A sore subject

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A sore subject
A sore subject
Wound management and prevention, like a wound itself, is a painful subject for many long-term care providers. It often ranks highest among their resident care-related concerns. 

And for good reason: It's been estimated that pressure ulcer prevalence and incidence in long-term care residents can reach as high as 28%— and some geriatric wound experts believe that figure is actually low. Such wounds come at a hefty price, both fiscally and figuratively. Not only are pressure ulcers attributed to increased morbidity and mortality, it's been estimated that the total national cost of pressure ulcer treatment tops $1.3 billion. 

What's more, pressure ulcer development is being viewed by some as a quality indicator, resulting in a litany of lawsuits that can do serious damage to a facility's reputation and its bottom line. Increasing the anxiety for many providers is the October enforcement date for the Centers for Medicare and Medicaid Services' revised pressure ulcer regulations (F-314), which will deny reimbursement for wounds that the agency deems avoidable.

Inadequate resources pose their own set of problems. As one physician explained, it's not that providers are falling short in regard to the prevention and management of pressure ulcers, but rather that the system, as a whole, is. 

“If I'm an administrator of long-term care these days, I'm strapped for resources. If you don't have stable staffing or enough [funding] for education, then it will be difficult to tackle complex problems. And a wound is a complex problem,” says Robert Warriner III, MD, chief medical officer for Jacksonville Diversified Clinical Services. “I'm afraid we're not going to be able to do as much on the prevention side as we'd like without some restructuring.”

Some contend that standards of care related to wound management also are inadequate. While each facility has standards of care, “most of the standards are below what is necessary to decrease the incidence of wounds and manage current wounds,” explains Margaret Bryant, PT, a physical therapist and wound expert for Parkland Health & Hospital System in Dallas.

Training methods that fail to adequately address why certain wound prevention and management steps must be taken are further compounding the problem, she says.

“To have a basic understanding of skin as an organ—which needs blood and oxygen to survive—can lead to preventing and managing wounds. I know there is training in long-term care facilities on transfers, mobility and [repositioning], but the why behind it is [often] not there.”

That's not to say successful prevention and management of pressure ulcers is out of reach, however. Despite the myriad challenges, many providers are practicing due diligence by devising and consistently implementing comprehensive policies that effectively tackle pressure ulcers from all sides, and across all disciplines. 

“Preventing and [managing] pressure ulcers takes a very aggressive approach—one that requires facility-wide buy-in and multi-disciplinary involvement,” notes Heather Hettrick, PT, PhD, director of clinical education for American Medical Technologies Inc., Santa Anna Heights, CA.

Prevention is key

Keeping pressure ulcers at bay requires a proactive, consistent preventive approach that includes ongoing risk and skin assessments, detailed documentation and communication across the continuum.
“When it comes to risk assessments, I say the sooner the better. You have to understand co-morbidities, normal dermatological changes of aging skin, and factors that can place a person at greater risk for a pressure ulcer. Without that, you can't come up with a good, individualized care plan for that resident,” Hettrick says.

Operating under the assumption that every resident is at risk is a good strategy, and it's one that more long-term care providers are adopting, adds Bryant. “The positive force at this time is the tools for risk assessment. Long-term care facilities now allocate resources for pressure ulcer prevention,” she observes, noting that, upon admission, preventive resources are now being applied to every resident.
Of course, head-to-toe skin assessments are an equally important component of a comprehensive pressure ulcer prevention assessment. Not only must skin be thoroughly assessed upon admission, experts say it must be an ongoing process.

Regency Hospital of Minneapolis, a long-term acute care facility, takes photos of every heel, every existing wound, and any suspicious skin presentations.

“We check for temperature and color changes of the skin and look for scars or [other characteristics] that might indicate a previous wound,” says Regency CEO Deborah Graves.

Regency caregivers also perform hourly rounds and focus extensively on what they call the Three Ps: positioning, pottying (incontinence issues) and pain.

“Often, it's the simple things that really work,” notes Kathy Irons, WOCN, a wound care nurse for Regency. She stresses that while Regency is somewhat different from the typical long-term care facility in that it treats those who are very sick and fragile, many of these approaches can be easily applied in a step-down setting.

Regency has gotten creative in regard to repositioning. Every two hours, a snippet of music plays as an audible reminder for caregivers, patients and their family members that it's time to change positions (some individuals require more frequent turning). A “turning wheel” is also available in each room to show which position to switch to next, and a wound and skin care book is also kept at the bedside to communicate best practices and help ensure that proper care processes are being followed.

