most importantly, in the service support they receive. The skill, reliability and even the personalities of service personnel are critical. I have seen hospitals change products on the basis of service provider alone.

Peck: Given the reimbursement and staffing difficulties they face, how might responsible facilities approach the selection and use of support surfaces?

Dr. Krouskop: Facilities don't need an air-filled product on every bed. What is needed is a protocol addressing the needs of your particular facility and resident population. As a rough guide, you might look into foam replacement mattresses as an excellent preventive measure to nurse Stage 1 and 2 ulcers and, for treatment of Stage 3 and worse, an air-filled product of some kind. And remember, you have to budget for monitoring the performance and replacement of these products.

Thomas Krouskop, PhD, PE, professor of physical medicine and rehabilitation at Baylor College of Medicine, Houston, Texas,