Passing on the risk: managing pressure ulcers between care setting transfers

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Passing on the risk: managing pressure ulcers between care setting transfers
Passing on the risk: managing pressure ulcers between care setting transfers
Avoiding skin breakdown and pressure ulcers is an ongoing challenge for long-term care providers as they care for an older, sicker and increasingly compromised resident population. And those challenges become even greater when residents are transferred back and forth among care settings.

With as much as a $70,000 price tag on complex pressure ulcer treatment—and the fact that the Centers for Medicare & Medicaid Services no longer reimburses for avoidable pressure ulcers—providers must be intently focused on maintaining good skin health and ensuring that they don't bear the financial burden of treating preventable deep tissue injuries and skin breakdown that occurred on another facility's watch. That isn't always easy, though, sources acknowledge.

Not only is a lack of communication between skilled nursing and acute care facilities still all too common, each setting's care priorities—and protocols—can differ greatly, which makes it more likely that a resident will not receive consistent, seamless care.  

“It would seem reasonable that there should be an agreed upon transfer protocol or process between healthcare organizations within a specific locale,” says Alexis Roam, nursing home services program manager for Primaris, a Columbia, MO-based nonprofit healthcare consulting firm. “However, this is not always the case.”

No skin in the game

A long-term care provider can do a great job of maintaining skin health while a resident is in its care, and all the way up to the point of transfer, but it can't always count on the same level of due diligence when the resident is admitted to another setting, particularly a hospital where tending to the immediate, acute illness takes precedence over other potential risks, such as skin breakdown.

“Typically, the focus on transfers is with the paperwork and in getting the [resident moved]—and not on the resident's needs before, during and after the transfer,” explains Deborah Bakerjian, assistant adjunctive professor at the University of California, San Francisco, and chair of Advancing Excellence in American Nursing Homes' clinical advisory workgroup. “Skin is not seen as a priority. More focus is typically given to cardiac and respiratory status.”

Sometimes, caregivers in acute care settings aren't even aware of the skin breakdown risks, which explains why transferred residents often aren't repositioned, off-loaded or adequately assessed.

“It is possible to have an elderly person in a hospital bed for three to four days and the skin condition being overlooked,” notes Roxanne Merkes, certified wound nurse and skin care team member for Cedar Lake Health Care Community in West Bend, WI.

One point experts agree on is that proper skin care is anything but a back-burner issue, and that caregivers across the care continuum have a responsibility to the resident or patient to ensure that skin integrity doesn't fall by the wayside.

“Creating seamless care is really what we're talking about here,” stresses Dr. James Spahn, CEO/founder of EHOB Inc, an Indianapolis-based manufacturer of pressure ulcer prevention and treatment products.

“Keeping skin healthy requires every setting to really know the physiological status of the person being transitioned in and out of their care, and this information must be provided in a timely, accurate way. You can't have that without effective, ongoing communication.”

Closing the gaps

Establishing good communication between care settings can be challenging, and it often requires education and an organization-wide culture change. But sources assured that putting in the extra effort can pay big dividends, both in terms of fewer pressure ulcers and increased resident satisfaction across the care continuum.

Effective, consistent communication takes a multilayered approach, beginning with a facilitywide understanding of the need for multidisciplinary intervention, process improvement and targeted education. There also must be a willingness to ditch the pressure ulcer “blame game” and partner with neighboring facilities for improved resident care.

“Start by forming a task force with representation from all settings that can address the issue,” Bakerjian urges. “Identify specific problems and work on shared solutions. This requires each side to stop finger-pointing and agree that it is a shared problem. These groups need to develop a culture of mutual respect so the process can be open and positive.”

Because of long-term care providers' experience in skin breakdown treatment and prevention, it may be appropriate for them to take the educational lead with referring hospitals and other care settings.
“One of long-term care's strong suits is skin care, so they really have an advantage,” confirms Courtney Lyder, dean of UCLA School of Nursing and former president of the National Pressure Ulcer Advisory Panel.

If applied properly, that experience can help protect long-term care providers from other facilities' shortcomings, while also guiding better care and documentation across all settings.

A long-term care wound specialist or other experienced staff member is a logical choice for educator and may also serve as liaison between transferring and receiving facilities. An admissions nurse assumes a lead role in the process  at Humility of Mary Health Partners, a provider of long-term care, assisted living, retirement living, acute care and home and hospice care across three Ohio counties. Before a patient or resident is transferred to another care setting, the admissions nurse visits the referring facility to speak with caregivers, residents/patients and their families, and gather pertinent information to ensure that proper care and planning is in place before they transition.

