How MDS 3.0 can influence pressure ulcer management

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.

Sturdevant explains the importance of nursing interventions in holistic care and reiterates that all levels of staff are empowered to immediately manage all potential problems within their scope of practice, but also focused on nutritional interventions. She talks about the importance of getting an appropriate level of protein into each resident’s diet to not only stop an existing ulcer from getting worse, but also prevent ulcers. Preventing protein energy malnutrition is central in creating a nutritional status that will both help prevent skin breakdown and aid in the healing of any stage of a pressure ulcer.

The discussion of creating a diet that is conducive to pressure ulcer prevention must include the dietitian. Get everyone in the act. Open communication is imperative; from the moment that resident arrives at the facility. Creating an effective dietary plan requires interviewing the resident and/or resident’s family. If you have a resident that is a vegetarian, it is unlikely that creating a diet with lots of lean meat is going to effectively manage a protein deficiency.

The MDS requires a resident interview and is a good example of a federal regulation bowing to the importance of resident-directed care. Talk to the resident and empower your staff to move forward on balancing that resident’s preferences with their medical needs. Open the doors of communication between staff members so when those potential complications are identified upon admission, they are also immediately acted upon. Bring in your IDT and create a care plan that includes interventions that are agreeable to the resident and focused on the problem at hand. It may not prevent that Stage 1 from becoming a Stage 2, but you have certainly decreased the odds of that pressure ulcer getting worse.

The combination of the mandated MDS 3.0 assessment, which requires resident input, and the insight of the interdisciplinary team should lead to more effective care plans, improved care and fewer avoidable complications. Using the MDS 3.0 as a foundation to improve assessment and open the doors of communication between staff and residents can help move every facility toward a more safe, warm and home-like environment. This is long-term care at its best and facilities like, Diana Sturdevant’s, are proving every day that it can be done.

Ingrid Johnson Serio, RN, BSN, MPP, is the Director of Content Management for the American Association of Nurse Assessment Coordination (AANAC). She can be reached at iserio@aanac.org.

Resources

C. Allison Russo, C. S. (2008, December). Hospitalizations Related to Pressure Ulcers Among Adults 18 Years or Older, 2006. Retrieved May 2, 2011, from AHRQ: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb64.jsp

Courtney H. Lyder, E. A. (2008). Patient Safety and Quality: An Evidence Based Handbook for Nurses. Retrieved May 2, 2011, from AHRQ: https://www.ahrq.gov/qual/nurseshdbk/docs/lyderc_pupsi.pdf

Demling, R. H. (2009). Nutrition, Anabolism and the Wound Healing Process: An Overview. Retrieved April 28, 2011, from MedPub Central: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2642618