Nearly one in ten Missouri nursing home residents develop pressure ulcers. The cost of treating pressure ulcers is great, let alone the pain of suffering endured by the residents. Throughout this year we have presented you with practical tips on reducing the prevalence of pressure ulcers. By focusing on changing residents’ positions, redistribution of pressure, hydration, nutrition, communication, and other factors, these PUP tips shared useful steps as well as resources and tools that could be implemented in your home.
As the year ends, let’s look back at some of our key action steps that can lead to a pressure ulcer-free home.
Reposition bed-bound persons at least every 2 hours, chair-bound persons every hour.
Avoid pulling the resident across a surface and use a lift sheet and extra assistance to perform a safe turning or transfer.
Maintain the head of the bed at or below 30 degrees or at the lowest degree of elevation consistent with the resident’s medical conditions such as feeding and respiratory tubes.
Monitor and document skin changes before and after showers by using a skin monitoring tool.
Ensure verbal and written communication is in place for all staff to be aware of pressure reduction strategies for all persons. Use the repositioning reminder posters available through www.primaris.org.
Find out from staff their preferred schedule and make assignments based on care needs and personal relationships with residents.
Determine resident’s food preferences and incorporate into resident’s meals. Note preferences on care plan.
Provide fresh water or resident’s choice of beverage at frequent times during the day. Assist residents requiring assistance.
Conduct an in-service highlighting the importance of tracking pressure ulcers. Discuss current methods and revise if necessary. To obtain a tracking poster with stickers, please email sejaz@primaris.org or call 1.800.735.6776 ext. 187
Construct a team to analyze potential opportunities for improvement by utilizing Root Cause Analysis. Review your current processes to assess each resident and identify gaps where the process failed.
Remember that YOU are responsible for the health of a resident’s skin!
Every action you take can directly affect their quality of life!
Have you ever taken care of a fussy puppy? Just by looking at it, you can tell it’s uncomfortable but figuring out the reasons why can be difficult. He could be hungry, thirsty, or sleepy. He could be cold, hot, or wet. Without investigating the cause, helping the puppy is challenging. Rounding up all the reasons for its behavior can help you understand which steps to take to relieve its discomfort and prevent it from happening again.
Similarly, the National Pressure Ulcer Advisory Panel strongly encourages nursing homes to implement an educational program for the prevention of pressure ulcers that focuses on the origin and definition of the most common causal factors associated with ulcers. Understanding the root cause of these factors can help in determining ways to heal and prevent. This is why understanding factors such as pressure, shear, friction, and moisture is essential in improving the quality of life for your residents.
Pressure is defined as the amount of force exerted on a given area. Excessive external pressure causes the vessels in residents to compress and cause ischemia. By restricting blood flow and oxygen to a particular area on the body, pressure can be damaging by causing cell and tissue death. A common practice to prevent pressure is to teach residents to reposition themselves every 15 minutes.
Shear is any force that is parallel, rather than perpendicular, to an area that causes the tearing and stretching of blood vessels in the resident’s deep tissue. Dragging or sliding residents across a surface such as sheets can cause shearing. Shearing can decrease the time in which tissue is damaged and may even cause triangular-shaped sacral ulcers with tunneling or deep sinus tracts. One way to prevent shearing is to avoid massages over bony/reddened areas.
Friction can be classified as the occurrence of two surfaces moving across one another which can cause wounds that resemble an abrasion. Pulling a patient across a bed linen may rub away the protective outer layer of skin. This mechanical erosion of surface tissue increases the potential for deep tissue damage. The effects of friction can be prevented. For example, it can be reduced during baths by minimizing excessive scrubbing of the skin.
Moisture on the skin is five times more likely to cause pressure ulcers than dry skin. Constant exposure to wetness can macerate the skin by softening the connective tissue and eroding the skin causing tissue sloughs. Moisture can be a result of perspiration, wound drainage, extended soaking during baths, and fecal/urinary incontinence. To prevent ulcers caused by moisture, have residents avoid long baths with extreme temperatures.
Information obtained from: Makelbusrt, J. Siegreen, M., Pressure Ulcers, Guidelines for Prevention and Management. Springhouse: 3rd edition, 2001
There are numerous factors that can influence the health of a resident’s skin. We are responsible for understanding, nurturing, and protecting it. For more information, and practical tools, visit www.nhqualitycampaign.org, www.moaha.org and www.mohealthcare.com.
