Product innovations, combined with tried-and-true methods, are a winning formula for skin and pressure ulcer care.Wound care is literally a sore subject for many long-term care providers. Considering the incidence rate and related treatment costs, liability implications, and new regulatory and reimbursement challenges, it's little wonder.
An estimated 23% of all long-term care residents will develop pressure ulcers, and that percentage jumps nearly three-fold for high-risk residents, such as those with femoral or hip fractures, diabetes, pulmonary vascular disease, low blood pressure, edema or other medical conditions, the Agency for Health Care Policy and Research reports.
The cost of treating individual pressure ulcers can be crippling, between $500 and $50,000, depending on the severity of the wound. Further compounding provider concerns is that 8% of all deaths in nursing homes are attributed to pressure ulcers, according to the Journal of Chronic Disease. Lawsuits related to the condition remain the second most common claim, notes the Mayo Foundation for Education and Research.
"Wounds can be a very big problem, particularly because of the risk factors present in many [residents], but thankfully, it's one that can be prevented by being proactive with the development of effective policies and procedures, and being diligent in implementing them," noted Thahn Dinh, doctor of podiatric medicine and spokesman for the American College of Foot & Ankle Surgeons.
For best results, it is necessary to adhere to established protocols, use quality products and stick to the basics learned in nursing 101, experts advise.
Regs cut deep
Proactive wound management can keep facilities out of hot water with regulatory agencies. The Centers for Medicare & Medicaid Services has included pressure ulcers as one of three sentinel events for long-term care, with development of a pressure ulcer or deterioration of a pressure wound resulting in fines up to $10,000 per day. The agency, working under the notion that pressure ulcers can be prevented with proper care, is now considering cutting off payment for the treatment of wounds that develop in the long-term care setting.
"Long-term care facilities have been highly motivated to be in compliance with CMS requirements for wound care management by implementing things such as pressure sore management plans, comprehensive approaches to dealing with any wound or pressure sore situation, and a unified approach that is practiced throughout a facility or chain of facilities," explained Larry MacPhee, vice president of sales and marketing for Dallas-based Swiss-American Products, a skin and wound care product manufacturer and marketer.
MacPhee pointed out that aside from facing heavy fines, non-compliant facilities also might have their incidence data published on the CMS Web site for all prospective residents to see, posing both a short- and long-term revenue risk.
"As of 2006, non-compliance can now mean not having in place the correct management processes for incontinence – a precursor to pressure sore and wound development," he continued. He added that CMS now considers poor incontinence management as dire as poor wound care and is willing to fine facilities accordingly. Nearly one-half of all skilled nursing residents are incontinent, according to federal healthcare statistics.
Given the negative implications related to wound development and the proliferation of high-risk residents entering the skilled nursing environment, facilities are becoming more focused on solutions and strategies that can keep skin healthy and intact.
"The incidence of peripheral vascular disease is quite high in [long-term care residents] and we're also seeing those with diabetes, severe edema, end-stage renal disease and other conditions, including obesity and poor nutrition, that make them more susceptible to wound development," said Patti McCloskey, RN, director of clinical standards and quality improvement at NewCourtland Elder Services in Philadelphia.
"The only way to be successful in managing and preventing wounds is to be [diligent]."
Strategies for success
A wave of wound care products and technology has helped to head off potential problems. Advanced solutions — such as negative pressure therapy devices, sealants, antimicrobial and honey-based dressings, pressure distribution surfaces, and electrostimulation systems — have made their way to the forefront.
Many providers are relying on specialized chair cushions and mattresses with pressure-relieving surfaces to reduce the likelihood of wound development in high-risk residents.
"Here everyone has a special mattress, and we have a mattress protocol for staff to follow to determine the most [appropriate] pressure redistribution surface for each resident," explained McCloskey. Bariatric residents and those with multiple stage-two wounds receive a special mattress with a low air loss pressure redistribution surface, for example. Those at increased fall risk receive a raised bolster to reduce the risk of injury and subsequent deep tissue injury.
[Note: The National Pressure Ulcer Advisory Panel has revised its pressure ulcer definition and stage categories to now include suspected deep tissue injury, which can be difficult to detect initially and may present as a discolored localized area, often accompanied by pain. The updated staging system can be found on NPUAP's Web site at www.npuap.org.]
For the prevention of heel ulcers, which account for roughly 36% of all pressure wounds, Dr. Robert Williams, a physician at Conroe Regional Medical Center in Conroe, TX, said he has had "remarkable success" with soft shell heel protectors to off-load pressure in patients at high risk for wounds.
"Our facility was seeing a relatively high rate of heel ulcers — eight percent — and after implementing the [soft shell heel protector] we saw our rates drop to 0.64 percent." The facility initially used the boots — one on each foot to prevent uneven pressure — on every at-risk patient. Eventually, it switched to using them only for those at highest risk as a way to curb costs.
"We made the change to only apply the boots to those at highest risk a year a year and a half ago, and we still haven't seen our prevalence rate for heel ulcers increase," Dr. Williams continued, adding that his hospital's experience is good news for budget-conscious long-term care facilities that also could see good outcomes by applying the device on those at greatest risk for heel ulcers. "Heel ulcers are very common, but they're also one of the easiest wounds to prevent."
Electrostimulation systems, which have contributed to reduced pain and swelling, also are garnering positive results. Unlike transcutaneous electro-nerve stimulators, or TENS, which block pain, these next-generation electrotherapy systems actually treat and heal wounds by providing localized therapy to damaged tissue. The technology does not affect healthy skin and can be applied over clothing, blankets, dressings and even casts.
