Often-overlooked simple preventive techniques can carry big rewards
October 1, 1997
Often-overlooked simple preventive techniques can carry big rewards
Are you following even the most basic techniques?
The most effective way to manage pressure ulcers and other types of chronic wounds is to prevent them from occurring in the first place. There’s no scarcity of prescriptive actions designed to prevent chronic wounds, especially pressure ulcers. Yet the gulf between the lip service paid to the importance of prevention and the actual implementation of preventive practices is often broad.
Frequently, the most basic prescriptive preventive measures, detailed in well-known publications such as the guidelines issued by the federal Agency for Health Care Policy and Research (AHCPR), Pressure Ulcers in Adults: Prediction and Prevention, are not applied universally for at-risk patients. These practices include regularly turning immobile patients, choosing appropriate pressure-reducing support surfaces, and regularly inspecting areas of the skin, particularly around bony prominences, for signs of breakdown. Maintaining proper nutritional balance also has become a crucial part of the wound prevention matrix.
But if prevention is such a straightforward proposition, why is it practiced only sporadically in many health care facilities and in some, not at all? Kay E. Jewell, MD, an associate scientist at the University of Wisconsin Center for Health Systems Research and Analysis in Madison, posits that one of the main reasons is wound prevention gets lost in the more immediate concerns of caregivers, especially in acute- and intermediate-care hospitals where patient stays are relatively short and where clinicians may rarely see a pressure ulcer develop due to their actions or inactions.
Even in long-term care facilities, a focus on prevention is not a given. Overall, ulcer prevention is simply not a high priority in the medical mix, especially among patients with more immediate threats to their health.
"You have to practice prevention on so many people every day that it’s easy to lose sight of that among all of the other concerns in a patient’s life," Jewell says. "One of the complaints I here at the subacute and nursing home level is that a lot of things aren’t taken care of in the hospital. Hospital personnel assume that such things will be taken care of later, such as blood pressure, blood sugar, and nutrition. The mind set is, We’ll treat them, but we won’t invest in their long-term care because they won’t be around for long.’ Patients may stay at a hospital for only a few days or in intermediate care for a week or two, which is often too short a time to see the impact of variables of diet, for example, on wound prevention or adapt to the comprehensive needs of a patient with limited mobility."
In addition, Jewell says, a typical patient who is shuffled around for tests is often cared for only briefly by a variety of caregivers, none of whom are aware of an individual patient’s pressure ulcer risk status. For instance, a patient may lie on a gurney for hours while awaiting a battery of tests. Often, the hospital personnel simply don’t know that a particular patient is at risk for pressure ulcers and thus don’t realize that the absence of preventive measures may further increase the risk of skin breakdown.
"So nursing homes end up with a high rate of patients who get pressure ulcers as a result," Jewell adds. To address the problem, some hospitals Jewell has worked with identify at-risk patients by flagging their charts and educating staff about the importance of prevention.
The problem is exacerbated by the fact that modern health care has produced a growing number of people who are functionally impaired, adds Rita A. Frantz, PhD, RN, FAAN, a professor at the University of Iowa College of Nursing in Iowa City. "Health care has done tremendous things to extend life but not correspondingly increase function," she says. "We are left with a greater part of the population of patients who we take care of and maintain at something less than optimal function and are therefore more at risk for pressure ulcers."
In addition, managed care and Medicare still tilt in favor of treatment rather than prevention, even though the latter is apt to cost more over the long run.
Noteworthy results
When comprehensive pressure ulcer prevention programs are put in place, the results can be dramatic, resulting in a measurable decrease in the incidence of wounds. In one study, Frantz and her colleagues measured the incidence rate of pressure ulcers at a long-term care facility that had taken virtually no prevention measures. A staggering one-third of the residents had at least one pressure ulcer. The investigators then collaborated with the facility to implement a rigorous prevention program based on the AHCPR guidelines. The guidelines also were applied to patients with existing ulcers. Six months later, the incidence of patients developing new ulcers declined dramatically to about 3%, Frantz reports.
A subsequent analysis revealed that the cost of the prevention program and the resulting savings from reduced treatment expenses offset one another. "The total costs essentially didn’t change, but the way in which the facility allocated its resources did change," Frantz says. She notes that since the facility spent almost nothing on prevention and relatively little on post-ulceration care to begin with, these results weren’t all that surprising.