Action Steps:
To Address Pressure • Turn and reposition resident at least every two hours or more frequently depending on the resident’s tissue tolerance. If he/she is in a chair, repositioning should be every hour. Also, utilize a 30 degree lateral position instead of directly lying on the side by using pillows and foam positioning devices. Remind staff of repositioning residents through the use of Primaris’ repositioning reminder poster found at www.primaris.org.
To Address Shear • Maintain the head of the bed at or below 30 degrees or at the lowest degree of elevation consistent with the resident’s medical conditions such as feeding and respiratory tubes.
To Address Friction • Remember to avoid pulling the resident across a surface such as a bed and utilize a lift sheet and extra assistance to perform a safe turning or transfer.
To Address Moisture • Monitor and document skin changes before and after showers by using a skin monitoring tool. Remember to gently
Have you ever seen a puppy that is not eating? Can you tell by just looking at him? Probably not! Think about times when you haven’t felt like eating. Maybe you were sick or the weather was too hot. You might have even been bored, lonely, or sad. The same situations affect our residents, but often we do not recognize them or their impact on nutritional status.
Poor nutrition can compromise the ability to heal in many ways, which includes contributing to skin failure. Most homes initiate referrals to dieticians and speech therapists when a resident is targeted for nutritional concerns due to weight loss, inadequate amounts of eating, or abnormal lab values. Along with encouraging residents to eat more, a supplement or food protein additive is usually provided. However, it should not end there! Staff, including CNAs, should consider other factors that impact the desire to eat:
Depression. Use a standardized depression assessment tool to evaluate this possibility and cause.
Prescription medications. Some are known to decrease appetite (such as digoxin, prozac, antacids, etc), others cause drowsiness/dry mouths/“bad” taste. Consider reducing or changing the timing so that meals aren’t impacted. Apply interventions to ensure mouth is moistened and clean before the meal.
Environment. Is the dining area too warm or cold for that particular resident? Changing the seating area, providing a sweater, or placing a small heater or fan close to the resident can help.
Loneliness. Remember that eating is a social event! Relationships are very important and have even been identified as central to the culture change movement. Consider allowing the CNA to eat or drink along with the resident.
Feeding Assistants. Research indicates that having someone available in the dining room encouraging eating can prevent many cases of weight loss and failure to eat.
Meal Sizes. Often the elderly are not able to eat as much during one meal as they used to. Consider offering smaller portions more frequently, finger foods in-between meals, and eating the protein portion of their meal first.
Supplements. Do not put supplements on the table or tray during the meal. Encourage eating the meal first and then the supplement can be offered after.
The Clinical Practice Guideline, “Unintentional weight loss in the elderly” University of Texas, School of Nursing: 2006 May. 21p. Available at: http://www.guideline.gov.
Ensure all staff assigned to the resident (including CNAs, med-techs and staff nurses) are included in care planning for residents.
Conduct daily 2 minute standup-discussions lead by charge nurses for each shift/unit on nutrition. Suggestions for topics include how protein works in the body, the importance of giving mouth care or lubricating the mouth before the meal, how exercise increases appetite, how proper positioning and socialization affect appetite, etc.
Supervisors should observe a few meals each week, noting whether staff is engaged in the types of care associated with increased intake. Use a standardized protocol, available from the UCLA Borun Center for Gerontological Research website at http://borun.medsch.ucla.edu/modules/Weight_loss_prevention/wlformsQImeals.pdf, for conducting these observations.
Who doesn’t fall for the leader of the pack? Successful. Committed. Determined. We all strive to become leaders of the pack in the prevention of pressure ulcers!
The first step to preventing future pressure ulcers is to monitor your current rates so that you have adequate knowledge of where your nursing home stands at any given time of the year. Utilizing a tracking tool will help acknowledge your successes and highlight opportunities for improvement. Identifying the number and source of pressure ulcers in a home will help in setting goals to achieve a pressure ulcer-free home.
By maintaining a weekly tracking system, your home will be able to see patterns from week to week and will also allow you to focus in on particular weeks where there was a significant spike or drop. One unique way to track ulcers is by using Primaris’ pressure ulcer prevention (PUP) tracking poster with stickers. This poster allows you to track the number of pressure ulcers while also visually indicating an increase or decrease from week to week through the use of paw print stickers. It also provides a separate tracking space for ulcers acquired outside your home, making sure that the proper source is clearly indicated.
