MDS 3.0 has brought with it increased accountability for nursing homes (NHs) and a change in quality measures. The possibility of decreased reimbursement for facility-acquired pressure wounds is real. According to Wake,1 “the current costs of providing care for one pressure ulcer can range from $3,500 to over $60,000, depending on the stage of the ulcer.”
Pressure ulcer rates range from 0.4 percent to 38 percent in acute care to 2.2 percent to 23.9 percent in long-term care.2Advancing Excellence in America’s Nursing Homes (AE) Quality Campaign has already demonstrated improvement in clinical outcomes through the QAPI measurements in Skin Management. AE offers free resources that are structured around good organizational practices and person-centered care.
Managers and administrators need to ask, “Who needs to implement changes in care practices?” When it comes to skin, CNAs are most frequently in a place to observe the residents’ skin.3 They truly are the people who can maintain or improve skin integrity, under the guidance of RNs and LPNs.
Because nurses are not usually trained in geriatric care and the time and funding for professional education are limited, they may not be current in evidence-based procedures. It takes a culture of inquiry and sharing of knowledge as well as collaboration to improve this aspect of care. Because of this, education and employee retention are vital to meet quality skin goals. AE is one source for the tools to provide quality skin programs.
Today’s nursing homes have a diverse population ranging from recently active to long-term immobile residents. Providing quality skin care for such a population takes excellent nursing knowledge, assessment, planning and interventions.
SKIN AS IT AGES
As we age, our skin becomes dry, rough and thinner, giving it a paper-like appearance. Thinning of the epidermis makes the older skin more vulnerable to trauma and injury. Collagen decreases one percent every year in adulthood after age 20. Vascularity decreases, and the immune response of the dermis declines with age making it high risk for infection. Sweat glands atrophy and apocrine glands produce less oil, putting the older adult at risk for overheating and dry skin. All of these factors make the older adult more vulnerable to skin breakdown slower wound healing. When you add comorbidities, it becomes increasingly difficult to heal skin in the older adult.4
RISK ASSESSMENT BASICS
Determining risk factors beyond age will assist staff in focusing on residents with the most needs. Examples of risk factors include immobility and decreased functional ability; co-morbid conditions such as end-stage renal disease, thyroid disease or diabetes; drugs such as steroids; impaired diffuse or localized blood flow; resident refusal of care and treatment; cognitive impairment; exposure of skin to urinary and fecal incontinence; under nutrition and hydration deficits; and a previously healed ulcer. The Braden Scale for Predicting Pressure Sore Risk is the most widely used tool to determine risk.
WOUND ASSESSMENT ON ADMISSION
Quality outcomes and financial stability are closely linked to the initial assessment upon entry into your facility. An accurate and thorough skin assessment is necessary for an effective prevention and skin treatment program.
To determine need in your facility, examine the admission assessment process. Are there any staffing or work components that make this difficult to accomplish in a timely, thorough manner? Good leadership, education and retention should be high on your priority list for successful quality initiatives. All nurses need to measure consistently measure and accurately document to create a plan of care that includes interventions that maintain or treat the resident’s skin issues.
Wound assessment criterion has changed under MDS 3.0 and staging of pressure ulcers differs from the National Pressure Ulcer Advisory Panel (NPUAP). Make sure that everyone at the facility is using the correct measures for MDS. To evaluate their ability to measure and stage a pressure ulcer, consider having three of your best nurses assess a wound without seeing each others’ results. Compare their results and work with your nursing leaders and educators to address concerns.
Consider joining AE’s Quality Campaign to begin setting goals for your facility. Your nurse educator will have access to evidence-based clinical resources that are updated routinely. Other resources include the National Gerontological Nursing Association (NGNA), the Hartford Institute for Geriatric Nursing Partnership, Nurses Improving Care for Health System Elders (NICHE) and HRSA Medical Education Initiative. In providing nurses with the tools to keep up with the challenge of being real coordinators of care, nurses will become able to teach and supervise the CNAs who perform the tasks of wound prevention.
When a resident is admitted to the facility, the admitting nurse should review the records from the last institution or level of care. The whole body must be observed. Good lighting is needed. It is best to have two nurses available to perform a skin assessment on a new resident. This will assure comfort for the resident if he/she needs to be held in a side-lying or other awkward position. There is no shortcut in the assessment, but with one nurse to document and one to perform the assessment, the process will go more swiftly. This improves the overall quality of and resident’s satisfaction with the admission experience.