Reducing Pressure Ulcers


Prevention and treatment of pressure ulcers has long been recognized as a serious clinical issue by home -based care organizations. Up to 17% of home health patients may have pressure ulcers, and many more are at risk. Reducing frequency and severity of pressure ulcers represents an opportunity for home-based care organizations to contribute to improved quality and value in the health care system.

Pressure injuries are the source of considerable cost and patient morbidity. According to CMS pressure ulcers are a significant factor causing pain, decreased quality of life, and increased mortality in aging populations. The IMPACT Act of 2014 made skin care an even higher priority. The IMPACT Act requires reporting of post-acute care measures relating to skin integrity. CMS issued a mandatory measure examining the percent of patients with pressure ulcers that are new or worsened during the episode (modified NQF measure #678), effective January 1, 2017.*
 
* Note: In 2016 the National Pressure Ulcer Advisory Panel (NPUAP) recommended that the term “pressure injury” replace “pressure ulcer” to more accurately describe pressure injuries to both intact and ulcerated skin. However, the CMS measure adopted as part of IMPACT Act continues to use the term 'pressure ulcer.' For clarity, the ElevatingHome Blueprint uses the term pressure ulcer, except when quoting or discussing resources in which the term pressure injury is used.
 
Relevant Measures:
  • IMPACT Act: National Quality Forum measure number 0678: “Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (Short Stay)”
Home Health Compare
  • How often patients’ wounds improved or healed after an operation
  • How often the home health team checked patients for the risk of developing pressure sores (bed sores)
  • How often the home health team included treatments to prevent pressure sores (bed sores) in the plan
  • How often the home health team took doctor-ordered action to prevent pressure sores (bed sores)
Most home health agencies address pressure ulcer prevention and treatment as one component of a wound care program that may also apply to surgical, stasis and other wounds. Interventions and tools developed for more systematic wound care management will impact agency performance on the IMPACT act pressure ulcer measure, and may also improve overall wound care. The Blueprint for Excellence identifies best practice recommendations from our Work Group that are aimed specifically at addressing challenges experienced by home health agencies.  Pressure ulcer management also requires very specific clinical practices. For links to the most up to date clinical practices, visit our Resources pages. In this section, we discuss interventions in three areas:
  • Developing a systematic agency-level approach to wound care prevention and management;
  • Strategies to prevent new pressure ulcers; and
  • Treatment approaches to managing pressure ulcers present on admission. 
Best Practices to Reduce Pressure Ulcers
Goal: increase agency-level expertise on wound healing through training, quality management, and education/relationship building
Wound management and prevention are one of the most important issues in home care. Agencies need to educate all clinicians on the basics of protecting skin integrity and managing pressure ulcers, and provide access to specialized practitioners for advanced management strategies. Developing a program for wound management training and competency testing is particularly important for home health, since practitioners coming from other settings may not have had experience or accountability for wound management.  
Barriers
  • Burdensome documentation systems for wound assessment and management
  • Use of non-standard tools for evaluating wounds
  • Understaffed for certified wound care staff
  • Lack of continuity of staffing
  • Lack of coordination of care
  • Physician lack of knowledge and order for evidence-based wound care
  • Difficulty obtaining authorization for appropriate durable medical equipment (DME) to prevent pressure injuries
Best Practice Interventions
 Training:
  • Offer regular in-services on new/improved products for wound healing. Educate all staff on pressure ulcer risk factors and the need for holistic prevention strategies.
  • Provide refresher training on full skin risk assessment on admission
  • Use competency testing to ensure effective and standardized wound assessment and management skills
  • Use best practice information on improvement in surgical wounds - for example, training through HHQI.
  • Provide regular education on wound documentation, including clinical features and ICD-10 coding.
Enhance Expertise and Staffing:
  • Enlist OT and PT for training on prevention strategies to improve mobility, reduce friction, evaluate trunk strength
  • Identify a pressure ulcer prevention ‘champion’ at the agency level available for consults
  • Use in-house expertise from the agency certified wound certified care nurse to develop policy and documentation standards needed to ensure Medicare coverage of supplies and durable medical equipment (DME)
  • Involve certified wound care nurse in agency-level supply formulary decisions
  • Increase number certified wound assistants and certified wound care nurses, using incentives and educational opportunities
Quality Management
  • Adopt and train on standardized protocols / algorithms for assessment, prevention, and treatment of wounds or patients at high risk for pressure ulcers.
  • Ensure all clinicians are using a standard method to measure wounds, since the new IMPACT Act measure evaluates worsened injuries. Use standardized wound assessment protocols, including standard measurement tools, use of photographs, and sizing metrics.
  • Consider adopting digital photography or online wound programs that use digital photography linked to EMRs
  • Consider developing a skin integrity protection team that includes RNs, OT, and PT staff, to be activated for patients at high risk for pressure ulcers.
  • Provide wound consults by certified staff for non-certified clinicians if a wound is not healing on current treatment.  Develop protocols and criteria for triggering an electronic or on-site consultation.
  • Develop and implement clinical protocols for on-site or remote wound care consults.  With patient consent, clinicians may transmit a photo of the wound via HIPAA compliant technology and conduct a phone consult with an agency wound care expert.
 Education and Relationships
  • Develop relationships with local wound care programs to improve continuity of care and evidence based wound care management
  • Meet with referring physicians to provide materials / education on evidence-based wound care, including providing guidelines
  • Use SBAR communications with physicians to adjust wound care prescriptions to reflect evidence-based practice
  • Serve as a liaison with DME vendors to ensure vendors have documentation and orders for DME indicated for wound management
  • Develop and use forms to support and simplify physician orders and DME documentation
Goal: Increase use of patient level preventive strategies to reduce the number of new pressure sores
Barriers:
  • Cognitive changes in patient
  • Patient immobility, incontinence, poor nutrition
  • Lack of available caregivers to implement preventive protocols
  • Patient reluctance to allow DME into the home, including specialized beds 
Best Practice Interventions
  • Use a nationally recognized clinical practice guideline to drive evidence-based treatment and prevention approaches. See Resources for 2016 Guidelines. 
Risk Assessment and Planning
  • Implement policy of skin risk assessment upon admission and specified frequency thereafter.  Best practice recommendation is for a Braden Scale skin assessment at every visit for high risk patient
  • Use the Braden Scale or other standardized tool for clinical risk assessment, and provide training to ensure all clinicians apply and interpret the results in the same way.
  • Implement skin care planning process that aligns with risk factor scores on Braden Scale.
  • Review prealbumin as possible indicator of need for nutrition consult
  • Educate patients and families on the skin care plan
Top Priorities in Clinical Interventions
  • Moisture management
  • Pressure redistribution and offloading
  • OT and PT to help patients reduce shearing, friction movements
  • See Table 1 below, Best Practice Interventions to Promote Skin Integrity
Table 1: Home Health Best Practice Interventions to Promote Skin Integrity
Provide skin care
  • Prevent excess moisture
  • Keep skin clean and dry, avoid hot water
  • Prevent massage and pressure on bony prominences
  • Clean areas of wound draining, sweat, and incontinence regularly and address perineal area
  • Use barrier creams and ph balanced soaps to prevent dry skin. Consider changing from soap to cleansers (may need to change formulary from soap to cleansers)
  • For bariatric patients, manage moisture in skin folds for example use wicking fabric or AMD gauze
Manage Incontinence
  • Manage fecal / urinary incontinence (See VNAA Manual for strategies and teaching)
  • See pressure injury / pressure ulcer guidelines for managing moisture related to incontinence, including timed voiding and other strategies
Improve mobility
  • Provide physical therapy and occupational therapy for patient and care giver teaching on specific strategies to offload or redistribute pressure
  • Limit sedating medications
  • Reduce spasticity with medications (for spinal cord injured)
  • Identify and agency level “seating specialist’ - a physical therapist who specializes in spinal cord injured patients on seating and appropriate wheelchair use. For example, the specialist can discuss tilt strategies for an electric wheelchair to help with position changes
Maintain adequate skin perfusion
  • Prevent hypotension
  • Manage peripheral artery disease
  • Maintain hydration
  • Manage edema – use compression, understand underlying etiology such as dyspnea impacting positioning
  • Provide Doppler testing onsite for ankle-brachial pressure index (ABPI) or ankle-brachial index (ABI)
Reduce pressure - offloading
Correct malnutrition
  • Calculate and ensure adequate protein intake
  • Obtain nutrition consult
  • Consider social services consult if food availability or financing is a concern
Manage related risks
  • Manage risk factors such as diabetes, other vascular co-morbidities
  • Maintain functional status
  • Address cognitive deficiencies in care planning and support plan
  • Recommend home health aide services or refer to community resources
 