It’s also important to determine the reason behind the change in pressure ulcers. To do this, you can use a Root Cause Analysis (RCA). An RCA is a structured investigation utilizing a team that aims to identify the source of a problem and then develops appropriate action steps necessary to eliminate it.
Excel tracking tool that automatically calculates pressure ulcer rates and average yield to date figures while providing a graphical representation to see change over time
Action Steps:
Implement a weekly tracking system to monitor the rate of pressure ulcers in your community.
Create excitement by recognizing individuals who accurately keep track of pressure ulcers and attain success in prevention.
Construct a team to analyze potential opportunities for improvement by utilizing Root Cause Analysis.
Conduct an in-service highlighting the importance of tracking pressure ulcers. Discuss current methods and revise if necessary
Is your tongue hanging out? Do you find yourself panting? We can tell a puppy is thirsty by looking at him panting—but we can’t tell by just looking at residents. Proper hydration is important in preventing and treating pressure ulcers. In order to make sure our blood carries vital oxygen and nutrients to our cells, there has to be enough fluids in the body. Proper hydration is usually 64 ounces of fluids daily, or half of a person’ body weight in ounces (unless the person is on a fluid-restricted diet).
To prevent issues with hydration, some homes have developed a color coded system for their resident’s pitchers and glasses that indicate special fluid needs, such as thickened fluids or fluid restricted diets. Others have initiated a hydration cart that offers a variety of fluids from water and juice to hot chocolate and coffee. Remember that any fluid is better than no fluid, so offering an assortment of choices may help increase hydration and prevent pressure ulcers.
Acknowledge and adhere to a resident’s fluid temperature preferences. Care plan resident’s preferences and make sure that CNAs have access to the care plan.
Provide fresh, new water on a regular basis.
Reassure residents that toileting assistance will be provided as often as necessary.
Check to make sure resident can reach and lift a nearby pitcher of fluid.
Consider implementing a hydration cart that consists of a variety of fluids.
Ask resident if they want water at least twice per shift.
Offer fluid to every resident who is scheduled to be turned.
Okay, pay attention. Focus on how many times you move your body while reading this document. Think of how many times you move around during a meeting or while sitting through a movie. Now imagine what it would feel like if you could not move. Can you feel the discomfort and pressure?
Relieving pressure for the people we provide care to is the most important thing that we can do to prevent pressure ulcers. This is not always dependent on expensive equipment. A lot can be done with pillows! Here are some key points in relieving pressure:
Reposition bed-bound persons at least every 2 hours, chair-bound persons every hour
Teach chair-bound persons to shift weight every 15 minutes
Use a written repositioning schedule
Use pressure-reducing mattress or chair cushion
Use pillows or wedges to keep knees and ankles from direct contact with each other
Use a pillow under the calf to relieve pressure on the heel
Elevate the head of the bed as little (max 30 degree angle) and for as short a time as possible
These key points will help in the prevention of pressure ulcers in all care settings. It is important that all prevention strategies are shared with staff by making this a topic for your in-services. Additionally, it is beneficial that residents and their family members are aware of the prevention strategies your home uses.
Has this happened to you? Mr. Jones is admitted to your facility following hip surgery and you see a reddened boggy patch of skin on his opposite hip? Or you’re readmitting a resident following a hospital stay for an acute condition and you find a Stage 3 pressure sore on his heel. It’s not surprising: 17-35% of residents have ulcers when admitted to nursing homes with many being transferred from hospitals.
Some hospitals and nursing homes significantly decreased pressure ulcers by effectively sharing information at transfer through transfer forms. Examples are contained in a toolkit you can find on the Missouri Hospital Association website, entitled Continuity of Care Transfer Project. These forms also help you improve MDS accuracy and decrease its completion time, develop care plans, and support the need for skilled care.
Both hospital and LTC forms in the toolkit contain information needed by physicians and care givers to identify both, residents with pressure ulcers and those who have a high risk for developing pressure ulcers. It also includes information for developing individual care plans and taking preventive measures. The forms help you share vital information such as the resident’s mental status, mobility, physical impairments, other disabilities, infections, nutrition, and elimination. Most importantly the forms identify non-intact skin areas and the current treatment. Without this information, the facility receiving the resident can fail to provide the correct number and intensity of preventive measures or treatment and sometimes may even fail to identify persons at risk.