Cost vs. effectiveness
Factors to which a monetary value cannot be applied, such as patient suffering, clearly were reduced. What did astonish Frantz, though, was the fact that she was still able to find a facility where prevention was totally absent. "We didn’t think there would be anything quite like this still around, and I hear stories about others all the time," she says. "We thought we’d have to go back and historically identify a time and a setting where this was true."
Frantz also found repeatedly that preventive measures need not be complex or costly to be successful. "In a number of studies we’ve conducted over the last four years, we found that we didn’t need sophisticated support systems to get results," she says. "Often, we used nothing more than foam overlays on beds or foam cushions on chairs. For patients with existing wounds, we used primarily saline gauze dressings and a little bit of hyrdocolloid. Frantz notes that her work has been confined to long-term care environments and may not be applicable to other types of health care facilities.
In another of Frantz’ studies, pressure ulcer incidence at a long-term care facility with a well-established prevention program was compared with that of a London geriatric hospital in the 1960s, which had kept detailed records on chronic wounds. (From that voluminous hospital report evolved the Norton Scale for Risk Assessment, Frantz notes.) "No prevention was used at that time. People were put to bed when they got sick. They weren’t turned and didn’t use special support surfaces," she says. "Those patients who developed pressure ulcers were usually those who could not move themselves independently in bed."
The same proved true at the existing facility, but prevention substantially held down the proportion of patients who actually developed ulcers. "With an active prevention program, you keep your pressure ulcer rate relatively low, around 3-4%, but you probably can’t prevent them all," says Frantz. She adds that the prevention-related expenses need not be high. In this instance, prevention-related costs came to an astoundingly low $1.15 per ulcer-free day of life.
Even in the face of such encouraging numbers and the apparent simplicity of a basic prevention program, prevention is still widely overlooked. Gradually, the situation is improving, in large part because pressure ulcer incidence is more frequently used as a quality of care indicator at extended-care hospitals. Both the Health Care Financing Administration and the Joint Commission on the Accreditation of Healthcare Organizations have begun to scrutinize pressure ulcer prevention.
"A lot of issues related to wound care become non-issues if you use enough prevention," Frantz says. Even common preventions lack scientific basis
Rely on the best available knowledge
Pressure ulcers are preventable. While that statement is widely accepted as a truism among wound care professionals, it does not go undisputed. Practices that are broadly considered effective, such as regularly turning immobile patients and using special support surfaces, may work some or even much of the time. But solid clinical evidence is scarce, say researchers such as Louise Colburn, RN, MS, at Johnson & Johnson Medical in Arlington Texas, who recently wrote a book chapter on chronic wound prevention.1
Prevention data on other types of chronic wounds, such as venous stasis ulcers and arterial ulcers, also are sparse, she adds. Without the objective proof supplied by large, well-designed clinical studies, clinicians will lack the leverage needed to persuade managed care to pay for pressure ulcer prevention, Colburn says. The development of wounds, especially pressure ulcers, is increasingly identified as an indicator of less-than- quality care, yet there has been no universally agreed upon approach to prevention, she adds.
"It is curious that saving patients from pain and suffering does not provide adequate rationale for preventive actions," she says. "Health care providers have traditionally dedicated themselves to relieving pain and suffering without expecting a cost saving. However, in today’s managed care and outcome-oriented environment, it is expected that definitive clinical and cost- efficacy data will be provided."
A handful of clinicians are investigating the merits of preventive practices. In one study, researchers discovered that 28% of low-risk patients who were prescribed to be turned regularly developed pressure ulcers, while only 7.9% of those not turned developed pressure sores. A similar but less dramatic pattern was seen among higher-risk patients: Forty-two percent of those who were prescribed to be turned developed ulcers, compared with 39.5% of the subjects who were not turned. The researchers also were unable to explain why 42.6% of patients in the moderate- and high-risk groups who were provided with pressure-reduction surfaces developed ulcers, compared with 37% of those without pressure-reduction surfaces.
