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| Now that Medicare and Medicaid will no longer reimburse for hospital-acquired Stage III and Stage IV pressure ulcers, it’s imperative that clinical teams re-examine their procedures and processes for preventing these conditions. To help facilitate prevention, experts suggest all body systems should be assessed on admission. What follows is a detailed examination of this issue and how one hospital is addressing this important subject that is critical to restoring the health of patients and avoiding costly expenses to facilities. |
On July 31, the final ruling of hospital-acquired conditions (HACs) was posted by the Centers for Medicare & Medicaid Services (CMS), Baltimore. As of October, Inpatient Prospective Payment Systems hospitals will not receive additional payments for 10 categories of HACs. Among the costliest and most life-threatening are Stage III and Stage IV pressure ulcers.
A pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction.
According to an article in the April 2006 issue of Nursing Management, an estimated 2.5 million pressure ulcers are treated on a yearly basis; 900,000 patients develop a new pressure ulcer each year; and 60,000 patients die from complications due to hospital-acquired pressure ulcers each year.
The prevalence in acute care has remained high at 13.9 percent, according to the Hill-Rom Inc. 2007 International Pressure Ulcer Prevalence Survey.
In 2000 and 2001, pressure ulcers were cited as one of the top three hospital errors that lead to patient deaths. The average cost per hospitalization for patients who develop a Stage III and IV pressure ulcer has been reported to be $43,180.
The annual direct cost of treating hospital-acquired pressure ulcers ranges from $400,000 to $700,000 per year for hospitals. The elderly and critically ill patients are at a significantly higher risk than the general population.
In the 2004 Interpretive Guidance to Surveyors, CMS identifies the following as risk factors for developing pressure ulcers and for difficulty healing existing pressure ulcers:
- Impaired mobility and functional ability
- Comorbid conditions (e.g., end-stage renal disease, thyroid disease, diabetes mellitus (DM))
- Treatments that affect healing of wounds (e.g., steroids)
- Urinary and fecal incontinence
- Malnutrition, undernutrition or dehydration
- Impaired blood flow (e.g., generalized atherosclerosis, peripheral vascular disease)
- Refusal by some patients of preventive care or treatment
- Cognitive impairment
- Presence of a healed pressure ulcer (Pressure ulcers are more likely to develop on areas of healed Stage III or IV pressure ulcers.)
To facilitate prevention, all body systems should be assessed (including the integumentary system) on admission, with each shift change, change in condition and when a patient is transferred to another unit within a hospital.
When checking skin, it is important to perform a head-to-toe assessment, removing any existing dressings to identify any pressure ulcers present on admission.
Ongoing assessments must be conducted with each patient in all positions during lifting, turning and repositioning as well as skin contact with medical tubing such as foley catheters, nasal cannulas, nasogastric tubes and/or endotracheal tubes.
Pressure ulcers have derived from antiembolic stockings rolling down and from sequential compression devices (SCDs) becoming too tight. Continuous positive airway pressure machines are being used more for patients with pulmonary and cardiac problems; to work properly, the mask must seal tightly on a patient’s face. It is necessary to inspect the areas of contact, especially across the bridge of the nose.
There are several risk assessment tools available that provide nurses with a systematic means of identifying patients at risk for pressure ulcers.
When choosing a risk assessment tool, select one that has been tested for validity and reliability.
Assessment options
The two most common tools used are the Braden Scale for Predicting Pressure Sore Risk and Norton’s Pressure Area Risk Assessment Form. Clinicians also should be aware that the risk of developing pressure ulcers may change if the condition of a patient changes (e.g., altered mental status, weight loss, congestive heart failure, acute renal failure).
The next step is to create an individualized plan of care based on the assessment data, identified risk factors and patient goals. The plan should be collaborative with the patient, family and other health care professionals.
A physician must address comorbidities and work toward optimizing a patient’s condition. Some of these diagnoses include thyroid disease, auto immune disease, congestive heart failure, chronic pulmonary disease, coronary artery disease, DM (check neuropathies), end-stage renal disease, peripheral vascular disease, paralysis, liver disease, musculoskeletal deformity, vasculitis, malignancy, malnutrition and the abuse of tobacco, illicit drugs and alcohol.
Existing conditions that place patients at risk are impaired mobility, nutrition, pain, infection, malperfusion/hypoxia, continence, edema, psychosocial issues, excessive body heat, age and knowledge base. Medications that hinder healing are steroids, statins, nonsteroidal anti-inflammatory drugs, chemotherapy and ACE inhibitors.
