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Risk Management » Practice Tips
June 2008
Pressure Ulcers: Prediction & Prevention in Long Term Care
The objective of this practice tip is to help identify adults at risk of a pressure ulcer and to define early interventions to constitute a preventative plan of care.
Pressure ulcers can be known as pressure sores, bedsores, decubitus ulcers, and tissue trauma. Regardless of the terminology, they are any skin lesions caused by unrelieved pressure that damages tissue. The severity ranges from reddening of the skin to severe, deep craters that can expose muscle and bone. Pressure sores usually occur over bony prominences and are graded or staged to classify the degree of tissue damage observed.
Staging:
- Stage I: Non-blanchable redness of intact skin, the heralding lesion of skin ulceration.
- Stage II: Partial thickness skin loss involving epidermis, dermis or both.
- Stage III: Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater.
- Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structure.
Long term care facilities continually struggle with the challenges of pressure ulcer prevention. A recent study by the National Pressure Ulcer Advisory Panel revealed a pressure ulcer incident rate of 2.2 to 23.9% in long term care. Conservative estimates at the cost for pressure ulcer management range up to $50,000 per ulcer. There are approximately 1.5 to 3 million adults suffering from pressure ulcers.
The US Centers for Medicare and Medicaid Services (CMS) has included pressure ulcers, in residents assessed as being at low risk for pressure ulcers, as one of the sentinel events in long term care. According to CMS, the only residents who are at high risk are those who have impaired transfer or bed mobility, are comatose, malnourished, or have end-stage disease; any other patient is at low risk.
In an effort to ultimately improve the quality of healthcare, many regulatory agencies that review and accredit health care facilities require formal pressure ulcer prevention and risk assessment programs be implemented. An organization without such programs in place is not only at risk of being cited deficient by a regulatory body, but is in jeopardy of facing potential litigation if its practices cannot be defended in light of the current standards of care.
The clinical practice guideline on pressure ulcer prevention from the Agency for Healthcare Research and Quality [AHRQ] provides a starting point for identifying at-risk individuals who need preventive interventions and the specific factors that place these individuals at risk. Two risk assessment scales - the Norton and the Braden Scales - are mentioned in the AHRQ guideline as being appropriate clinical tools for determining pressure ulcer risk because of the amount of clinical research supporting their reliability and validity.
Pressure Ulcer Prevention Program
A comprehensive program should be in place and include all of the components discussed below:
- Risk Assessment Tools & Risk Factors
- Skin Care & Early Intervention
- Mechanical Loading and Support Surface
- Education
- Risk Assessment Tools & Risk Factors
Using a validated risk assessment tool such as the Braden Scale or Norton Scale can accomplish a systematic patient risk assessment. Pressure ulcer risk should be reassessed at periodic intervals. The AHRQ clinical practice guideline on pressure ulcer prevention recommends that initial pressure ulcer risk assessment be done on admission and that reassessments be done at periodic intervals. However, the guideline is not specific as to how often the reassessments should be done.
Bed and chair-bound individuals or those with impaired ability to reposition themselves should be assessed for additional factors that increase risk for developing pressure ulcers. Other factors to be aware of are:- Immobility
- Incontinence
- Diminished nutritional intake
- Altered level of consciousness
This skin assessment should be documented in their medical record.
- Skin Care & Early Treatment
To prevent skin injury a maintenance program should be established to improve tissue tolerance to pressure. Listed below are some key areas to follow:- All individuals targeted to be at risk should have a systematic skin inspection daily.
- Skin cleansing should occur at the time of soiling and at routine intervals.
- Avoid hot water and use mild cleansing agents.
- Dry skin should be treated with moisturizers.
- Avoid massage over bony prominences.
- Minimize skin exposure to moisture from things such as incontinence, perspiration or wound drainage. Use a commercial moisture barrier, and use absorbent pads or diapers that wick and hold moisture. Address the cause of moisture if possible, and offer a bedpan or urinal in conjunction with turning schedules.
- Skin injury due to friction and manual force should be minimized through proper positioning, transferring and turning techniques.
- An adequate dietary intake of protein or calories is important to monitor. Consult a dietitian and act quickly to alleviate nutritional deficits. Increase the patient's protein intake and increase his or her calorie intake if needed. If it is determined that the resident is unable to maintain an appropriate dietary intake, nutritional supplements may be required.
- Maintaining their current activity level, mobility and range of motion is an appropriate goal for most; however, if there is potential to improve rehabilitation, efforts should be implemented.
- All interventions and outcomes should be monitored and documented in the medical record.
- Mechanical Loading and Support Surfaces
Protecting residents against the adverse effects of external forces such as pressure, friction and manual force should be watched carefully.- Any resident who is assessed to be high risk for pressure ulcers should be turned or repositioned every two hours.
- Bed-bound residents should have position devices such as pillows or foam wedges to keep bony prominences from direct contact with one another.
- Residents that are completely immobile should have a device that completely relieves pressure on their heels. This is usually accomplished by raising the heels off the bed. Do not use donut-type devices.
- Avoid positioning the patient directly on the hipbone when the side-lying position is used.
- Limit the amount of time the head of the bed is elevated.
- Use lifting devices such as a trapeze or bed linen to move individuals who are unable to assist during transfers. Avoid dragging the patient.
- Pressure reducing devices, such as foam, static air, alternating air, gel, or water mattresses should be used on residents assessed to be high risk for developing pressure ulcers.
- Residents that are wheelchair bound should be repositioned every hour or put back in bed for periods of time. The use of pressure-reducing devices such as foam, gel, air or a combination is also suggested for chair bound residents. Do not use the donut type devices.
- A written plan of care may be useful to clarify the use of all the positioning devices and repositioning maneuvers.
- Education
Comprehensive educational programs can reduce the incidence of pressure ulcers.- Education for the prevention of pressure ulcers should be directed at all levels of health care providers to include patients, families or caregivers.
Medical Mutual's "Practice Tips" are offered as reference information only and are not intended to establish practice standards or serve as legal advice. MMIC recommends you obtain a legal opinion from a qualified attorney for any specific application to your practice.