Under pressure: why can't SNFs cut pressure ulcer occurance?

It's been three years since CMS swept through the long-term care industry with F-Tag #314, detailed and complex guidance for the management and prevention of pressure ulcers in skilled nursing facilities.

But how much, really, has changed in the realm of pressure ulcer prevention? Experts are divided as to how effective nursing homes have been in stemming what has long been one of long-term care's most prevailing resident safety issues.

"The database studies are still showing a similar incidence [of pressure ulcers]," says Jacqueline Vance, RN, C, CDONA/LTC, director of clinical affairs for the American Medical Directors Association. "While risk assessment is a very important part of risk management, it doesn't necessarily mean you're able to prevent a pressure ulcer."

Yet a fair number of nursing homes are holding up their end of CMS' strict regulations. "Nursing homes are doing a relatively good job with [F-Tag #314]," says Dr. Courtney Lyder, ND, GNP, FAAN, professor of nursing, internal medicine, and geriatrics at the University of Virginia in Charlottesville.

A cocreator of F-Tag #314, Lyder thinks nursing home staff have to be honest with themselves about the nature of pressure ulcer prevention. Much of it is vigilance, he stresses, and the understanding that resident acuity will only continue to increase.

"One of the challenges for facilities is that a lot of pressure ulcer prevention is fairly rudimentary care, day in and day out," he emphasizes.

Lyder does think national pressure ulcer incidence can be reduced to the hoped-for 5%-or-less marker, but "it takes a concerted effort from all members of the team, from the administrators to the directors of nursing, to the nurses in charge, to the medical directors."

Administrators can't effectively lead the charge for prevention if their pressure ulcer knowledge is cloudy.

"The first thing [they] need to do is actually take a vested interest in the topic," Lyder says. "In our experience, once administrators become acutely aware of the issue, you almost always see reductions in pressure ulcers. But it has to be a priority. Long-term care remains a rather litigious environment, and a savvy administrator would seek to implement the guiding principles of [F-Tag] #314 to guard against that and against citations from the feds."

However disparate their opinions on how nursing homes have responded to F-Tag #314, revamped in late 2004, Lyder, Vance, and countess other experts agree that a prevention program will never lose its value.

PREVENTION ON ALL FRONTS

Any successful pressure ulcer prevention program must cover the following areas:

1. POSITIONING

Frequent repositioning of the resident is recommended to prevent capillary occlusion, which leads to tissue ischemia and pressure ulcers. Pressure ulcer formation is the result of a combination of the intensity and duration of pressure. Although repositioning will not reduce the intensity of pressure, it will reduce duration, which is more critical.

The Agency for Healthcare Research and Quality recommends repositioning at least every two hours. However, the frequency of repositioning required to prevent ischemia depends on capillary-closing pressures, which vary by person and pressure point. (For more detailed discussions of positioning and the danger of pressure ulcers in heels, see the sidebars on p. 20 and p. 21.)

For example, take a 40-bed unit, of which 30 residents are at risk for pressure ulcers. Thirty residents turned a minimum of every two hours (12 times per day) means 360 turns per day, or 120 turns every shift, and 15 turns per hour.

Positioning remains a contentious topic among industry leaders. Like all preventive means, it is not a blanket solution for pressure ulcer prevention. When CMS redid its pressure ulcer tag, Vance recalls, there was a lot of information about personalizing the guidelines and doing root-cause analyses to determine the reason for a condition.

"There's no data at all that shows repositioning totally prevents pressure ulcers," Vance says. "People do things experientially. For some people it will, for some people it won't. You're treating causes, not symptomology. You need to be looking at what preventive strategies do exist."

2. SUPPORT SURFACES

A cornerstone in reducing pressure is choosing support surfaces, such as pressure-reducing cushions, mattresses (e.g., high-density foam, gel, etc.), and specialty beds or mattress-replacement systems. The intent of these products is to reduce interface pressure, forces that act between the body and the support surface that are primarily affected by the composition of the body tissue, the stiffness of the support surface, and the characteristics of the resident's body.