The admitting physician should perform a full, head-to-toe assessment, removing any dressings to capture present-on-admission (POA) pressure ulcers.
Many hospitals are using photography to record POA pressure ulcers. To use this method for recordkeeping, it is important to place the digital camera on a docking station for photograph printing.
If a photo is downloaded to a computer, it can be altered and therefore not accepted in court. (Using a 35mm camera is an option, but that method is becoming obsolete.)
The photo should have a patient’s identification and date to guarantee authenticity and should be printed and placed on the chart.
To guarantee payment of any POA pressure ulcers, it is important that the proper ICD-9 code be assigned and double checked. All pressure ulcers are identified and staged using the National Pressure Ulcer Advisory Panel criteria.
If a patient is at risk for pressure ulcers or pressure ulcers are identified on admission, either routine protocols should be in place or a routine wound and skin care order set be made available for physicians and nurses.
These protocols or orders should include choices for prevention tools, beds, mattresses, off-loading boots, rehab services and barrier creams.
If a patient has a pressure ulcer, protocols or the wound care order set should also include localized wound care according to the stage, drainage, location and surrounding tissue; possible wound cultures; nutrition consultations for Stage III and IV pressure ulcers; and wound, ostomy, continence nursing (WOCN) department consultations (if available) for additional recommendations.
These protocols should be formulated using best practices. Also, having a physician involved in the process is important along with the WOCN department and input from the nutrition and rehab departments. Setting the standard using best practices is the foundation to a successful prevention program.
Hospitals have created tools that formulate reports of wounds present on admission as well as hospital-acquired pressure ulcers.
Processes also have been put into place. For example, the medical records department can perform ongoing audits of HACs and POA conditions.
If a pressure ulcer is identified and a physician has not adequately addressed the wound, medical records then contacts the physician for clarification.
At this point, a physician must document in the patient’s assessment and history the presence and stage of any pressure ulcers. It is completely acceptable for a physician to make an addendum to the history and physical to address any existing pressure ulcers.
A standardized approach
To have protocols available or routine wound and skin care orders, you must standardize supplies the clinical staff will use. Education must be offered for all levels of health care professionals, patients, families and caregivers.
Include step-by-step instructions on the etiology of and risk for pressure ulcers, risk assessment tools and how to apply them, a comprehensive skin assessment, selection and use of support surfaces, nutritional support, incontinence management, demonstration of positioning to decrease risk for breakdown, indications and use of off-loading boots, wedges and pillows as well as transferring and lifting devices.
Handouts for these topics should be posted for physicians and nurses and also posted at the head of the bed for appropriate patients and family members to view.
Vendors offer free education material such as posters and they are usually willing to tour facilities they service, rounding unit to unit and providing education on their products.
Repeating the educational sessions on a quarterly basis is a great way to introduce hands-on learning to new staff.
This is an invaluable service, freeing hospital staff for other duties.
Having the right bed surface and knowing how to use a bed’s features are paramount and have the greatest impact on preventing pressure ulcers and reducing costs associated with pressure ulcers.
Within a hospital’s bed fleet, a critical care bed is the most complex—a good bed should benefit patients of all kinds. Critical care beds typically have functions that optimize pressure redistribution, immersion and envelopment of the heel.
These beds also have an intelligent surface that incorporates a unique shear-relief algorithm that automatically adjusts for immobile patients, with multiple layers of 3-D fabrics that reduce friction and absorb shear.
A cardiac bed allows patients to exit from the foot of the bed, enabling them to achieve mobility sooner with reduced risk of injury to themselves and caregivers. It also is important to monitor the age of frames and mattresses.
Bed replacement programs should be maintained to ensure continuity across the care continuum.
Surgical departments should purchase pressure-redistributing devices for patients with a pressure ulcer or at risk for developing a pressure ulcer.
For added protection, a pre-op nurse should clean incontinent patients and apply skin barrier just prior to surgery. Intervention radiology and the cardiac cath labs should follow this same format.
A nutritional assessment should be performed on admission by both a physician and the nurse. If a patient is found to have a nutrition deficit, an existing wound or the person is at high risk for a nutritional deficit, a nutritional consult should be ordered. Look at albumin and pre-albumin levels. Consider weight loss of 10 percent of body weight or greater and consider hydration status.
