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September 7, 1999
Illinois Nursing Homes Successfully Address Challenges of Pressure Ulcers
(Chicago) -- Illinois
nursing homes have developed a variety of progressive
wound care programs to effectively treat and prevent
skin breakdown. Recent statistics illuminate their success.
As of 1999, according to statistics from the Health
Care Financing Administration, only 7.01% of all Illinois
nursing home residents have pressure ulcers.
This percentage is very low considering
the challenges that nursing homes face in preventing
pressure ulcers. One of the biggest of these challenges
is the fact that many patients admitted to nursing homes
from hospitals come in with pressure ulcers.
The acuity level of residents in long term care
has been increasing over time, because of hospital policies
of discharging patients earlier than ten years ago.
As a result, a higher number of residents are now coming
into nursing homes with serious medical conditions that
place them at a higher risk for skin breakdown.
According to the report “Pressure
Ulcers: Prevention and Management” published by
the Mayo Clinic in Rochester, the prevalence of pressure
ulcers in the United States is between 1.5 million to
3 million individuals. Up to 5% of patients admitted
to acute care hospitals will develop an ulcer in the
hospital. This figure is even higher for patients immobilized
in bed or a chair for at least a week. Sixty percent
or more of all pressure ulcers develop in the hospital,
while 18% develop in nursing homes, and 18% develop
at home. Approximately one in four people in the United
States who died in 1987 had a dermal ulcer at the time
of death.
Illinois nursing homes are addressing
the challenge of pressure ulcers aggressively and proactively.
The Health Care Financing Administration reports that
58.93% of all Illinois nursing home residents participate
in a preventative skin care program, reflecting the
commitment of nursing home professionals to not only
treat pressure ulcers that have developed, but ultimately
to prevent them from occurring.
“Over the years, nursing homes
have gotten better at assessing pressure ulcers and
providing effective treatment,” states Dr. Jack
Bulmash, Director of Postacute Care Services for Illinois
Masonic Medical Center and Physician Representative
for the Illinois Department of Public Health’s
Long Term Care Advisory Board.
“Many nursing facilities have developed
formalized skin care programs. Crucial to the success
of these programs is the communication between nurses
and cadre personnel -- particularly the nurse aides
who are vital in detecting reddened skin areas that
quickly lead to more advanced pressure ulcers.”
Illinois nursing facilities utilize
a variety of proven techniques for preventing and treating
pressure ulcers. Interventions include repositioning
patients, applying topical cremes, wound debridement
techniques, nutritional supplementation, and the use
of therapeutic mattresses to promote comfort and facilitate
healing.
Health care professionals realize
that not all pressure ulcers can be prevented. The nursing
home industry is very cognizant of the fact that residents
don’t have to get bed sores -- most of them are
preventable. However, for about one to two percent of
all nursing home residents, pressure sores are not preventable
due to the debilitating effects of their medical conditions.
The State of Illinois’ Public
Aid department has played an important role in promoting
the importance of wound care programs. Back in 1985,
the pressure ulcer rate in the state of Illinois was
at 11.6%. The state of Illinois implemented a new reimbursement
system called the DPA 2700 that reimbursed nursing facilities
for preventing pressure ulcers and treating those which
developed at home or in the hospital.
Around the same time, the state implemented
the Quality Incentive Program (QUIP) that provided additional
reimbursement for targeting at-risk populations for
pressure ulcer prevention, such as residents who were
immobile or nutritionally compromised. The combination
of the DPA 2700 and the QUIP program caused the pressure
ulcer rate in Illinois to fall dramatically.
Since then, the federal government
has also promulgated the Omnibus Reconciliation Act
of 1987 (OBRA) which mandated an increased emphasis
for nursing homes to address pressure ulcer treatment
and prevention. In addition, some nursing facilities
have participated in the state’s “Exceptional
Care Program,” in which nursing facilities which
specialize in wound care management take on patients
with multiple, hard-to-heal pressure ulcers.
The combined effects of all of these
statewide and federal initiatives is that many Illinois
nursing home professionals have, in effect, become experts
on preventing and treating pressure ulcers, developing
programs that enable residents’ wounds to heal
in a timely and successful manner.
“Most people don’t realize
that pressure ulcers can develop very quickly, even
in the matter of a couple of hours,” states Terry
Sullivan, executive director of the Illinois Council
on Long Term Care. “Illinois nursing homes have
long recognized that the importance of taking proactive
steps to prevent pressure ulcers, rather than simply
treating ulcers that have already developed. This focus
on preventative care has resulted in Illinois nursing
facilities being successful in reducing its rate of
pressure ulcers, which has had a profound effect on
maximizing resident health, morale, and outlook.”
