Wound care victories
Nursing staff at the Carl T. Hayden VA Medical Center in Phoenix test a pressure mapping system.
It's been nearly 30 years since nurse Nancy Bergstrom, Ph.D., helped formulate the Braden scale commonly used to assess a patient's risk of developing pressure ulcers.
Today, she's convinced that the health and financial costs linked to such sores are so steep that many facilities would do well to standardize bedding that alleviates pressure and keeps blood flowing to trouble spots.
“Everybody hates that pressure ulcers are still such an issue,” says Bergstrom, associate dean of the University of Texas Health Science Center at Houston School of Nursing. “High-density foam mattresses cut the whole facility so much slack.”
In her 2013 TURN study, Bergstrom found that staff might not need to shift residents sleeping on high-density foam every two hours, a standard practice for generations. The trial showed there was no difference in the incidence of pressure ulcers among moderate and high-risk residents who were turned every two, three or four hours.
It was, in essence, an endorsement of high-density foam mattresses, now the support surface of choice in many skilled nursing facilities. But a line of other innovations awaits, with wicking fabrics, air chambers, mapping technology and tension straps promising results for residents.
The difficulty for many administrators is deciding which prevention products and treatment options are worth the investment. Kristen Thurman, a certified wound specialist and corporate advisory member of the National Pressure Ulcer Advisory Panel, equates the process to guesswork.
“There are a lot of details to consider before you make a decision,” acknowledges Ron Resnick, owner of Blue Chip Medical, a therapeutic mattress company. “Really, you should go to a wound care expert and get some recommendations and references from other like facilities.”
More than 1 in 10 nursing home residents has had a pressure ulcer, according to the Centers for Disease Control and Prevention. Sores progress quickly from a red mark to a gaping wound if there is no intervention.
Bergstrom says opting for a preventative surface for all patients buys a facility time if a full risk assessment can't be done immediately. It's an easily documented intervention in an area that draws 17,000 lawsuits a year. The fact that Medicare no longer reimburses for treatment of wounds acquired during residency also provides an incentive.
“Facilities are realizing the value of forward investing in these products to prevent costly pressure ulcers as an outcome,” explains Thurman.
Pressure ulcers can lead to severe pain or amputation, and treatment costs the U.S. up to $11.6 billion annually, according to the Agency for Healthcare Research and Quality.
“What we try to stress is that you want all of your residents on a really good prevention surface so you don't have to step up to treatment,” says Courtney Rowan, product manager for therapeutic support services at Invacare.
She divides surfaces into two categories, with replacement options like high-density foam mattresses squarely in the prevention category and more expensive low-air loss and alternating pressure products in the treatment category. Invacare has seen an increase in the number of facilities replacing spring mattresses with high-density foam in every patient room. That reflects the latest NPUAP guidelines calling for “higher specification” foam mattresses for all at-risk individuals.
Rowan cautions that buyers go beyond descriptions to get facts about product quality. Invacare this summer will begin offering mattresses with a 2.5-pound density, the highest measure Rowan has seen.
Resnick says it's also important to know a mattress' life expectancy and indentation force deflection, or IFD, a standard measurement of the force required to indent the product to a predetermined level. It's possible to buy a high-density mattress with a low IFD, which allows a user to sink in and spread weight out over a greater surface area.
Though the mattresses in Bergstrom's trial were chosen by the 27 participating facilities, every incontinent resident was on a breathable surface and in briefs that effectively wicked away moisture. A comprehensive safety check required briefs to be inspected or changed as needed.
Modern mattress covers offer an added layer of defense against moisture. Most use a low-shear nylon, with either a PVC or neo-butyl backing. They are designed to breathe but lock moisture out of the mattress core. MedlinePlus recommends adding a disposable bed pad (also known as chux) to soak up sweat or urine.
Even details such as zippers are important. Resnick has seen an Alzheimer's patient hide food inside a zippered cover; Resnick's firm makes a French closure version that can be cut away for removal. Invacare, meanwhile, specializes in a four-way stretch cover that moves with residents to reduce friction. It can be washed or one section can be removed and replaced as needed.
Ascension Health, operator of about 30 long-term care facilities, studied new surfaces as it rolled out a strategy for preventing pressure ulcers about 10 years ago.
The “SKIN Bundle” is a series of steps intended for at-risk patients. It highlights surface selection, the need to keep turning patients, incontinence management and nutrition. As part of a trial, staff at one Ascension hospital swapped surfaces, trading up for 162 better quality beds.
The facility's incidence rate fell below 1% during the testing phase, and systemwide prevalence was at 1.8% (excluding stage I ulcers) in the 2013 Hill-Rom annual pressure ulcer study. The national rate was 2.4%.
Debbie Rapp, R.N., M.S.N., and senior director for clinical excellence at Ascension, says surfaces are as important as any other element of the bundle. Ascension continues to look for improvement and is currently negotiating the purchase of new mattresses.
Many recent advances aim to cut moisture, heat and shearing.
James Spahn, M.D., founded clinical device company EHOB in 1985 after being told that positioners he had created for his head and neck patients were successfully being used to treat stage III and IV pressure ulcers.
He created a line of products around an inflatable, inner tube-like device with cut outs that reduce pressure. The non-absorbent Waffle overlay is designed for single-patient use, but Spahn said he's seeing more of them moving from the hospital to skilled nursing, rehab or home care. They can also be ideal for a resident whose risk temporarily climbs, such as following surgery for a fracture.
Spahn has seen Waffles used atop foam mattresses or low air-loss beds. For now, the products are filled by hand pump. But within six months, Spahn plans to market an integrated pump that would run only when needed. He said his product would reduce electrical costs and eliminate concerns about fans that can spread highly contagious diseases.
Robert Jarmon, M.D., hopes to revolutionize surfaces with CircSupport, an FDA-approved system of straps that alternately tighten and release tension to alleviate pressure. The mattress resembles a poolside chaise lounge. Though it doesn't offer the comfort of a typical mattress, Jarmon says it could be ideal for comatose or other long-term care patients who are high risk because they have no sensation.
Jarmon was treating an ALS patient with pressure ulcers when he realized a chaise lounge addressed the shearing and moisture and heat build-up causing sores. His version includes a cooling fan and a quiet motor that slowly loosens every other strap according to an adjustable timer.
As it exerts and releases pressure, the system rhythmically compresses the veins and assists blood flow back to the heart.
Pressure ulcers are a major concern for patients who are not bed-ridden but spend much of their day idle. Resnick recommends solid seat inserts on every wheelchair, with “very economical” gel and foam combos available.
He also wants long-term care facilities with geriatric chairs — especially those for on-site chemotherapy or dialysis — to use padded, moisture-wicking surfaces. Reclining chairs hyperextend the body, with the 110-degree angle shifting pressure.
Resnick is a fan of mapping systems that show how well interventions are working; he recently began distributing SensorsEdge.
A competing product from Wellsense attaches to a pressure-sensing mat placed under the patient; twice-a-second readings provide a read-out that resembles a severe weather warning. Bright red and orange spots indicate a resident should be repositioned.
“From a prevention standpoint, if pressure can be visualized and removed or redistributed under a patient, this could certainly help to remove that risk,” comments Thurman.