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Only You Can Prevent Pressure Ulcers

April 1, 2002
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Interview with Kenneth Olshansky, MD
Only You Can Prevent Pressure Ulcers Interview With Kenneth Olshansky, MD Bedsores. Pressure ulcers. Decubiti. Pressure sores. No matter what you call them, the mere mention of these difficult-to-treat wounds can strike terror in the heart of caring caregivers and conscientious administrators everywhere.

Few challenges encountered in long-term care are more daunting, and few conditions to which the elderly or immobile are vulnerable can do more to erode quality of life. They are costly, both in economic and in human terms-and in survey deficiencies and legal exposure. As the old saying goes, the best treatment lies in prevention. The methods for preventing pressure ulcers are common knowledge among long-term care providers, and there is quite an array of pressure-relief products on the market designed to do just that. So why do they still occur? How might nursing homes improve their performance? Nursing Homes/Long Term Care Management Managing Editor Linda Zinn asked Richmond, Virginia, plastic surgeon Kenneth Olshansky, MD, to answer these questions, and more.

Zinn: How did you, as a plastic surgeon, become interested in the prevention and treatment of pressure ulcers in the nursing home?

Dr. Olshansky: One area of emphasis in a plastic surgeon's training is wound healing and surgery for wounds-particularly pressure ulcers. For many plastic surgeons this subject gets lost amidst the other aspects of training. In my case, it so happened that a friend who worked for the state got involved with an advocacy group that was working to improve care in nursing homes and asked me to serve on a committee.

Word got around that I was interested in pressure ulcer prevention and treatment, and soon nursing homes were calling me and asking me to see their residents and present staff in-services. Today, pressure ulcer treatment and prevention comprise a good part of my practice.

Zinn: Is surgery commonly used in the treatment of nursing home residents' pressure ulcers?

Dr. Olshansky: Only rarely. These individuals are usually too sick and debilitated to tolerate surgery. It's more common in younger residents who are in good overall health and who have had a spinal cord injury or suffer from multiple sclerosis or other diseases that compromise their mobility.

So when it comes to the management of pressure ulcers in the nursing home, the primary emphasis is on prevention, then wound care. When surgical debride-ment is appropriate, it is generally done at the bedside or in the physician's office.

Zinn: It would seem that an ounce of pressure ulcer prevention is worth several hundred pounds of cure. What can you tell our readers about prevention that they might not have heard before?

Dr. Olshansky: To my knowledge, there has never been a study to prove conclusively whether pressure ulcers are totally preventable. My contention is that, with very few exceptions, they are. If you review the medical literature, for years and years everyone has said that the key factor in the development of pressure ulcers is the patient's risk profile.

Studies have used measurement instruments such as the Braden scale to look at such variables as immobility, incontinence, nutrition, etc., that put people at high risk of developing pressure ulcers, but they haven't concurrently measured quality of care. That raises the following question: Are nursing home residents getting pressure ulcers because they're at high risk or because they're not receiving adequate care? That question has not been scientifically answered to my satisfaction, but my experience tells me that the greatest variable as to whether a nursing home resident will develop a pressure ulcer is who is caring for that resident.

I think the position that pressure ulcers are primarily attributable to residents' risk factors is indefensible, because the case mix does not vary widely from nursing home to nursing home, but the quality of caregiving does. We have no real choice about the case mix. We can't say, "You're too sick. Sorry." If they're sick, we take them.

Here's a theoretical illustration: Let's say we have 100 sets of identical twins, all terribly malnourished and with low scores on the Braden scale-individuals considered to be at highest risk. If we put half of the twins into a low-quality nursing home with no specialty beds and the other half into a topnotch facility with specialty beds, where bedridden residents are turned every two hours, common sense would tell us that the latter group would do better, even though both groups had the same Braden scale scores.

To those who say that a resident with poor scores on a Braden scale assessment is expected to get pressure ulcers, I would ask, why? We know how to prevent them: relieve pressure and make sure bedridden residents are moved frequently enough. If someone is identified as being at high risk, that's all the more reason that he should not get pressure ulcers! In fact, my contention is that it is the lower-risk resident-someone who might be bedridden but is in fairly good general health and able to move about in bed-who suddenly becomes sicker, more dehydrated and slightly obtunded, who's really at greater risk. That's the type of person who will be fine one day and the next day will have a pressure ulcer without warning.

Zinn: In light of the impact of quality of care on pressure ulcer prevention, what can facilities do to make sure their caregivers don't, in effect, become one more risk factor?

Dr. Olshansky: First, we need a core of staff who are knowledgeable about pressure ulcer prevention. This isn't like cancer or heart disease; there's nothing mysterious about it.