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Stopping Pressure Ulcers-Before They Start

May 1, 2004
by root
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Interview with Steve Mogensen and John Hertig

Hertig: It is our understanding that Medicare Part B pays for the use of this technology in mapping a wound prior to surgical debridement, to limit the amount of surgery to precisely what's needed. We're beginning discussions with clinical people at CMS, as well as with several of the national associations and state QI organizations, looking for support in expanding Medicare reimbursement to cover diagnostic scans for prevention of decubitus ulcers. Residents of nursing homes won't need debridement surgery if they don't develop pressure ulcers in the first place.

Everyone knows that pressure ulcers are a huge problem in long-term care. In fact, the Healthy People 2010 initiative sets a target of less than a 1% incidence of avoidable pressure ulcers; that will be hard to achieve without additional preventive methodologies. We have a great deal of knowledge about the problem; what hasn't gotten out is that there is now a diagnostic technology that can help to significantly reduce a nursing home's incidence of ulcers.

Nursing homes have been neglected in terms of technology for a long time, and cost constraints make it even more difficult for them to adopt new technology. Nevertheless, CMS acknowledges that technology can help, so I'm optimistic, and we're hoping CMS will approve Medicare reimbursement.

With or without Medicare reimbursement, this is a cost-effective approach to pressure ulcer prevention. The latest figures I've heard put the average cost of treating one pressure ulcer at approximately $3,500, and it's been estimated that an average of 23% of all nursing home residents will develop one or more pressure ulcer. That's a lot of residents who'll cost the healthcare system a lot of money, not to mention their having to suffer needlessly.

Zinn: Are there any other benefits to using this technology?

Mogensen: Yes, there are. High-frequency ultrasound scanning isn't limited to detecting potential decubitus ulcers. It also allows us to see other occurrences under the skin. In fact, it was used to prevent a lawsuit at one nursing home when the family of a resident with a superficial bruise was claiming the injury was caused by abuse. Scanning the subcutaneous tissue under the bruise failed to show the deep trauma that would have been consistent with the family's allegation. When the scans were showed to the plaintiff's attorney, the claim was dropped.

Hertig: It's also excellent for documentation. Let's say you have a resident with a pressure ulcer during a survey and, therefore, you have to document that it's improving. As mentioned earlier, without this technology that is an extremely subjective process. For one thing, sometimes wounds superficially look like they're getting worse when actually they're improving. Other wound-measurement techniques simply are not precise enough.

Mogensen: Better pressure ulcer prevention and assessment also should help to keep skyrocketing liability insurance premiums down. We're hoping that as this technology catches on, it will help both skilled nursing facilities and their insurance carriers to drive down costs.

Hertig: It certainly should help keep premiums from rising, since pressure ulcers have so often been the culprits in litigation. We're hoping that the long-term care insurance industry will become aware of this technology. I'd think it would be of great interest to them to insure facilities that use it. It helps everyone, from the residents and their families to staff to owners to insurers to third-party payers. It allows information that was previously unknown to be managed much more closely.

Nursing homes have been dealing with this problem forever. Wouldn't the best solution be for pressure ulcers never to develop? Many products are available for managing pressure ulcers after they occur. We want to shift the approach from treatment to prevention, allowing nursing homes to take control and improve their residents' quality of life. Soft-Tissue Management Interventions With Use of High-Frequency Ultrasound These protocols are to be used as a guideline for a facility utilizing high-frequency ultrasound for evaluation of the soft-tissue status of an individual. Advanced Vital Services assumes no responsibility for any unauthorized use of these suggested protocols.

The following protocols may be used in response to the phasing classification supplied with the Longport High-Frequency Ultrasound Scanner. In the event that an ultrasound procedure results in the collection of a scan that reveals the interpretation of a Phase 1, 2, 3 developing pressure ulcer, or Phase F (friction ulcer), the following protocols may be followed.

PHASE 1 PRE-ULCER
  • Pre-albumin level (serum albumin levels accepted if available).
  • Prescribe multivitamin and mineral supplement.
  • Granulex or skin prep to bilateral heels qd with soap-and-water wash between applications.
  • Moisture barrier cream to buttocks after each brief change.
  • Bowel and bladder program for incontinent patients.
  • Heels floated with pillows when in bed.
  • Evaluate support surface for "bottoming" with hand check.
  • OT or PT to provide appropriate wheelchair and wheelchair cushion.
  • May be up in chair in a.m., back to bed after therapies completed in p.m., up again for supper.

Rescan on post-assessment day 14. If this shows no deterioration, continue with Phase 1 interventions and rescan again on post-assessment day 28 and one (1) time per month for two (2) more months, then D/C. If condition has worsened, go to Phase 2 interventions.


PHASE 2 PRE-ULCER

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