“We take a very proactive approach where everyone is held accountable,” says Irons.

Appropriate use of pressure offloading devices also can go a long way toward preventing or hastening the healing of pressure wounds. And using rolled towels or pillows simply won't cut it, stresses another pressure ulcer expert.

Although pillows may be considered a simple relief system for cushioning bony prominences, they're usually not thick enough, which means they can compress and still put pressure on the skin, according to Tina Meyers, BSN, CWOCN, ACHRN, manager of WOC nursing services, Harris County Hospital District, Houston, TX. “For heels, off-loading boots are the best choice,” she says. “You want the heel to be in the air.” 

Because many long-term care providers may not be able to afford a large number of boots, however, they often are reserved for the highest-risk residents. “But any time a heel ulcer is present, a device is needed,” she emphasized.

Aside from off-loading, caregivers must be well-educated on proper skin care and well-trained on proper use of various products. It's a critical component of wound management, and many experts feel it isn't being adequately addressed. 
Some caregivers are using irritating detergents, surfactants and even petroleum-based products, for example, which can delay skin healing or even promote skin breakdown. 

During one educational forum, for example, Adrianne (Patti) Smith, MD, senior medical advisor, Diversified Clinical Services, says she was shocked to discover that no one present knew the right way to apply moisturizers. 

“After cleansing, it's important to pat the skin dry – never rub – and then moisturize with a good, non-petroleum moisturizer,” she explains. “Lubricants are not the same as moisturizers.”

If a wound is present, Meyers stresses that caregivers should also be diligent about moisturizing the skin surrounding it. “If you allow any part of the skin to dry out and become cracked, you are greatly reducing the skin's ability to protect itself.” 

It appears some caregivers are falling short in regard to dressing changes, as well. 

“Research has shown that the majority of the time, bedside nurses don't even know what kind of dressing they're applying, and are not applying them correctly in about 88 percent of cases,” notes Cynthia Fleck, RN, BSN, ET/WOCN, vice president of clinical marketing for Medline Industries Advanced Skin and Wound Care division, Mundelein, IL. 

Write it down

While some wounds will undoubtedly manifest – or may be present upon admission to long-term care – the onus of responsibility falls on the provider to show that the wound was indeed unavoidable.

CMS will want proof that the facility properly assessed risk, implemented an appropriate care plan, evaluated the resident's outcome, and revised the care plan as needed. The only way providers can demonstrate that they did everything within their reasonable power to prevent the development of a wound is with consistent, detailed documentation.

“Be objective and as descriptive as possible, and make sure what's being documented is legible because if they can't read it, it didn't happen,” Hettrick says. 

Providers potentially could face even more stringent documentation requirements in the future. Acute-care providers soon will be required to have the individual who is legally responsible for writing a diagnosis (i.e., a physician, physician assistant or nurse practitioner) document the presence of pressure ulcers upon admission, explains Cynthia Sylvia, program manager for educational development at Gaymar Industries, Orchard Park, NY. If that doesn't occur, treatment and management of the pressure ulcer will not be reimbursed.

“Right now, this is a requirement geared toward acute care, but I don't think it's much of a stretch for long-term care, either. I think it's very much in the realm of possibility that long-term care could be seeing something similar in the future.” 


Pressure ulcer prevention 

- Perform risk assessment upon admission, weekly for the first four months, and then quarterly (and any time functional or cognition changes occur). 

- Perform daily head-to-toe skin assessments. 

- Keep skin moisturized.

- Protect skin of incontinent residents from exposure to moisture.

- Protect high-risk areas (elbows, heels, sacrum and back of head).

- Do not massage bony prominences.

- Use protective barriers/dressings, and proper lifting techniques/devices to avoid skin shearing during transferring and repositioning.

- Turn and position bed-bound residents at least every two hours (or more frequently, based on individual resident needs/risk assessments).

- Reposition chair- or wheelchair-bound residents every hour (or more frequently, based on resident needs).

- Use off-loading devices to raise heels of bed-bound residents off the bed. 

- Use a 30-degree lateral side lying position; do not place residents directly on their trochanter.

- Elevate head of bed no more than 30 degrees.

- Use pressure-reducing devices when appropriate (avoid using donut-shaped devices). 

- Manage nutrition and hydration; offer a glass of water with turning schedules.

Source: Agency for Health Care Policy and Research

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