In the nursing home setting, standard green-colored hospital mattresses are outdated and associated with higher incidences of pressure ulcers. Foam ring "doughnuts" also are outdated, because they concentrate the intensity of the pressure on surrounding tissue.

Most facilities have replaced or are in the process of replacing standard mattresses with static pressure--reducing mattresses, most often high-density foam mattresses. But not all mattresses are created equal. Facilities spend thousands of dollars each year to purchase foam-replacement mattresses, and too often they make these decisions by cost comparison. Rather, nursing homes should base decisions on knowledge of the characteristics of foam in the context of effective pressure reduction. Such characteristics include base height, density, indentation load deflection--which measures the firmness of foam--and contours.

"Bottoming out" describes a situation in which the pressure-reducing surface does not provide adequate support. To check for this problem, place a palm up under the mattress or cushion that is below the area at risk of a pressure ulcer. You should feel at least 1 in. of support material between your hand and the at-risk skin. If you feel less than 1 in., there is inadequate pressure reduction, which can cause the resident to bottom out.

3. FRICTION AND SHEAR

Friction usually, but not always, accompanies shear--that is, friction and gravity often result in shear. Friction is the force of rubbing two surfaces against one another, but friction without force or pressure causes damage to the epidermis and upper dermal layers, commonly known as "sheet burn."

Shear is the result of gravity pushing down on the resident's body and the resistance between the resident and the chair or bed. Shear damages the tissue layers that slide against each other and the underlying blood vessels. Therefore, when combined with gravity/pressure, friction causes shear--and the outcome can be more devastating than pressure alone.

4. MOISTURE AND INCONTINENCE

Urinary incontinence results in overhydration or maceration of the perineal skin. In an overhydrated state, the skin is at greater risk for erosion and impairment of integrity. Maceration compromises the skin's ability to function as an effective barrier. Fecal incontinence is even more damaging because of the presence of bacteria and digestive enzymes.

Moisture from incontinence enhances both friction and shear, so it is important to dean and dry the skin promptly after each incontinence episode. If reestablishing continence is possible, initiate a bowel and bladder program. Remember, you reduce the resident's overall risk every time you positively affect a subscale of the environment. Even a change from total incontinence to frequent incontinence positively affects resident risk.

Routine preventive skin care should consist of cleaning, moisturizing, and protecting. Know the risks associated with pads and the dangers of "overpadding" (see "Overpadding might mean planned neglect!").

5. NUTRITION

Nutrition remains a controversial topic relevant to pressure ulcers. Most research relative to nutrition deals with its effect on healing rather than its role in prevention. Although it has not been determined that improving nutritional intake reduces the incidence of pressure ulcers, various studies and statistics certainly imply that trend. Many studies show that impaired intake is an independent predictor of pressure ulcer development.

"There is no data that says proper nutrition prevents pressure ulcers, though there are those who say thinner people are more likely break down,' says Vance. "When you look at the subject of weight loss in the elderly--nonpreventable weight loss due to cancer, Parkinson's, Alzheimer's, or whatever it is--you start looking into the intrinsic factors of the patients currently in long-term care."

Nevertheless, nutrition interventions are important in risk management and must incorporate resident preferences, special needs, and common sense. For instance, medical conditions may require special dietary restrictions, but there may be cases in which the resident chooses not to comply with them. Honor resident preferences within the parameters of those restrictions and note them in the clinical record and care plan as additional risk factors. Allow common sense to prevail in your approaches.

Other notable factors associated with pressure ulcer development include age, body temperature, blood pressure, anemia, hydration, disease, and psychosocial issues. Even in the absence of definitive research, these are all important in risk assessment.

URBAN LEGENDS OF PRESSURE ULCERS

Lyder and Vance agree that the risk management of pressure ulcers has in many cases become a situation in which facilities often miss the proverbial forest for the trees. The best way an administrator or nurse leader can get a handle on pressure ulcer prevention and risk management is to debunk three major myths:

Myth #1: Pressure ulcers aren't fatal.