“When our admissions nurse sends admission information to our team, she'll make preliminary recommendations on wound care needs and prevention strategies,” explains Shelly Mazerik, RN, manager of long-term care education, performance improvement and medical records for Humility of Mary Health Partners. “The goal is to have a true, holistic picture of the resident, so you feel as though you have a relationship with them before they even come to the facility.”

Likewise, when residents are transferred from Humility of Mary Health Partners' long-term care or assisted living facilities, the accepting facility receives a thorough transfer sheet with complete physiological history, the name of the referring physician, the resident's habits and schedules, limitations, risks and so on, adds Marilyn Graff, a wound care specialist for Humility of Mary Health Partners. Wheelchair-bound residents are transferred with their pressure-relieving cushion to help ensure continuity of care.

Daily interdisciplinary “stand-up” meetings also are policy, according to Mazerik. They provide a snapshot of resident changes that could increase their risk for skin breakdown and other complications. “Every discipline is represented.”

Southfield, MI-based Ciena Healthcare relies on all staff members, from CNAs and housekeepers to maintenance workers and dietary staff, to complete an “early warning report” if any resident changes (or perceived changes) are identified.

“The more eyes that are on the residents, the better,” says Lisa Anetrini, Ciena's director of clinical services. “A lot of times, it's the employees you wouldn't necessarily expect who spot important changes first.”

Skin breakdown can begin during long trips in the ambulance, Bakerjian warns, which makes education of ambulance drivers and paramedics on the risk for skin breakdown during transfers equally prudent.

And don't forget to educate residents and their families, Merkes adds.

“When our residents discharge home, they are very aware of our concerns and what we have encourage [them] to do while at our facility to prevent skin breakdown,” Merkes says. “They are well educated on what to continue while at home.”

Data-gathering diligence

Facilities that don't have the luxury of a traveling admissions nurse or other advocate to step in and personally inquire about a resident's status prior to admission or transfer still can cover their bases through diligent data gathering and documentation.

“At a minimum, each referring setting should conduct a skin assessment, along with the overall assessment of the person, and share their findings with the receiving setting,” reasons Rome. “New and appropriate interventions need to be implemented based upon the person's most current assessment.”

A transfer form that clearly documents the resident's history and current treatments should be required. The forms should be comprehensive, including the current Braden score, continence details, toileting schedule, dietary or hydration changes, underlying illnesses and high-risk diagnoses, medication use or changes, ambulatory status, mental health, when and where a fall or other injury occurred, and other key factors that might contribute to injury and skin breakdown, various experts say.

Of course, each setting also must understand the rationale behind specific documentation entries. Clinical consultant Sharon Hamilton, of Briggs Medical Services Co. in West Des Moines, IA, said she has seen blank lines present on otherwise good forms because the clinicians were not educated on how to use the tool to its greatest advantage.

“There have been instances where clinicians add information in the margins of the forms that didn't prompt the writer to communicate the information,” she says.

The right questions

Effective documentation often requires additional data-gathering and questioning. Because each resident will be admitted and discharged under unique circumstances, Merkes urges providers to ask the right questions to help establish a more detailed resident history.

“If they fell, how long did they lay at home before someone found them?” Merkes asks. “How long was their ambulance ride? How long did they lay on the hard gurney? Were they on wound prevention interventions at the hospital? Did they get out of bed or were they bedridden the whole time?  Were they on a special turning schedule? Did they have an open area present before admission?”

These are just a few pertinent questions that long-term care providers should ask to identify the risk for potential tissue injury prior to admission and determine the best course of action, Merkes reasons.

While written documentation is critical, long-term care providers shouldn't stop there. Lyder urges facilities to take photos of residents' skin upon admission, as well as before transferring them to another facility. He stresses that the photo must be dated, clearly identify the resident, and be placed in the resident's file.  

“It is incumbent upon each facility to know what exactly is going out or coming in with each resident or patient, and then have the data to back that up,” Lyder explains. “State laws and federal regulations all say that if a facility doesn't identify a problem [or risk] upon admission and a pressure ulcer develops, they own it. This is why good, solid assessments and documentation are so critical.”