"The fact that those who did not have turning prescribed had proportionally fewer pressure ulcers than those who had a turning prescription is puzzling," writes study author Nancy Bergstrom, PhD, RN, FAAN, from the University of Nebraska Medical Center in Omaha. Perhaps, she hypothesizes, some of the pressure-reduction surfaces prescribed may not have been of sufficient quality to provide therapeutic pressure reduction, or perhaps patients on pressure-reduction surfaces were not turned as often as those on standard mattresses.
"In the absence of turning, pressure-reduction surfaces may not prevent pressure ulcers inasmuch as it has been demonstrated previously that low interface pressure of long duration produces tissue injury in the same manner as high interface pressure of short duration," Bergstrom adds.
"Some of what they found flies in the face of what we would expect," says Kay E. Jewell, MD, an associate scientist at the University of Wisconsin Center for Health Systems Research and Analysis in Madison. "It raises lots of questions."
Further complicating the mix is the need to identify patients who are at high risk for developing pressure ulcers so that preventive measures, such as they are, can be applied selectively, thus affording scarce resources to those patients most in need while keeping down costs. Bergstrom concludes that performing a risk assessment based on the Braden Scale, not primary diagnosis or demographic characteristics, should be the foundation for prescriptive decisions.2
"We still don’t know how to identify the patients who are most susceptible to wounds," Jewell says. "Even though we know what some of the risk factors are, such as being bedfast, no one factor is usually sufficient as a predictor by itself. A patient can be bedridden for years and have nothing happen to him, even if he wasn’t getting turned. It might be that just being bedfast wasn’t enough of a factor. One nursing facility chain noted that many of their bedridden and incontinent patients didn’t have pressure ulcers, then all of a sudden they developed sores after years in bed. What changed that tipped them? These are the kinds of details that we don’t totally understand."
Jewell herself is participating in a Health Care Financing Administra-tion (HCFA) project to provide nursing facilities with information on how their patient population is faring in terms pressure ulcer prevention (along with other gauges of quality of care). The data are derived from the minimum data set (MDS), which HCFA requires every long-term care facility to file quarterly for a predetermined number of patients. The MDS is not itself a measure of quality but a collection of patient care information, such as the incidence and prevalence of pressure ulcers, Jewell explains. MDS questions are standardized across the country. From such data, researchers are hoping to create quality indicators from which long-term care facilities can improve patient outcomes.
In another project being conducted at the University of Wisconsin in Madison, a national nursing home chain is providing raw data on patient care in exchange for cohesive reports on quality of care.
"Nursing homes traditionally have not had data to see what’s going on such as Do we have a pattern of who’s getting ulcers, what floors are they on, and do they occur more often during certain times of the year?’" Jewell says. "They haven’t been medically focused. Getting this type of information gives them something they can use to follow their progress over time."
But if pressure ulcer prevention is, at best, an inexact science, what course should health care providers choose? To Colburn, the most direct answers can be found in the Agency for Health Care Policy and Research (AHCPR) clinical guideline, Pressure Ulcers in Adults, Prediction and Prevention.3 The publication is a frequent reference for wound care providers, and for good reason, Colburn says. She calls the development of the guideline the "greatest advance in pressure ulcer prevention," but cautions, however, that "many of the [AHCPR] recommendations are reflective of minimally conclusive research. "Where the data is inconclusive or lacking, the recommendations often reflect the opinion of an expert multidisciplinary panel."
Despite the gaps in knowledge about consistently identifying at-risk patients and the true benefits of specific preventive measures, leaders in the wound care field still recommend routine application of common-sense preventive measures. They specifically invoke their colleagues to begin following or continue to follow the AHCPR guideline. The evidence, while certainly not overwhelming, strongly suggests that the practices outlined by the AHCPR are effective in many cases. (For a summary of the guideline, see p. 113.)
It is almost certain that, under the pressures of managed care and the current outcomes-oriented environment, serious study into the costs and benefits of pressure ulcer prevention practices will expand. From the information gleaned will result more conclusive evidence than is currently available, Colburn says.
"Wound care clinicians would know which interventions and programs produce the desired outcomes, and the cost could be built into the systems and budgets. Precious resources including dollars would not be spent on ineffective or prohibitively high-cost activities and products that produce negative or questionable results. Health care providers could make comparisons between interventions leading to informed decisions and programs that are clinically and economically effective."