"Aside from treating wounds, this technology is also great for preventing them because it reduces inflammation and brings blood to the area, which is how healing occurs," said Chip Fisher, president, Fisher Wallace Labs LLC, New York.
Even the most severe, chronic wounds respond well to electrical stimulation therapy, according to Andre DiMino, co-CEO of Ivivi Technologies Inc., Northvale, NJ. "When used as an adjunctive therapy, it's effective in even the most challenging wounds. And the best part is it [induces] natural healing and is easy to use."
DiMino said Ivivi Technologies' solution has grown in long-term care and is currently being used in 70 to 80 facilities.
Recently, there also has been much buzz about the healing power of honey, which contains antimicrobial agents that are active against even the most resistant bacterial strains.
"Studies show it's highly effective and it's also easy to use and [well-tolerated]," said Diane Maydick, RN, MSN, CWOCN, director of clinical affairs, Derma Sciences Inc., Princeton, NJ.
The company recently received clearance from the Food & Drug Administration to market and sell its manuka honey absorbent dressing, Medihoney, representing the first FDA-approved honey-based product for the management of wounds and burns.
Despite its healing properties, experts are quick to point out that all honey is not created equal. Raw honey found in grocery stores is not sterile and contains bacterial spores, and should not be used on wounds.
Back to basics
While more advanced wound care solutions are gaining ground, they still aren't replacing some of the tried-and-true approaches, such as the routine use of pH-balanced cleansers, gentle moisturizers, barriers and perineal ointments.
"A good protective ointment is the first line of defense. It helps seal out moisture and protects against chapping and chafing," confirmed Maydick.
Keeping skin and wound care products simple and standardized is a good approach, add Madhuri Reddy, MD, a physician who oversees the wound care program at Hebrew SeniorLife in Boston. The organization relies heavily on a product evaluation committee to determine the best products for the job.
"There are thousands of wound care products on the market, but some of the most simple and inexpensive products are just as effective as [some of the pricier ones]. You don't have to spend a lot of money to get good results," she emphasized.
Joan Junkin, WOC, clinical nurse specialist at BryanLGH Medical Center in Lincoln, NE, agreed. Junkin, who also consults long-term care facilities, said a good pH-balanced cleanser is a vital, yet inexpensive, component to any good wound management program. Yet, many of the caregivers she teaches — half of whom are long-term care professionals — fall short in this area.
"You'd be surprised how many people are still using plain old soap and water. I also see a lot of confusion around what pH-balanced actually means. Many are under the [false] assumption that pH-balanced and pH-neutral are the same. pH-neutral products are gentle, yes, but you need to have some acidity to help maintain the barrier protection of the skin," she explained. The range for pH-balanced falls between 4.5 and 5.5 (more acidic), whereas pH-neutral ranges from about six to nine (more alkaline).
Experts stress that even the best products won't be effective unless they're applied in a workplace culture that takes an interdisciplinary, multi-tiered approach to wound management.
"A wound care committee in every community is essential," emphasized Peggy Brenner, RN, director of education and special care programs for ACTS Retirement-Life Communities Inc.
Each ACTS community has a wound care nurse who makes daily rounds, and a wound care committee (comprised of a nursing supervisor, charge nurse, certified nursing assistant, director of nursing and dietician) that meets weekly.
Hebrew SeniorLife designates nursing assistants and nurses as "unit-based champions" to more effectively monitor and manage wounds, and promote unit-wide adoption of wound care policies and procedures. Unit-based, hour-long meetings occur weekly. Ongoing skin assessments help determine the best method of individualized care.
Each unit completes a standard pressure ulcer log each month, which then is submitted to a central source at the end of the month. Staff receives ongoing education on wound management and prevention, and caregivers are well versed on the importance of frequent pressure off-loading.
There's also careful attention paid to proper skin preparation and the safe, effective use of skin care related products.
"Our incidence rate for pressure ulcers has been 1.7 and 1.8 percent for the last two months, compared to the national average of approximately 12 percent," said Tammy Retalic, RN, MS, director of professional development, Hebrew SeniorLife.
Because each resident – and wound – is unique, sources stress the importance of taking an individualized approach to care, such as turning residents more or less frequently, depending upon their needs.
"Some need to be turned every two hours and others may need it every half hour to one hour. There are others who may just need to be cued to stand up and walk," Brenner explained.
"Good, quality, individualized care takes a [facility-wide] commitment and a lot of education. While policies and procedures, and good products are very important, we need to remember that wound management isn't one-size-fits-all. We're dealing with individuals, so we need to use individualized care."
Facts and Figures
Statistics from the Quality Indicator database show that up to 17% of chronic long-term care and 20% of short-stay residents in skilled nursing facilities suffer skin ulcers.
• A 100-bed SNF averages 17 Medicare Part B residents with pressure ulcers who may require skilled rehabilitation intervention for wound care. Note: This statistic does not include additional patients suffering from Venous and Arterial lower extremity ulcers.
• Treatment of pressure ulcers can cost $500 to $50,000 per episode, depending on the severity of the wound.
• The formation of a pressure ulcer or the deterioration of an existing pressure ulcer can lead to a maximum penalty from the Centers for Medicare and Medicaid Services of $10,000 per day.
• About 95% of pressure ulcers occur in the lower part of the body. The sacrum is the most frequent site, accounting for 36% of all ulcers, followed by the heel (30%).
• About 70% of all pressure ulcers occur in those older than 70 years.
• Hospitals have a higher incidence rate for pressure ulcers than long-term care facilities. Between 57% and 60% of ulcers occur in the hospital, compared to roughly 23% in long-term care facilities.
• Fewer than 20% of pressure ulcers occur outside healthcare institutions, with the prevalence rate in home care patients ranging from 9% to 20%.