Goal: Prevent exacerbation or infections of pressure ulcers
Barriers
  • Wound care orders not always evidence based
  • Patient factors make care and prevention challenging
  • Variability in staff assessment approaches to wounds
  • Difficulty getting wound care supplies on formulary
Best Practice Interventions
  • Use a nationally recognized clinical practice guideline to drive evidence-based treatment and prevention approaches. See Resources for the latest Guidelines.
  • Apply prevention best practices discussed earlier to prevent exacerbation
  • Apply standard staging method for pressure ulcer staging.
  • Adopt a specific evidence-based protocol for treatment of ulcers at each stage.
  • Use educational materials and SBAR communications with treating physicians to align orders with guideline recommended care.
  • Provide tools and strategies to educate clinicians on wound management strategies. (For example, DIMES (Devitalized Tissue, Infection/Inflammation, Moisture Balance, and Edge Preparation) mnemonic can help clinicians address critical wound healing elements.
  • Address co-morbidities impacting wound healing: diabetes, arterial or venous insufficiency
  • Remove factors contributing to new or ongoing ulceration due to pressure: redistribute pressure through positioning and supportive devices and get OT / PT involved to improve transferring and reduce shearing.
  • Control pain (this is a Home Health Compare measure and impacts Patient Experience measures)
  • Monitor closely for and treat infection.
  • Develop collaborative patient education on care plan and have patient or caregiver explain-back what to do. Use Zone tools for alerting the care team of signs and symptoms of infection or exacerbation.
  • Use Agency-level wound care specialist to consult on challenging wounds, advocate for supplies and equipment, and educate referring physicians.
Recommended Resources:
  • National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. This Guide presents a comprehensive review and appraisal of the best available evidence at the time of literature search related to the assessment, diagnosis, prevention and treatment of pressure ulcers in the U.S. and internationally.
  • CMS Cross-Setting Pressure Ulcer Measurement & Quality Improvement webpage.  This site provides information on CMS work to develop a cross setting measure of pressure ulcer prevention. It also includes links to resources from national organizations on pressure ulcer assessment, prevention, and management.
   
Partner with referring clinicians and hospitals to develop programs and strategies to improve health outcomes and patient experience, and to help them meet accountability goals.  
By effectively engaging patients and caregivers as partners in care, home-based care organizations improve experience, activation, and ultimately, outcomes.
   
    Educate payers on opportunity to improve outcomes by more effectively care for people in their homes. Drive smarter spending by preventing admissions and avoidable ED use.
   
    Drive better outcomes by supporting practitioners to practice at the top of their license, training for excellence, and recognizing achievement.