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Battling Pressure Ulcers: Consistency Means Success

January 1, 2004
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Interview with Courtney H. Lyder, ND
Battling Pressure Ulcers: Consistency Means Success

INTERVIEW WITH COURTNEY H. LYDER, ND Pressure ulcers are a cloud that hovers over long-term care like the cigar smoke that lingers after an all-night poker game: Attempts to make it go away are not always easy. Given the risk factors inherent in a frail elderly population-e.g., immobility, nutritional deficits, and the tendency for skin breakdown-it's no surprise that pressure ulcers occur in nursing homes. On the other hand, never before have caregivers had available more products and equipment aimed at preventing these wounds, and never before have they had so many options for treating them. So why, despite the advances in prevention and treatment, do pressure ulcers still occur at such high rates in some long-term care facilities? Nursing Homes/Long Term Care Management Editor Linda Zinn asked that question of respected wound care researcher Courtney H. Lyder, ND, and asked him to comment on recent developments.

Zinn: Why, when pressure ulcer treatment is so costly, when the potential costs associated with litigation related to pressure ulcers are so high, and when it is so widely known how to prevent and properly treat pressure ulcers, are they still such a problem in long-term care?

Dr. Lyder: This problem is largely a consequence of staff turnover. In studies regarding pressure ulcer prevention, we see that if a prevention program is implemented and followed consistently, a significant reduction in the incidence rates occurs. And if you implement treatment programs, you see an increase in wound healing. The problem is maintaining the prevention and treatment protocols consistently. Maintaining consistency is the biggest challenge, and that is difficult with staff regularly coming and going.

One way to improve that consistency is to have someone in facility administration-it could be the administrator or the DON-champion the cause of pressure ulcer prevention and treatment. Along with that person you need one or two clinical staff who will also promote the program and motivate line staff to follow it. With that kind of "top-down" support, you can convert the entire staff.

I published a study last year on pressure ulcer prevention programs in two nursing homes that previously had been heavily cited by state surveyors for a high incidence of pressure ulcer occurrences. At one of these facilities, the administrator became the program's champion, and at the other the DON became the driving force behind it. Once they were committed, we identified two experienced nurses at each facility who had been on staff for a long while and, therefore, were unlikely to leave, and we motivated them to help implement the programs.

Within only five months, one facility went from a 13.5 to a 1.5% incidence of pressure ulcers; the other went from 15 to 3.5%. That was the good news. The bad news was that the administrator got transferred from one of the two study facilities, and the DON left the other. Without these champions to continue the momentum of what they'd started, the staff got discouraged and the rates went right back up. In fact, a nurse who was one of the clinical champions got so disgusted that this occurred after all the work they'd done, that she also left-after being with the facility 11 years.

Zinn: It seems obvious that all frontline staff should be trained in pressure ulcer prevention protocols when they're first hired. Do you think that happens?

Dr. Lyder: I believe nursing homes that aspire to and provide evidence-based nursing care do orient their staff to pressure ulcer prevention protocols. These protocols, when written correctly, can be easily disseminated to staff. Moreover, good protocols can be easily incorporated into the care that is provided to residents on a daily basis. For example, placing a turning schedule at the bedside of a bed-bound resident is an excellent reminder to staff that the resident needs to be turned at least every two hours.

Another example is having a pressure ulcer prediction tool as a part of the admission process. Thus, staff can perform a Braden Scale or Norton Scale exam as a part of the routine admission, so they will be less likely to forget this important assessment.

Zinn: What have researchers learned about pressure ulcer treatment recently?

Dr. Lyder: Wound bed preparation is something we're learning more about. We now know, for example, that wounds heal best when we remove the edema from the wound bed. Conversely, they don't heal as efficiently or effectively if the fluid remains.

Zinn: In light of that, is negative-pressure wound therapy effective for these edematous wounds?

Dr. Lyder: Yes, it works well on highly exudating, full-thickness stage III and IV wounds. However, I'd be more likely to use it on a stage IV than a stage III wound, and I wouldn't use it at all on stage I or II wounds.

Zinn: How about the silver-containing dressings?

Dr. Lyder: This is one of the biggest recent breakthroughs in wound care. It goes back to wound bed preparation again-in this case as it relates to the bacterial burden within wounds. Silver, regardless of how it's delivered, is a good product for decreasing the bacterial loads in pressure ulcers that are infected or are on their way to being infected.

Zinn: Aren't all wounds potentially on their way to being infected?

Dr. Lyder: Yes, but there are certain signs to look for: a wound with excessive exudate or drainage, or more than the usual amount of blood; or a wound site that is warmer to the touch than normal. These are indications that there's something brewing.