Pressure's on

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Pressure's on
Pressure's on
Treating and preventing pressure ulcers and other wounds has long been a challenge for long-term care providers. But ever since the Centers for Medicare & Medicaid Services issued its revised interpretive guidelines for Federal F-tag 314 in November 2004, some facilities believe the pressure to prevent such wounds never has been greater.

Their lingering angst revolves around the regulation's more stringent interpretation of what constitutes avoidable and unavoidable pressure ulcers. The revised F-314 guidance was intended to make surveyor expectations clearer regarding pressure ulcer care. But some skilled nursing providers contend F-314 is too strict for a geriatric population that is more fragile, often immobile and may have comorbidities that make residents more susceptible to difficult-to-treat wounds.

“Although I'm obviously in favor of doing everything possible to prevent wounds, a lot of us are somewhat worried because, based on our interpretation of F-314, the scope of what CMS considers as an unavoidable pressure ulcer has become smaller and the definition of what is avoidable has broadened,” explained one geriatric nurse. “If a pressure ulcer is present and CMS comes in and says it could have been prevented, then we're in trouble – both in terms of reimbursement and possible fines.”

Wound care experts have witnessed similar anxiety across the care continuum. “I've seen a lot of fearful nurses, both in hospital and nursing home environments, and I believe they have this slanted view of the [regulation] because they don't fully understand what's going to be expected of them when surveyors walk through that door,” reasoned Mary Cook, RN, CWOCN, national director for clinical and development support for Diversified Clinical Services of Jacksonville, FL. 

While providers' concerns are understandable, wound management experts – some of whom played a role in the final F-314 interpretive guidance revisions – believe much of the fear surrounding the regulation is overblown. 

“Actually, I believe long-term care facilities are doing a pretty good job when it comes to preventing and treating wounds,” said Elizabeth Ayello, Ph.D., RN, CWOCN, president of Ayello, Harris and Associates Inc., Copake, NY. A foremost expert in the field of wound management, Ayello played a role in the F-314 interpretive guidance revisions and also serves as senior advisor at the John A. Hartford Institute for Geriatric Nursing. She said many facilities are already being proactive in their quest to curb preventable wounds and effectively manage those that arise.

Wound care professionals who are well-versed on F-314 are trying to assure caregivers that CMS is not – and never was — pushing a zero-tolerance pressure ulcer program.

“Certainly, Medicare understands that not every pressure ulcer or wound is preventable. They will still reimburse for [the treatment of] pressure ulcers, just not ones that are avoidable. That's key,” Cook explained.

A watchful eye

When assessing pressure ulcer prevalence rates, secondary complications can arise. Combined with the near-stratospheric costs associated with their treatment, it's no wonder CMS has taken a stricter stance. 

As many as 23.9% of skilled nursing residents develop pressure ulcers at some time, and that percentage skyrockets to more than 60% for high-risk individuals with femoral and/or hip fractures, the National Pressure Ulcer Advisory Panel reports. 

Cumulatively, 1.8 million Americans develop pressure ulcers each year (with 70% occurring in those age 70 or older), at an overall treatment cost of $1.3 billion. 

Given those statistics, it's not especially surprising that more than 17,000 lawsuits linked to pressure ulcers are filed each year – and that F-314 was the most often cited tag nationally in 2003 by state surveyors. It also helps explain why the government's goal with its Healthy People 2010 Initiative is to cut the incidence of pressure ulcers in nursing home residents by 50% by 2010.

Relative to F-314, CMS is looking to curb the number of pressure ulcers by emphasizing prevention and increasing expectations for care. Specifically, the regulation stipulates that, based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure ulcers does not develop pressure sores unless the individual's clinical condition demonstrates that such a wound was unavoidable.

Beyond that, a resident with a pressure ulcer must receive necessary treatment and services to promote healing, prevent infection and prevent new sores from developing, according to experts.  
They are quick to point out that even if a resident who develops a pressure ulcer was determined to be at high risk, that still doesn't necessarily mean the pressure sore was unavoidable.  

“Early and more complete evaluations of high-risk [individuals], and aggressive pre-pressure ulcer care would certainly diminish the incidence [of avoidable pressure ulcers],” said Denis Drennan, MD, president, DM Systems Inc., an Evanston, IL-based manufacturer and distributor of wound care products.

Managing the pressure

So, what should long-term care providers be doing to better address wound prevention and management – and keep in good standing with surveyors? A consistently delivered, yet surprisingly simple strategy is often the best approach, sources agree.