"Pressure ulcers can kill people," Lyder says. "It's not this little, minor breakdown in the skin--there is mortality associated. Get staff thinking of pressure ulcers as a resident safety issue, just like a wrong medication or a fall."

Myth #2: It is more cost effective to treat pressure ulcers as they occur than to devote resources to their prevention.

Wrong. Pressure ulcer prevention measures--resources, inservicing, and top-quality equipment--can, in fact, be cost effective. "It is cheaper to prevent pressure ulcers by providing staff with necessary equipment and manpower than it is to fight lawsuits," Lyder advises.

When designing inservices, Vance adds, it's important for licensed nursing staff and practitioners to look at what residents' comorbidities are--a key ingredient to understanding how to assess a resident for risk.

"They have to have a higher understanding of what those combinations mean, and [they] need to do so right at admission;' she says. "I know it's a nursing home, but you need greater physician involvement."

Myth #3: The best care can entirely prevent pressure ulcers.

Neither Lyder nor Vance would suggest pressure ulcer prevention is a futile enterprise. It's a critically important one--CMS handed down its strict F-Tag #314 regulations for a reason. "But that doesn't mean every single pressure ulcer can be prevented," Lyder cautions.

"You can document what's modifiable and what's nonmodifiable, and [have] a good plan in place," Vance stresses. "But the person may still break down, even if you have that documentation there. It's our responsibility to have it there, but it still might happen. If things were totally unavoidable, no one would die."

It was pressure ulcer complications that caused actor Christopher Reeve's death, Vance notes. "He had the best care money could buy, but he died of complications of a pressure ulcer. Nobody sued his caregivers, though," she adds. "If someone with that kind of care can break down, what about somebody who doesn't have it?"

Like many long-term care professionals, Vance sympathizes with some facilities that have been hit by hefty pressure ulcer-related liability lawsuits. For example, she notes one case that involved "an absolutely beautiful care plan [with] good pressure reducing devices, and they were turning the patient. Of course, it goes to suit, and here's this great care plan, and, unfortunately, the plaintiff in the case won."

Perhaps, then, it is mindsets that need to change if pressure ulcer incidence is going to decline. "If we keep returning to it [as an issue], we need to see why," Vance says, "because it isn't just negligent care."

RELATED ARTICLE: The reposition mission.

It is difficult to meet repositioning requirements, even under normal circumstances with full staffing. But no matter what your staffing circumstances, use the "rule of 30" when repositioning residents.

This rule indicates elevating the head of the bed to 30 degrees or less and placing the body, when repositioned to either side, in a 30-degree, laterally inclined position. In this position, the resident's hips and shoulders are tilted 30 degrees from supine, which prevents pressure over the trochanter and sacrum. If the head of the bed is elevated beyond 30 degrees, limit the duration of the position to minimize shear forces and pressure.

Use positioning pillows, pads, or foam wedges to keep bony prominences from direct contact with one another. Also use them for residents with splints or multipodus boots, which could create significant pressure should they come into contact with an unprotected opposing limb. Doing so will help to maintain proper body alignment and reduce the potential for pressure ulcer formation from bone-to-bone contact.

ADDITIONAL POSITIONING CONSIDERATIONS

Contractures, which cause shortened and flexed positions of the affected area, develop in predictable patterns, so splinting, range of motion exercises, and proper positioning can help prevent their occurrence. Preventing contractures is necessary, not only because of the loss of strength and function they cause, but also because they may compromise positioning and hygiene.

Repositioning clocks are used in some facilities to monitor repositioning schedules. The basic concept is that a clock placed at the bedside prescribes a particular position at a specific time (e.g., 10:00 left side, 12:00 back, 2:00 right side, etc.). Theoretically, it is easier for supervisors to detect whether a resident's repositioning schedule is being adhered to if they know that at 10:00 all at-risk residents will be positioned on their left sides. Remember to use positioning clocks judiciously and always in the context of your residents' individual needs and preferences.

