Pressure Ulcers: Tips for Treatment, Prevention

Stage III and IV pressure ulcers, which cause significant patient morbidity and generate substantial treatment costs, are among the hospital-acquired conditions considered to be preventable by the Centers for Medicare and Medicaid Services (CMS). These so-called "never" events are among the preventable adverse events being addressed by CMS as part of the pay-for-performance mandate in an effort to improve patient safety, reduce medical errors, and meet regulatory requirements. Stage III pressure ulcers are defined as full thickness with skin loss, while stage IV pressure ulcers are described as full thickness with tissue loss, according to the Pressure Ulcer Prevention Quick Reference Guide, published jointly by the National Pressure Ulcer Advisory Panel (NPUAP) and the European Pressure Ulcer Advisory Panel (EPUAP). 

To review, section 5001(c) of the Deficit Reduction Act (DRA) of 2005 requires identification of conditions that are: (a) high cost or high vol-ume or both, (b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. For discharges occurring on or after Oct. 1, 2008, hospi-tals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis were not present. CMS also required hospitals to report present on admission information for both primary and secondary diagnoses when submitting claims for discharges on or after Oct. 1, 2007.

CMS provides specific regulatory guidance and oversight on the prevention of pressure ulcers in long-term care residents. As the CMS State Operations Manual F314 §483.25(c) states:
- A resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demon-strates
that they were unavoidable; and
- A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing.

The Association for Professionals in Infection Control and Epidemiology (APIC)'s Infection Preventionist’s Guide to Long-Term Care notes that, "LTCFs are required to have individualized interventions in place for residents at risk of developing pressure ulcers to prevent their formation. For residents with pressure ulcers, CMS requires that facilities have treatment protocols in place based on current standards of practice and in accordance with facility policies and procedures."

APIC's guide explains further that "Pressure ulcers develop due to immobility through prolonged lying or sitting position and a sedentary life-style. The constant pressure deprives the tissues of oxygen and nutrients, resulting in ischemia, cellular death, and tissue necrosis. A shear can cause additional injury." According to the APIC guide, additional risk factors for pressure ulcer development include: fever, anemia, infection, hypotension, malnutrition, spinal cord injury, neurological disease, decreased body mass index, increased metabolic rate, skin maceration, ad-vanced age, chronic illness such as diabetes, weakness, altered mental status, skin conditions such as edema or pruritus, incontinence, vascular disease, and a history of pressure ulcers.

Quality Measures
Healthcare reform mandates call for increasing compliance with quality measures, and the NPUAP advocates incidence density as the best quality measure of pressure ulcer prevention programs. According to the NPUAP, pressure ulcer incidence density is a computation based on the number of in-patients who develop a new pressure ulcer(s) divided by 1,000 patient days. Using the larger denominator of patient days allows fair comparisons between institutions of all sizes. Incidence is a commonly reported measure; however it is computed by counting the number of patients with newly acquired pressure ulcers and dividing that number by the number of patients examined for pressure ulcers over a given period of time. Smaller facilities can appear to have a higher percentage of patients with ulcers because there are fewer patients in the de-nominator.  As the NPUAP explains, for example, five patients with ulcers out of 100 patients assessed equals a 5 percent incidence. The same number of patients with ulcers among 500 patients assessed is only 1 percent. Using patient days as the denominator stabilizes the result. Many state reporting systems and hospital-acquired conditions, such as for catheter-associated urinary tract infections (CAUTIs) currently use incidence density.

The hospital-acquired pressure ulcer (HAPU) rate counts a “new case of pressure ulcers” when an ulcer is identified and there is no docu-mentation of the ulcer in the medical record at the time of admission. The NPUAP says it supports the use of this measure as a proxy measure of incidence for use within an agency, but recognizes the potential for errors in reporting due to reliance on the medical record. HAPU rates can also be artificially inflated when individuals with ulcers are counted more than once in sequential measurement.  For example, a person with a pressure ulcer is counted each month as a new case. And finally, HAPU rates do not account for the size of the facility.

Prevalence may sometimes be used as another measure of quality. Prevalence describes the number of patients with pressure ulcers at a specific time and includes both cases of pressure ulcers that began in the facility as well as cases of pressure ulcers that existed before admission. Prevalence is best used to examine the burden of pressure ulcers for a facility when providing wound care staff and supplies. NPUAP does not support the use of prevalence as a quality measure because it includes cases of pressure ulcers that did not develop in the facility, therefore inflating the number.

Prevention
The NPUAP has outlined a set of interventions to help control and prevent pressure ulcers:

1. Risk Assessment
- Consider all bed-bound and chair-bound persons, or those whose ability to reposition is impaired, to be at risk for pressure ulcers.
- Use a valid, reliable and age appropriate method of risk assessment that ensures systematic evaluation of individual risk factors.
- 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 and should be based on individual acuity and the patient-care setting:
• Acute care: assess on admission, reassess at least every 24 hours or sooner if the patient’s condition changes
• Long-term care: assess on admission, weekly for four weeks, then quarterly and whenever the resident’s condition changes
- Identify all individual risk factors (decreased mental status, exposure to moisture, incontinence, device related pressure, friction, shear, im-mobility, inactivity, nutritional deficits) to guide specific preventive treatments. Modify care according to the individual factors.
- Document risk assessment subscale scores and total scores and implement a risk-based prevention plan.

