CMS to Put Pressure on Providers for Decubitus Ulcer Prevention

Another program is called the SKIN©® bundle and was released in 2004 by Ascension Health, the nation’s largest not-for-profit healthcare system. It reduced pressure ulcer incidents to about 1.4 per 1,000 patient days.¹ At many Ascension hospitals, no new stage three or four pressure ulcers were acquired from August 2004 to February 2006.¹

The SKIN©® bundle stands for:

Surface selection

Keep turning

Incontinence management

Nutrition

A successful pressure ulcer prevention program includes the establishment of protocol, says Tina Meyers, BSN, RN, CWOCN, ACHRN, manager of wound, ostomy and continence nursing services at Harris County Hospital District in Houston.

“Frequent use of a standard data collection tool to ensure appropriate evaluation is essential,” Meyers says. “To promote caregiver compliance with pressure ulcer protocols, standardize care and make it easy. Regarding patient care, nutritional status plays a key role in prevention and minimizing pressure and friction helps to eliminate risk of development.” 

References

1. Armstrong DG, et al. New opportunities to improve pressure ulcer prevention and treatment: implications of the CMS inpatient hospital care present on Admission (POA) indicators/hospital-acquired conditions (HAC) policy. A consensus paper from the International Expert Wound Care Advisory Panel. May 2008.

2. Medline press release. Medline’s Pressure Ulcer Prevention Program addresses new CMS deadline of October 1, 2008. PR Newswire Association. May 2008.

3. Nursing opinion poll reveals pressure ulcer prevention not seen as a top priority. Sage survey. www.infectioncontroltoday.com. July 2004.

4. Cullum N, McInnes E, Bell-Syer SEM, Legood R. Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews. Issue 2. May 2004.

Risk Assessment

1. Any patient who is bed-bound, chair-bound persons, or has an impaired ability to reposition is at risk for pressure ulcers.

2. Use a valid, reliable and age appropriate method of risk assessment that ensures systematic evaluation of individual risk factors.

3. Assess all at-risk patients/residents at the time of admission to healthcare facilities, at regular intervals thereafter and with a change in condition. A schedule is helpful.

Acute care: assess on admission and reassess at least every 24 hours or sooner if the patient’s condition changes.

Long-term care: assess on admission and weekly for four weeks, then quarterly and whenever the resident’s condition changes.

Home care: assess on admission and at every nurse visit.

4. Identify all individual risk factors (decreased mental status, exposure to moisture, incontinence, device related pressure, friction, shear, immobility, inactivity, nutritional deficits) to guide specific preventive treatments. Modify care according to the individual factors.

5. Document risk assessment subscale scores and total scores and implement a risk-based prevention plan.

Skin Care

1. Perform a head-to-toe skin assessment at least daily. Pay special attention to pressure points such as the sacrum, ischium, trochanters, heels, elbows, and the back of the head.

2. Individualize bathing frequency. Use a mild cleansing agent. Avoid hot water and excessive rubbing. Use lotion after bathing. For neonates and infants follow evidence-based institutional protocols.

3. Establish a bowel and bladder program for incontinent patients. If incontinence is unavoidable, cleanse the skin when it becomes soiled, and use a topical barrier to protect it. Select under pads or briefs that are absorbent and provide a quick drying surface. Consider a pouching system or collection device to contain stool and protect the skin.

4. Use moisturizers for dry skin. Minimize environmental factors that lead to dry skin such as low humidity and cold air. For neonates and infants follow evidence-based institutional protocols.

5. Avoid massaging bony prominences.

Mechanical Loading and Support Surfaces

1. Reposition bed-bound patients at least every two hours and chair-bound patients every hour.

2. Consider postural alignment, distribution of weight, balance and stability, and pressure redistribution when positioning people who are chair bound.

3. Teach chair-bound persons (who are able) to shift weight every 15 minutes.

4. Follow a written repositioning schedule.

5. Place at-risk persons on pressure-redistributing mattress and cushion surfaces.

6. Avoid using donut-type devices and sheepskin for pressure redistribution.

7. Use pressure-redistributing devices in the operating room for people who are at a high risk for pressure ulcer development.

8. Use lifting devices (a trapeze or a bed linen) to move patients rather than dragging them.

9. Use pillows or foam wedges to keep bony prominences (such as knees and ankles) from direct contact with each other. Pad the skin that is subjected to device-related pressure and inspect those sections regularly.

10. Use devices that eliminate pressure on the heels. For short-term use with cooperative patients, place pillows under the calves to raise the heels off the bed. Use heel suspension boots for long-term use.

11. Do not position directly on the trochanter when using the side-lying position. Instead, use the 30-degree-lateral-inclined position.

12. Maintain the head of the bed at or below 30 degrees or at the lowest degree of elevation that is consistent with the patient’s medical condition.

13. Institute a rehabilitation program to maintain or improve the patient’s mobility status.

Education

1. Implement pressure ulcer prevention educational programs that are structured, organized, comprehensive, and directed at patients, family, and all levels of healthcare providers.

2. Include information on:

etiology of and risk factors for pressure ulcers

risk assessment tools and their application

skin assessment

selection and use of support surfaces

nutritional support

program for bowel and bladder management

development and implement individualized programs of skin care

demonstration of positioning to decrease risk of tissue breakdown

accurate documentation of pertinent data

Nutrition

1. Identify and correct factors that compromise the patient’s protein/calorie intake.

2. Consider nutritional supplementation for nutritionally compromised persons.

3. Keep the patient hydrated.

4. With a physician’s approval, administer multivitamins with minerals. ICT