The long-term care industry is too often saddled with the reputation of giving nursing home residents pressure ulcers. Media reporting frequently leaves the impression that pressure ulcers only exist in long-term care and those ulcers are completely the fault of those facilities. To be clear, this discussion is not meant to exonerate caregivers for skin breakdown, which any first-year nursing student can tell is the one completely preventable complication of immobility. However, it is curious that outside of long-term care, rarely does the pressure ulcer conversation consider the fact that a huge number of pressure ulcers identified in long-term care originate in an acute-care hospital.
Many people arrive at a LTC facility for the first time with “mushy heels” or a discolored sacrum. Neither of which may have any external skin breakdown, yet, but a trained eye will know that those areas are very likely breaking down internally and it is only a matter of time before the external skin breaks down as well. The Agency for Healthcare Research and Quality (AHRQ) has documented that as many as 15% of elderly patients will develop skin breakdown within a week of being hospitalized.
Another AHRQ study showed that “stays related to pressure ulcers were more likely to be discharged to a long-term care facility (e.g. a skilled nursing facility, an intermediate care facility or a nursing home), as compared to hospitalizations for all other conditions. In fact, over half of principal pressure ulcer stays (53.4%) and secondary pressure ulcer stays (54.5%) were discharged to long-term care—more than three times the rate of hospitalizations for all other conditions (16.2%).”
The same study reported an average cost of $37,800 to manage each pressure ulcer. This cost will vary depending on the severity of the pressure ulcers but the statistic is staggering in terms of the preventable nature of this complication. Such a high cost explains why the Centers for Medicare and Medicaid Services (CMS) include an explicit section on skin care in the MDS 3.0.
The discolored area described above would be documented as a “Stage 1” pressure ulcer. The MDS 3.0 would designate this level of skin breakdown as “present on admission.” This means that LTC facility did not have this patient under their care when the pressure ulcer formed. Of course, once that external skin breaks or blisters, those fragile areas are now a “Stage 2” and the facility is considered, in MDS terms, responsible for the exacerbated problem. The Quality Indicator Survey (QIS) specifically measures resident outcomes regarding the incidence of pressure ulcers, adding to the importance of preventing any exacerbation. The eternal question, therefore, that plagues LTC nurses is: How do we prevent further breakdown of ulcers that are present on admission?
One of the first actions that will serve to improve outcomes is to bring the entire interdisciplinary team (IDT) into the act of managing and preventing pressure ulcers. The creation of any care plan that is based on MDS data should have input from every member of the IDT. AHRQ documentation states that “when health care providers are functioning as a team, the incidence rates of pressure ulcers can decrease. Thus, pressure ulcers and their prevention should be considered a patient safety goal.”
Diana Sturdevant, MS, GCNS-BC, PhD, student and director of nursing at Mitchell Manor Convalescent Home in McAlester, Okla., has overseen a facility that has been deficiency free in survey for two years straight. When asked about her success, she focuses on the importance of staff empowerment and education, which in turn has allowed her to create a real home for her residents. Most of her LPNs have earned their RAC-CT certification (the accepted certification for completing the MDS) even though they may not be responsible for the completion of the MDS in her facility. She is able to support this investment because all LPNs are responsible for documentation that will support the MDS. Sturdevant regularly sends staff members to continuing education programs and has focused on wound care and prevention.
The CNAs have enough continuing education and experience to look at a Stage 1 ulcer and have a strong sense of immediate actions that they can perform. They are empowered to put interventions into place to prevent an exacerbation and know to call in a more trained eye. The nurses also have enough experience and education to know what actions to take and when to call in Sturdevant or the MD. They all talk and discuss next steps as a team.
Educating staff and empowering them to take the necessary steps to keep residents safe and in optimal health is one side of culture change we do not often talk about. It is changing the culture for the staff. All levels of staff feel responsible for the well-being of each resident and in turn, each resident feels cared for and important. Residents will then state their needs and let staff know when they aren’t feeling well and staff will be better able to identify status changes immediately, which increases the chances of succeeding at early interventions for emerging complications. This level of open communication both allows and encourages the residents to become a part of the healthcare team.