Pressure ulcers

Five fatal flaws in prevention, management

Pressure ulcers have numerous negative outcomes. They can cause physical pain and even result in sepsis and death. Emotionally, they may result in isolation, withdrawal, and depression. Healthcare facilities’ relationships with families may be damaged as trust is replaced with doubt. They also cause a strain on staffing.

Dressings to treat pressure ulcers are often time-consuming and complicated. Pressure ulcers are costly in several resources, including supplies, support surfaces, and nutritional supplements. They often result in survey citations, affecting Quality Measures and Five-Star Quality Rating, which can negatively influence the public’s perception of a facility and its staff. This can have an impact on hospital referrals and a facility’s ability to maintain census.

Added to all of this is the very real threat of lawsuits from families. Given the emotional nature of these cases, families often have an advantage over the healthcare facilities. “Bed sores” have long been associated with poor care and, although some are unavoidable, the public still holds a strong opinion that there is a correlation between poor care and pressure ulcers.

The National Center for Health Statistics survey of 2004 revealed several eye-opening statistics:

• One in 10 nursing home residents had a pressure ulcer, most of which were Stage II.

• One in five residents with weight loss had a pressure ulcer.

• Short-stay residents of less than a year were twice as likely to develop pressure ulcers as long-term residents.

Although pressure ulcers date back 5,000 years, government-sponsored studies and guidelines go back to only the early 1990s. Clinical practice guidelines that we follow today may not be the same tomorrow as studies continue to evolve. Although there are many aspects to pressure ulcer prevention, I have found that there are five flaws that can have serious negative outcomes:

1. Failure to maintain current policies and procedures. If your facility is still using outdated policies, you are at risk of survey citations and, in the event of a negative outcome, lawsuits. Policies should reflect the most current evidence-based practices; should consist of a simple, workable document used as a basis for staff education; and should be reviewed by a certified wound expert. The policy should be strongly enforced among all staff members and needs to be current. Policies are always requested by surveyors when there is a skin issue and will be requested by the plaintiff’s attorney in the event of litigation.

2. Failure to ensure staff competency. Poor outcomes result when there is no consistent standard. Issues should not be given tacit approval by being acceptable one day and not the next because surveyors are in the building. Education needs to be part of the daily routine. Daily rounds are a great time to reinforce positive care approaches on a consistent basis and serve as a time for teachable moments when the standard is not met. As a director of nursing, I conduct “drop by” observations when treatments are being completed to observe technique. It is important to inspect the work of your employees. Competency verification must be more than paper compliance; you must see it in action. For example, breaks in infection control practices during dressing changes contribute to a wound’s bioburden that results in infection and sepsis. As I conduct “drop by” observations, I take such an opportunity to provide a teachable moment for someone not following best infection control practices.

3. Failure to correctly assess. Competent assessment is critical. Incorrectly documenting a deep tissue injury as a Stage I on admission or recording a stasis ulcer or diabetic foot ulcer as a pressure ulcer can have far-reaching consequences. While it is the physician’s responsibility to diagnose the type and etiology of wounds, nurses should be knowledgeable of defining characteristics of various types of ulcers. Invest in training nurses in the assessment process; it will pay off.

4. Failure to use the team. Pressure ulcers are not only a nursing problem. Pressure ulcer development is complex and requires an interdisciplinary team to manage. Since pressure intensity, duration, and tolerance are known risk factors, wheelchair seating should be evaluated as soon as possible after admission by an occupational therapist. Because poor nutrition can delay wound healing, a dietician referral within 24 hours of admission for high-risk residents is recommended. Social service may need to make a psychological referral if symptoms of depression are noted, and the activity department may need to adjust programs if limited time out of bed is allowed.

5. Failure to have ongoing program evaluation. Continually evaluate your program. Identify root causes for failure to meet goals and establish a working action plan that is continually reviewed and revised until resolution.

Avoiding these five fatal flaws can help you ensure not only the future progress of your facility but also the health and well-being of your residents.

Wilma Wheeler, RA, BA, WOCN, RLNC, RAC-CT, is Senior Risk Management Consultant for Risk Management Solutions. Ms. Wheeler has been a registered nurse for more than 20 years and is an enterostomal therapist with a specialty in wound management. She has been a director of nursing as well as a corporate nurse. She also served as the educational coordinator for an independent consulting company, presenting state-wide training in Indiana on issues related to the long-term care industry. She has worked to prepare facilities for Joint Commission accreditation, and she has conducted state survey audits. She can be reached at wilma.wheeler@rmsol.net. Long-Term Living 2010 November;59(11):46