Prevent pressure ulcers: Is it possible?

With the paradigm shift toward health promotion and disease prevention, much emphasis is focused on chronic diseases. Undoubtedly, most people do not think about pressure ulcers as a chronic condition. In fact, the number of individuals developing or being hospitalized with pressure ulcers is growing.

Age alone is not the only contributing factor to pressure ulcer development. It is also about the inconveniences of old age such as impaired mobility, poor nutrition, changes in mental status or chronic diseases. High blood pressure, heart disease and diabetes affect blood flow to organs including the skin, increasing the risk of pressure ulcers. Quality of life and increased costs to patients, families and healthcare organizations can be correlated to pressure ulcer management. 

BACKGROUND

Pressure ulcers are the fourth leading preventable medical error in the United States.1 Each year, 60,000 individuals die from pressure ulcers as a secondary diagnosis. The hospital stay for pressure ulcer treatment is three times longer compared to other chronic diseases. In 2010, pressure ulcer care averaged between $10.5–17.8 billion. 

The Joint Commission listed pressure ulcers as a National Patient Safety Goal for long-term care in 2006.1 The Centers for Medicare & Medicaid Services (CMS) list stage III and stage IV pressure ulcers as “never events.” The Institute of Healthcare Improvement included the prevention of pressure ulcers in its “5 Million Lives Campaign.” The widely recognized complications from this preventable event have stirred awareness toward prevention. 

A MULTIDISCIPLINARY APPROACH

The skin is the first line of defense against infections. Healthy skin requires the correct pH and moisture balance to protect it from bacterial invasion. Moisturized skin prevents dryness which causes cracks in the skin. Skin that is too wet increases the risk of shear and friction. These basics are often forgotten in lieu of the many tasks that nurses perform; however, the responsibility of pressure ulcer prevention extends beyond the nursing staff. 

In long-term care, best practices involve a multidisciplinary approach in pressure ulcer prevention.2 A pressure ulcer prevention (PUP) program provides a proactive approach to skin care. The main goal of a PUP program is to create a systematic method of assessing risk factors, developing strategies to eliminate risk factors, providing ongoing education and evaluating strategies. This approach provides standardized guidelines for all staff to follow. Second, a team process communicates an “all eyes” on the skin approach. To remove the hurdle of staff’s commitment to early identification of risk factors, they need to comprehend the lethality of pressure ulcers.

PREDICTING RISK

The key to any successful PUP Program is the early identification of risk factors, so appropriate strategies can be implemented. A pressure ulcer risk scale should always be used as part of a comprehensive clinical assessment. The Braden Scale for Predicting Pressure Sore Risk is the most widely used evidence-based risk tool. Six subscales (sensory perception, skin moisture, activity, mobility, nutrition and friction/shear) are used to score patients’ risk of developing pressure ulcers. The range of scoring rated 6 to 23 provides variation for risk based on the total sum of the subscales. For example, a score of 13-14 indicates the patient is at moderate risk for developing a pressure ulcer.

Each risk level is matched with researched strategies which provide specific guidelines for that patient. In long-term care, it is recommended that risk assessments be completed on admission, weekly for one month and then quarterly, or if a resident’s condition changes significantly. It is important for staff to understand risk factors and appropriate interventions to promote healing. Although nurses can communicate interventions, they do not always follow clinical practice guidelines due to staffing or focusing on other priorities. Comprehensive education for everyone involved in care of the patient is needed to improve knowledge and competency.

NURSING INTERVENTIONS

PUP programs must target the four leading contributors to pressure ulcers: pressure, moisture, friction/shear and nutrition. Pressure can be easily managed by frequent moving, the use of assistive devices for positioning, application of heel floaters, repositioning chair-bound patients and using pressure reduction surface devices for at-risk patients and pressure-relieving surfaces for those identified as very high risks or patients with existing pressure ulcers. 