Investigate factors that compromise dietary intake, and consider routine nutrition orders for the nutritionist to use for recommendations of support with vitamins, minerals and protein.
Keep in mind that critically ill patients should be considered for supplements, i.e., total parental nutrition or appropriate formula through a nasogastric tube.
Early mobility decreases a patient’s risk of developing pressure ulcers, deep-vein thrombosis and hospital-acquired pneumonia. It also shortens length of stay and increases a patient’s sense of well being and satisfaction.
Turn teams are recommended to ensure the safety of both the patient and clinician. Some facilities have an auditory cue such as music to remind clinicians to turn their patients. There are copyright issues when using published music and each hospital should include this in any dialog before adopting this routine.
Using an armband for identification and as a visual cue for patients with an existing pressure ulcer or who are at-risk helps promote prevention.
When these cues identify at-risk patients, they encourage dialog among clinicians, reduce waiting times for a patient and improve outcomes and patient satisfaction.
A full-time employee to oversee, educate and facilitate prevention is fundamental. In 2004, Conroe (Texas) Regional Medical Center was at a turning point. It participated in the Hill-Rom National Prevalence Survey for the first time.
This survey (200 patients) established a baseline. The national average was 7.7 percent and Conroe’s average was 15 percent. There was no housewide standard for pressure ulcer prevention at the time.
Task force delivers
A wound care task force was developed, comprising key people from the critical care department, rehab services, education, quality, nutrition, risk management, infectious disease and nursing staff from each floor as well as several wound care nurses from the wound care center.
They meet on a monthly basis to examine the problem of hospital-acquired pressure ulcers and make recommendations for improvements.
They also meet to discuss the yearly prevalence survey, weekly and monthly audits of processes, education, reviewing and writing policy and procedures for new tools introduced to the hospital.
A full-time dedicated employee from nursing services was assigned to accomplish the goal of reducing hospital-acquired pressure ulcers. This individual also is responsible for managing inpatient wound, ostomy and skin care services.
New beds were needed so the hospital spent $400,000 for bed frames and surfaces. This led to hospital-acquired pressure ulcer prevalence dropping by more than half.
In 2006, administration approved the capital expenditure of $200,000 for additional beds with a concurrent result in the decline of hospital-acquired pressure ulcers from 7 percent in 2005 to 2 percent in 2006.
In 2007, there were three key positions that were in transition, the chief nursing officer, the environmental services director and the director of the WOCN department. These three positions along with each nursing director were instrumental in identifying the need for mattress replacements.
As a result of this transition, the mattress replacement program fell through the cracks and the prevalence began to rise to 4.2 percent in 2008.
Fortunately, with the national survey done in April of this year, the problem was identified early and the mattress replacement program was reinstated. Each nursing director now is aware of the age of each bed in their respective departments and the needs for the upcoming year when the capital budget is prepared.
Test for validity, reliability
Choosing an off-loading boot should be done by testing validity and reliability. Conroe Regional was using pillows for off-loading and bed surfaces with zones of less pressure to the heels, but still encountered hospital-acquired heel pressure ulcers.
ICU nurses and the WOCN department performed a study of the Prevalon Boot (Sage Products, Cary, Ill.), which included 53 incapacitated patients. Nine had heel pressure ulcers on entry to the study.
After seven months of collecting data, the results were zero hospital-acquired heel pressure ulcers and no change or improvement for the nine with pre-existing heel ulcers.
This product was introduced to the entire hospital and Conroe has gone two years with zero hospital-acquired heel pressure ulcers.
The lessons learned at Conroe Regional are many. We benefited from administration support, capital expenditures on preventive equipment and proper bed surfaces either through purchase or rental services; we designated an employee to oversee the process; appointed a wound care task force; and gave a voice to the nursing directors.
Easy-to-use, off-loading devices were made available to the clinical staff, including boots and cushions. We standardized wound care supplies, skin barriers and cleaning supplies. Processes also were standardized including routine wound and skin care orders, using the Braden risk assessment tool for pressure sores.
Improvements were made in the electronic charting of pressure ulcers, with triggers for nurses to use preventive measures according to the actual Braden Scale score. Other steps included ongoing audits, education, early mobility and nutritional support.
Until we have zero hospital-acquired pressure ulcers and we maintain that standard, we have room to grow. The biggest barrier is getting others to believe that it’s possible. We can prevent pressure ulcers, so let’s do it.
This article first appeared in the October 2008 issue of Materials Management in Health Care.
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