--Karen S Clay, RN, BSN, CWCN 

RELATED ARTICLE: The heel-ing factor.

Heels pose a significant risk for pressure ulcer development. They are the second most common site for pressure ulcers (the sacrum is first) in the supine position.

Because heels have small surface areas and underlying bony surfaces, redistribution of pressure is nearly impossible. Heels also have lower resting blood-per-fusion levels, which are compounded by the fact that many elderly patients have compromised lower-extremity blood flow.

Beyond regularly scheduled pressure ulcer risk assessments, assess the potential for heel ulcer formation when an acute change in status occurs. Heel ulcers often develop when there is just a brief change in mobility, such as when a resident fails and sustains a hip bruise. The resident may be less mobile for a few days, either because his or her hip is sore or because he or she is on bedrest awaiting the results of an x-ray. In both cases, heel pressure ulcers can develop quickly, so initiate preventive activities.

Heels and support surfaces

Most support surfaces cannot adequately reduce the interface pressure under the heels. There are a few types of "zero-pressure," three-cell, alternating-therapy support surfaces that will eliminate heel pressure in seven-and-a-half-minute cycles.

There are also commercially available heel-lift products ranging from high-density foam blocks/boots to multipodus boots. When using these products, caregivers must assess the fit and provide close, ongoing monitoring to ensure that irritation or pressure does not occur at another site on the lower extremity. The most effective intervention, however, is total "offloading" of the heel by elevating the lower extremities on a pillow.

Contrary to popular belief, "bunny boots" do not provide pressure relief. These boots, made of soft or quilted cotton, may afford some protection from friction, but they do not relieve pressure. In residents with very sensitive skin or at extremely high risk of pressure ulcer development, problems can develop at the seams of new and well-maintained cloth bunny boots. If bunny boots are going to be employed to minimize friction, consider using those made of high-density, seamless foam.

Are bed linens an issue?

Assess bed linens for their impact on pressure ulcer development. Years ago, in nursing school students were required to make "foot pleats" at the bottom of the bed to ensure that the linens were not too tight there.

Both in practice and in theory, it made sense to do this to reduce pressure on the heels: If you envision a resident lying supine in a freshly made bed, the feet and heels are compressed to the bed by tight linens. Even if you don't make foot pleats, relieve pressure on the feet by loosening the sheets at the foot of the bed when assisting a resident back to bed or by using a foot cradle.

--Karen S. Clay, RN, BSN, CWCN

RELATED ARTICLE: Overpadding might mean planned neglect!

Many nursing home caregivers seem to think that if one underpad is good, then more must be better. In the midst of making wound rounds, I often find a resident with two or three underpads. This is a definite problem.

The reality: Only one pad is necessary. Subsequent pads usually overlap and pose issues with wrinkling and pressure from overlapped edges--which could lead to skin ulcers.

Caregivers sometimes defend this practice by explaining that a resident is a "heavy wetter." However, rarely is an elderly person so well hydrated that one brief or underpad cannot manage the amount of urine that could be present when routine rounds are being conducted. A more honest rationale is that the caregiver does not plan to do regular incontinence care and is worried that the bed will become wet and require a change of sheets.

If caregivers start their shifts by overpadding residents, they send a clear signal that they do not plan to provide incontinence care at frequent intervals. Caregivers who start their day this way are probably in the wrong business. Products today are designed to decrease caregiver time and provide better resident protection, so there is no reason to cut corners and perpetuate bad practices such as overpadding.

--Karen S. Clay, RN, BSN, CWCN

RELATED ARTICLE: Risk assessments you can use.

Nurses must automatically know which steps to put in place upon identifying a resident at high risk for a skin ulcer. They need to have access to effective policies and procedures, supplies for pressure relief and skin protection, and a clear understanding of their responsibility to locate high-risk patients.

"Doing a lot of risk assessment means doing risk assessment your staff can use," says Dr. Courtney Lyder, ND, GNP, FAAN, professor of nursing, internal medicine, and geriatrics at the University of Virginia in Charlottesville. "If they realize a resident is at high risk, they need to make sure, for example, the turning schedules meet that risk."