“I believe we really need to get the message out that preventive risk and skin assessment protocols must be in place and consistently implemented for each resident,” Ayello noted.

In the long-term care environment, it's widely recommended that risk assessments (using tools such as the Braden Scale or Norton Scale) occur upon admission, weekly for the first four months, and then quarterly. The risk assessment must take into consideration mobility, incontinence, sensory deficiency and nutritional status, including dehydration.

Reassessments also are in order any time a resident's condition changes. It's been shown that risk assessment upon admission has proven highly predictive of pressure ulcer development, and even more so when reassessment is completed 48 to 72 hours after admission.

“Many changes, even if they seem small or unrelated, can increase [a resident's] risk for wounds. If dentures don't fit, for example, that could impact their ability to eat, which then could impact their protein levels and lead to skin breakdown,” Cook explained, adding that other common condition changes, such as hydration deficits, incontinence or immobility, also increase wound development risks. 

For this reason, multidisciplinary teams well versed on wound prevention and management are essential.

“It isn't just the frontline caregivers who need to be involved,” Cook continued. She pointed out that social workers, physical and occupational therapists, dietitians, physicians, consultant pharmacists and even activities directors and other staff members can offer valuable insight into possible condition changes. 

Skin assessments are equally essential and must be coupled with risk assessments for optimal success. Thorough skin assessments should be performed at least daily, with careful attention being given to areas at high risk for pressure ulcers, such as the sacrum, back, buttocks, heels and elbows, notes the National Pressure Ulcer Advisory Panel.

Throughout the assessment process, sources agree that it's imperative that caregivers thoroughly and consistently document the activities and findings. Detailed documentation not only is critical for demonstrating that assessments were conducted in a timely manner, but also for showing that proper treatment and prevention protocols were implemented, and that individual, assessment-based care plans were devised and followed.

“Surveyors will require very good documentation – the more detailed, the better,” Ayello stressed. She explained that the chances of surveyors citing a facility for a pressure ulcer incident are significantly lessened if providers have carefully and consistently documented all assessments, care protocols and condition changes.

Taking a continuum of care approach to wound prevention and management is another highly effective approach, as demonstrated by the New Jersey Hospital Association's Pressure Ulcer Collaborative that began in 1994. With hospitals, home health agencies and skilled nursing facilities working together, the collaborative – led by Dr. Ayello — was able to reduce its pressure ulcer incidence by 70%. “Care bundling,” which involved diligent and ongoing risk and skin assessments, proper pressure redistribution, a focus on adequate nutrition, hydration and condition changes, and careful attention to skin care protocols, among other tactics, all contributed to the success.

“I would say the facilities that don't keep up with these types of approaches to prevention will fall behind and be seen as sub-par,” said Thomas Stewart, Ph.D., president and CEO of Gaymar Industries Inc., Orchard Park, NY.

Picking the right products

Of course, any effective wound management plan relies on keeping skin clean, dry and protected. Unfortunately, some providers aren't doing a good enough job of consistently delivering in those areas, pointed out Oscar Alvarez, MD, head of Calvary Hospital's Center for Palliative Wound Care, Bronx, NY.

“Many times, I think the problem is people aren't doing things in the right sequence. Rather than being as proactive as possible on the front end, they're dealing with wounds after they occur,” he said, noting that oftentimes, more advanced — and costly — treatments and products are being used before good standard skin care regimens and off-loading techniques.

Further compounding the problem, according to another prominent wound care physician, is the relative absence of random-controlled, evidence-based studies on skin and wound care products, which is leading some facilities to use too-harsh products and outdated skin care protocols that can increase the odds of skin breakdown.

“If CMS offered more guidance on what products should be used [on a general scope], it would help take away some of the questions that can lead to wrong decisions,” said Robert Williams, MD, a wound care physician at Conroe Regional Medical Center in Conroe, TX. Without that guidance, he said, some facilities are relying on standards of care of 30-plus years ago.

Even so, leading wound care associations and committees share some general skin care guidelines. These include hydrating the skin and using both a pH-balanced cleanser and a protective moisture barrier. 


Avoidable vs. unavoidable pressure ulcers

“Avoidable” means that the resident developed a pressure ulcer and that the facility did not do one or more of the following:

• Evaluate the resident's clinical condition and pressure ulcer risk factors

• Define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice

• Monitor and evaluate the impact of the interventions

• Revise the interventions as appropriate.

“Unavoidable” means that the resident developed a pressure ulcer even though the facility had taken the steps above.

Source: Centers for Medicare & Medicaid Services, Interpretive guidelines to Federal Tag F-314

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