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(Enclosed
with this press release is a resident case study on
a successful pressure ulcer prevention program in Illinois.)
Helpful Strategies for Preventing Pressure Ulcers
Pressure ulcers is a serious problem
for many elderly persons in the United States. Those
persons at risk for pressure ulcers include individuals
who are confined to a bed or chair, find it difficult
to move, have incurred a loss of bowel or bladder control,
don’t eat nutritionally balanced meals, or have
lowered mental awareness.
According to Preventing Pressure
Ulcers: A Patient’s Guide, published by the
U.S. Department of Health and Human Services, a pressure
ulcer is an injury usually caused by unrelieved pressure
that damages the skin and underlying tissue. Pressure
ulcers are also called bed sores and range in severity
from mild (minor skin reddening) to severe (deep craters
down to the muscle and bone).
Unrelieved pressure on the skin squeezes
tiny blood vessels, which supply the skin with nutrients
and oxygen. When skin is starved of nutrients and oxygen
for too long, the tissue dies and a pressure ulcer forms.
Skin reddening that disappears after pressure is removed
is normal and not a pressure ulcer.
Other factors cause pressure ulcers
too. If a person slides down in the bed or chair, blood
vessels can stretch or bend and cause pressure ulcers.
Even slight rubbing or friction on the skin may cause
minor pressure ulcers. Pressure ulcers are serious problems
that can lead to pain, a longer stay in the hospital
or nursing home, and slower recovery from health problems.
Pressure ulcers form where bone causes
the greatest force on the skin and tissue and squeezes
them against an outside surface. This may be where bony
parts of the body press against other body parts, a
mattress, or a chair. In persons who must stay in bed,
most pressure ulcers form on the lower back below the
waist, the hip bone, and on the heels. In people in
chairs or wheelchairs, the exact spot where pressure
ulcers form depends on the sitting position. Pressure
ulcers can also form on the knees, ankles, shoulder
blades, back of the head and spine.
Nerves normally “tell”
the body when to move to relieve pressure on the skin.
Persons in bed who are unable to move may get pressure
ulcers after as little as 1-2 hours. Persons who sit
in chairs and who cannot move can get pressure ulcers
in even less time because the force on the skin is greater.
Risk Factors for Pressure Ulcer Development
Some of the risk factors for the
development of pressure ulcers include:
1.
Bed or Chair Confinement -- Persons who
must stay in bed, a chair, or a wheelchair are at high
risk of developing pressure ulcers.
2.
Inability to Move -- Persons who cannot
change positions without help are at great risk of having
pressure ulcers. The risk of getting pressure ulcers
is much lower when persons can move by themselves.
3.
Loss of Bowel or Bladder Control -- Individuals
who cannot keep their skin free of urine, stool, or
perspiration have a risk of developing pressure ulcers.
These sources of moisture can irritate the skin and
lead to breakdown.
4.
Poor Nutrition -- The inability to eat
a balanced diet can prevent skin from being properly
nourished. Pressure ulcers are more likely to form when
skin is not healthy.
5.
Lowered Mental Awareness -- When mental
awareness is lowered, a person may not act to prevent
pressure ulcers. Mental awareness can be affected by
health problems, medications, or anesthesia.
Elderly patients and individuals
with spinal cord injuries, traumatic brain injury, and
neuromuscular disorders are high risk populations for
pressure ulcer development, especially in the acute
care hospital setting. Chronic systemic illness and
the presence of a fracture may also be predictive of
ulcer development. All of these factors are more prevalent
among the elderly, compounding the risk that age itself
confers.
Individuals who fall within these
risk groups should take proactive steps to lower their
risk of developing pressure ulcers. Several methods
have been proven to be effective in reducing this risk
for skin breakdown. The long-term care community has
been utilizing these techniques in helping residents
reduce their risk of pressure ulcer development and
optimize their physical health and quality of life.
Successful Strategies for Preventing Pressure Ulcers
Persons at risk for
pressure ulcers should inspect their skin at least once
a day. Attention should be paid to any reddened areas
that remain after one has changed positions and the
pressure has been relieved. These red areas may signal
the development of a pressure ulcer.
Skin should be cleaned as soon as
it is soiled. A soft cloth or sponge should be used
to reduce injury to skin. Every effort should be made
to minimize moisture from urine, stool, perspiration,
or wound drainage. When moisture cannot be controlled,
pads or briefs that absorb urine and have a quick drying
surface should be utilized. Gently applying a cream
or ointment to protect skin from urine, stool, or wound
drainage may be helpful.