2. Skin Care
- Perform a head to toe skin assessment at least daily, especially checking pressure points such as sacrum, ischium, trochanters, heels, elbows and the back of the head.
- 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
- Establish a bowel and bladder program for patients with incontinence. When incontinence cannot be controlled, cleanse skin at time of soil-ing, and use a topical barrier to protect the skin. Select under pads or briefs that are absorbent and provide a quick-drying surface to the skin. Consider a pouching system or collection device to contain stool and to protect the skin.
- Use moisturizers for dry skin. Minimize environmental factors leading to dry skin such as low humidity and cold air. For neonates and infants follow evidence-based institutional protocols
- Avoid massage over bony prominences.

3. Nutrition
- Identify and correct factors compromising protein/ calorie intake consistent with overall goals of care.
- Consider nutritional supplementation/support for nutritionally compromised persons consistent with overall goals of care.
- If appropriate offer a glass of water when turning to keep patient/resident hydrated.
- Multivitamins with minerals per physician’s order.

4. Mechanical Loading and Support Surfaces
- Reposition bed-bound persons at least every two hours and chair-bound persons every hour consistent with overall goals of care.
- Consider postural alignment, distribution of weight, balance and stability, and pressure redistribution when positioning persons in chairs or wheelchairs.
- Teach chair-bound persons, who are able, to shift weight every 15 minutes.
- Use a written repositioning schedule.
- Place at-risk persons on pressure-redistributing mattress and chair cushion surfaces.
- Avoid using donut-type devices and sheepskin for pressure redistribution.
- Use pressure-redistributing devices in the operating room for individuals assessed to be at high risk for pressure ulcer development.
- Use lifting devices (such as a trapeze or bed linen) to move persons rather than drag them during transfers and position changes.
- Use pillows or foam wedges to keep bony prominences, such as knees and ankles, from direct contact with each other. Pad skin subjected to device related pressure and inspect regularly.
- Use devices that eliminate pressure on the heels. For short-term use with cooperative patients, place pillows under the calf to raise the heels off the bed. Place heel suspension boots for long-term use.
- Avoid positioning directly on the trochanter when using the side-lying position; use the 30-degree lateral inclined position.
- Maintain the head of the bed at or below 30 degrees or at the lowest degree of elevation consistent with the patient’s/resident’s medical condition.
- Institute a rehabilitation program to maintain or improve mobility/activity status.

5. Education
- Implement pressure ulcer prevention educational programs that are structured, organized, comprehensive, and directed at all levels of health care providers, patients, family, and caregivers.
- 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 pro-grams of skin care; demonstration of positioning to decrease risk of tissue breakdown; and accurate documentation of pertinent data
- Include mechanisms to evaluate program effectiveness in preventing pressure ulcers.

Research Priorities
 The NPUAP has identified key research priorities for pressure ulcer prevention, treatment and policy to help guide researchers and stake-holders in the advancement of science for the prevention and treatment of pressure ulcers and to guide policy development. 

Prevention
- Co-morbidities,  age (neonate, children, adults, older adults), disparities, genetic influences and  other risk factors related to the incidence and prevalence of  pressure ulcers and DTI across settings (acute, OR, community acquired)
- Effects of nutritional interventions in the prevention of pressure ulcers and DTI
- Effects of microenvironment (sanitation, microclimate, microbiology) on incidence and prevalence of pressure ulcers and DTI
- Effects of compressive and shear stress and deformation on soft tissue injury associated with DTI and pressure ulcers
- Effect of turning and repositioning schedules on pressure ulcer and DTI prevention outcomes
- Prevalence and incidence of pressure ulcers and DTI associated with the use of medical devices
- Generation of fundamental knowledge on the etiology of pressure ulcer formation and deep tissue injury
- Patient literacy and teaching about prevention or treatment

Treatment
- Surgical solutions for treatment of pressure ulcers
- Selection of support surfaces based on assessment of patient clinical characteristics and support surface characteristics
- Effects of wound dressings on outcome of pressure ulcers
- Role of bioburden and biofilms in the treatment and healing of pressure ulcers
- Effects of nutritional interventions on outcomes of pressure ulcers
- Disparities, co-morbidities, age, genetics and risk factors related to outcomes of pressure ulcers
- Assessment and management of pain associated with pressure ulcers
- Time to healing in pressure ulcers (is there a time frame such as exists with diabetic foot ulcers and venous ulcers, such as 50 percent clo-sure in four weeks?)

Policy
- Standardization of patient records and documentation to support research
- Impact of government regulations on pressure ulcer management
- Standardization of terminology, tools, and outcomes, such as healthcare quality metrics
- Effective implementation of prevention and treatment guidelines
- Effective dissemination of implementation of prevention and treatment guidelines
- Skills to design research studies with adequate power and controls to generate data that can be rigorously interpreted
- Skills to design case/outcome studies as a decision aid for further research
- Caregivers (physicians, nurses, family etc.) knowledge and interest in pressure ulcer prevention and treatment
- Nurse and physician communication linked to quality measures, patient teaching/literacy as well as disparity/racial groups
- Pressure ulcer recurrence rates; consistency in what to call ulcers that recur at the same location/site, how to stage, when is it a new ul-cer? When is it just remodeling gone astray?
- Research into methods of cost/benefit calculations to be applied to compare efficacy of preventive measures