Nurses must determine the purpose of conducting an assessment and their follow-up responsibilities. Nursing management should convey the following:

* The expectations of staff conducting the risk assessment, which include identifying who is responsible for the first assessment and establishing a deadline for that assessment

* Facility protocol for high-risk residents

* The location of the necessary supplies

* Identification of staff who have access to supplies

* A permanent method of informing certified nursing assistants of their responsibilities when providing care to residents with pressure ulcers (e.g., repositioning the resident, using incontinence products, and providing pressure-relieving wheelchair cushions)

Risk assessment tools

The most widely used risk assessment tools in long-term care are the Braden and Norton scales. These scales query subsets of information that are assigned numerical ratings, which ultimately determine a resident's risk score/level. Clinical research supports the reliability and validity of both scales.

The Braden scale has six subscales that correspond to intensity and duration of pressure and tissue tolerance for pressure. Three subscales--sensory perception, mobility, and activity--address factors that expose the resident to intensity and duration of pressure. The remaining three--moisture, nutrition, and friction/sheer--address factors that affect tissue tolerance. Each subscale is ranked numerically, and the subscale scores are totaled to provide a final score. Total scores can range from six to 23; as the scores become lower, predicted risk rises.

The Norton scale has five subscales--physical condition, mental condition, activity, mobility, and incontinence. Each subscale has a numerical ranking, and total scores can range from five to 20. There also is a Norton Plus Scale that includes additional point deductions for diagnoses of diabetes or hypertension, low hemoglobin and hematocrit, low albumin levels, febrile illnesses, five or more medications, and changes in mental status over the past 24 hours.

Although both the Braden and Norton scales are validated tools for risk assessment used in the majority of nursing homes, they assess resident risk factors differently.

Providers should not rely on these scales entirely, cautions Jacqueline Vance, RN, C, CDONA/LTC, director of clinical affairs for the American Medical Directors Association. A full risk assessment combines these tools with an examination of all a resident's nonmodifiable risk factors that could lead to pressure ulcers.

In one case Vance describes, a woman developed pressure ulcers after coming in for physical therapy. Her caregivers tested her using the Braden scale, but neglected to factor in heart disease, uncontrolled diabetes, renal disease, and other afflictions, because none of those items is specifically listed on the Braden scale.

"She came in ambulating slightly, but no one looked at all these other risk factors during her two months there," Vance recalls. "Nobody reassessed her--they did the Braden scale and that's it. Whether they could have prevented pressure ulcers, who knows, but if you haven't put a [comprehensive assessment] in place, how can you try to prevent [them]?"

Frequency of risk assessment

Most often in long-term care, risk assessments are conducted upon admission or readmission, quarterly, and following significant changes in status. This is not a best practice. Bergstrom and Braden found in their long-term care research that 80% of pressure ulcers developed within two weeks of admission and that 96% developed within three weeks of admission.

The implications of these findings for long-term care show that if you conduct risk assessments on admission and then not again until the following quarter, you will miss the highest risk period. Further, if you conduct the assessment but don't take action in terms of care planning and risk-reduction intervention until the 14-day MDS assessment, you fail to properly manage the risk.

Assess risk under the following conditions:

* Upon any admission/readmission

* Weekly for four weeks

* Monthly or quarterly thereafter

* Upon change in resident status

Risk assessment tools are an adjunct to your clinical judgment. Intrinsic and extrinsic risk factors and the resident's clinical presentation should form the basis for the prevention program.

--Karen S. Clay RN, BSN, CWCN and Chad Berndtson

BY KAREN S. CLAY, RN, BSN, CWCN, AND CHAD BERNDTSON, EDITOR

Karen S. Clay, RN, BSN, CWCN, is the president of Clay & Associates (formerly Kare N' Consulting), a long-term care consulting company in Massachusetts, and the author of Long-Term Care Risk Management: Pressure Ulcers--A Prevention, Assessment, and Treatment Training Guide. Contact her at [e-mail].