Avoid massage (or heavy rubbing)
of skin over bony parts of the body. Massage may squeeze
and damage the tissue under the skin and make a person
more likely to get pressure ulcers.
Positioning plays a key role in avoid
skin breakdown. It is important to limit pressure over
bony parts of the body by changing positions or having
one’s caregiver change position. Persons who are
bedridden should have their position changed at least
every two hours to avoid pressure ulcers. For persons
in wheelchairs, positioning should be changed at least
every hour.
During this repositioning, friction
should be reduced by making sure that an individual
is lifted, rather than dragged. Friction can rub off
the top layer of skin and damage blood vessels under
the skin. If nurses or others are providing assistance,
bed sheets or lifters can be used. A thin film of corn
starch can be applied to the skin to help reduce damage
from friction.
There are many special considerations
for persons who are bedridden. It may be helpful to
use a special pressure-relieving mattress to prevent
pressure ulcers. Health care providers can recommend
the best mattress for each individual situation.
Pillows or wedges should be utilized
to keep knees or ankles from touching each other. If
one is completely immobile, pillows should be put under
one’s legs from midcalf to ankle to keep heels
off the bed. Never place pillows behind the knee, as
this will cause the heel to rub against the bed.
Persons who are bedridden should
avoid lying directly on their hip bones when lying on
their sides. Also, a position that spreads weight and
pressure more evenly should be chosen, with pillows
placed to provide support and comfort. The head of the
bed should be raised as little and for as short a time
as possible if consistent with medical restrictions
and other restrictions. When the head of the bed is
raised more than 30 degrees, one’s skin may slide
over the bed surface, damaging skin and tiny blood vessels.
For persons in a chair or wheelchair:
pressure-relieving cushions should be used. Avoid donut-shaped
cushions because they reduce blood flow and cause tissue
to swell, which can increase one’s risk of getting
a pressure ulcer. One must avoid sitting without moving
or being moved -- repositioning must be done at least
every hour to reduce the risk of pressure ulcers. Good
posture and comfort are important.
A very important component in reducing
one’s risk of pressure ulcers is eating a balanced
and nutritious diet. Research studies have shown that
nutritional well-being has a direct impact on an individual’s
risk of skin breakdown. The elderly are particularly
at risk for malnourishment. Protein and calories are
very important in maintain healthy skin. If one is unable
to eat a normal diet, health care providers can recommend
nutritional supplements that may prove to be helpful.
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Preventing and Treating Pressure Ulcers: A Resident Success Story
A little over a year ago, Frank Ciesel
of Forest Villa Nursing Center in Niles had seven pressure
ulcers on various parts of his body, the result of having
contractures which made his body difficult and painful
to move. Through Frank’s participation in Forest
Villa’s Skin Care Program, all of his wounds have
successfully healed.
“Having pressure sores made
me feel terrible,” Frank notes. “Now that
these sores have healed, I feel very good and am able
to be more independent. The staff members were very
helpful in encouraging me through my healing process.”
The treatment of Frank’s pressure
ulcers involved professionals from several disciplines.
Nurses and physicians were involved in making accurate
assessments of the pressure ulcers and in utilizing
such treatments as ordering a special therapeutic mattress
for Frank, applying topical cremes, and debriding his
wounds of dead tissue to encourage healing.
Nurse aides played an important role
in turning and repositioning Frank every two hours.
A big challenge was overcoming Frank’s compromised
nutritional status, as he had lost almost 20 pounds
in a six-month period. The facility nutritionist had
Frank take nutritional supplements along with vitamin
C and zinc to promote his nutritional health.
Along with these strategies, the
nurse aides helped increase Frank’s caloric intake,
leading to a dramatic weight gain of eighteen pounds
which made Frank’s body more able to heal the wounds.
Enabling all of Frank’s pressure
ulcers to heal was very rewarding for the staff members
at Forest Villa Nursing Center. “Seeing Frank’s
health and mental outlook improve so dramatically was
a great feeling for all of us,” states Kerry Owens,
former Assistant Director of Nursing at Forest Villa.
“Frank is now enjoying a much higher quality of
life, due to the caring efforts of the facility’s
interdisciplinary team.”
Frank’s story is but one example
of the many residents in Illinois nursing homes who
have overcome the pain and discomfort of pressure ulcers
through progressive wound treatment programs. The experiences
of nursing home professionals in treating pressure ulcers
have implications for many persons of advanced age.
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