With frequent repositioning and moving, checking for moisture should occur. A good barrier cream is needed for patients who are incontinent. The skin should be washed as soon as soiling occurs with warm water, mild soap and gentle cleansing. Absorbent pads that wick moisture are best. Many organizations are going diaper-free for bed-bound patients. When two-hour rounds are implemented, staff has the opportunity to provide good incontinence care. A bedpan and urinal should also be offered as well. Moving patients tend to result in skin tears from lack of attention, or hurried or inexperienced staff.

To prevent friction or shear, the head of the bed should be no higher than 30 degrees unless medically contraindicated. A lower degree prevents patients from sliding down and shearing buttocks. A flat sheet used as a lift sheet or slider is an inexpensive way to avoid dragging patients when repositioning or turning. To prevent elbows and heels from rubbing against the sheets, at-risk patients should be given protectors and socks.

Like any other injury, healthy eating plays a major role in wound healing. For patients with poor intake, malnutrition or who are underweight, vitamins and supplements will fortify the diet. Offering water every couple of hours keeps the skin moisturized. If necessary, a dietary consult should be done to ensure the necessary nutrition for pressure ulcer healing.

Other general guidelines should be considered when caring for high-risk patients. Bony prominences, such as the ankle bone, should not be massaged as this can damage underlying tissue. Donut-type devices should be avoided because they have been found to further concentrate pressure. Patients should not be positioned directly on the hip bone when in the side-lying position. Avoid multiple layers of linen and pads they interfere with pressure-reduction/pressure-relieving surfaces and cause patients to sweat.

EDUCATION

The responsibility of preventing pressure ulcers belongs to all members of the healthcare team, patients and families. A patient-centered approach to evidence-based education is needed. Appropriate strategies should be tailored for the type of pressure ulcer. Educate patients and families on the causes of pressure ulcers, safe cleaning techniques, proper positioning and frequency, proper use of assistive devices and the role of nutrition in wound healing. The healthcare team should receive standardized education about skin assessment, identification of risk factors, correct use of the risk assessment tool, pressure ulcer staging and proper positioning. Everyone should be doing the same thing. As important as it is to tailor education to meet the needs of patients, it is equally important to tailor education for staff based on their education, skills and role in pressure ulcer prevention. To increase competency with prevention, an annual review is suggested, identifying skin prevention champions on all units and creating a PUP program or Skin Committee with monthly meetings.

CONCLUSION

Florence Nightingale stated: “It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm.” There is much truth in this statement as it relates to pressure ulcers. When a pressure ulcer is the primary diagnosis, the result is 1 in 25 deaths. With patients hospitalized with pressure ulcers as a secondary diagnosis, 1 in 8 deaths occur.

The length of stay for pressure ulcers is 13 or 14 days. This is almost three times that of an average hospital stay.3 The amount of human suffering and health care costs are immeasurable. If a comprehensive preventive program is implemented, most pressure ulcers can be avoided. Proactive assessment and managing at-risk patients can save millions of dollars annually.

Rhonda Antonetti, RN, MSN, CWON, is an Inpatient Wound and Ostomy Nurse at the Ralph H. Johnson VAMC, Charleston, S.C. Donna L Pittman, RN, MSN, CCNS-BC is the Health Promotion and Disease Prevention Program Manager at Ralph H. Johnson VAMC. For more information, email Rhonda.antonetti@va.gov.                                                                                     

REFERENCES

1. Duncan KD. Preventing pressure ulcers: The goal is zero. Joint Commission Journal on Quality and Patient Safety 2007;33(10):605-10.

2. Lourde K. Preventing pressure ulcers: Evidence-based clinical practice guidelines that offer the latest in the management of pressure ulcers emphasize an interdisciplinary team approach. Provider 2008;8.

3. Russo CA, Steiner C, Spector W. Hospitalizations related to pressure ulcers among adults 18 years and older. HCUP Statistical Brief #64. December 2008. Agency for Healthcare Research and Quality, Rockville, MD. Available at: https://hcup-us.ahrq.gov/reports/statbriefs/sb64.

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