Consistent assignment of caregivers in nursing homes can help prevent pressure ulcers. Inspecting a resident’s skin regularly and noticing if changes are occurring is vital in making sure the skin is intact and stopping pressure ulcers from developing. Noticing changes in a resident’s skin is much easier when the caregiver is very familiar with the resident and this is easiest when homes use consistent assignment.
Consistent assignment means that residents see the same caregivers (nurses, med techs, and nursing assistants) at least 85% of the time. Caregivers who are consistently assigned are much more likely to notice even the slight changes in a resident’s health. This can prevent larger health problems, such as skin breakdown and pressure sores. When employees are given rotating assignments, it is difficult to build relationships with the residents or their coworkers. Consistent assignment also benefits residents who feel more comfortable when the same people help them with intimate aspects of care such as assessing their skin. It also benefits your home with less call outs and turnover and more satisfied staff.
Consistent assignment is not just a good thing; it’s possible! To learn how, first go to page 2 of "Change Ideas for Consistent Assignment" for a process to easily change from rotating to consistent assignments.
Learn more about how to implement consistent assignment by attending the “On the Road to Culture Change Conference”, June 17-18 in St. Louis. For more information visit www.MissouriMC5.com or www.moaha.org
Target one group of residents for consistent assignment.
Establish a team that will regularly work together to care for these residents.
Find out from staff their preferred schedule and make assignments based on care needs and personal relationships with residents.
Ask team to work with each other to provide back-ups and substitutes for when they need to change their schedule or call in.
Dig in and get started with consistent assignment today!
Accurately coding the MDS is important. It affects you and the facility in many ways:
Most importantly, it helps you develop individualized care plans for residents.
The data feeds the QI/QM report, your best tool to see how your home is performing and to identify areas for improvement.
It drives your Medicare Part A reimbursement.
This data is reviewed by surveyors prior to coming onsite.
And finally, it feeds the nursing home compare web site and your 5 star rating both of which are available to the public and are used much more by families prior to nursing home selection.
Let’s take a closer look. A review of recent MDS data shows almost 2,000 residents in Missouri with a pressure ulcer. Of these, over 300 were low-risk—it should be unusual for them to develop a pressure ulcer. In all likelihood many of these 300 residents were high risk but just not coded properly. A review of these residents likely would find that they were malnourished and/or had poor transferring and bed mobility—all MDS indicators of high risk.
What does that mean to you? Because they were not correctly coded:
they were not identified as high risk which would have triggered care plans and interventions to prevent pressure ulcers,
your surveyors will be more closely scrutinizing your home, and
the public who views your 5 star rating will think your care is poor because people at low risk are getting pressure ulcers.
There are many resources to assist you with MDS coding. The state assigns one person to this, Joan Brundick, RAI coordinator. Contact her at 573-751-6308 or Joan.Brundick@dhss.mo.gov (information current as of April 2009). You may also contact the QIPMO program: (573) 882-0241 or www.nursinghomehelp.org. They also sponsor MDS support groups which meet regularly in various regions of the state.
Pressure Ulcers (F314) continue to be frequently cited in Missouri.
Over the years, Section for Long Term Care Regulation (SLCR) has cited many things that could possibly go wrong with pressure ulcer care: from basic turning and repositioning to life threatening lack of treatment (scope and severity level Immediate Jeopardy: IJ). Many times F314 is cited at D or G levels. D level includes lack of prevention or a missed treatment with no harm. G level examples are lack of identification and treatment resulting in actual harm.
Surveyors say that many F314 citations result from a failure to do basic prevention: lack of nursing risk assessment and consistent prevention such as keeping skin clean and dry and using pressure relief devices in beds and/or chairs. SLCR staff frequently observes the use of heel boots or pillows, but often the heels are pressed into the mattress or pillow. The pillow needs to be placed above the heel, keeping the heel afloat to avoid pressure.
Surveyors often see that front line staff do not identify and report skin breakdown to charge nurses/DON/physician for proper treatment even when these systems are in place in the home. Often this is related to a high turnover in nursing, especially DON’s and direct care staff. As direct care staff come and goes, unless someone keeps up with the training of new staff, systems fall apart. Survey staff stresses the importance of timely assessments on initial admission and on return from the hospital. If a prompt nursing assessment occurs, the facility can document tissue damage that is present on admission.
Preventing skin breakdown is not as costly as treating a pressure ulcer. Medications, dressing changes, and nursing time are expensive, not to mention the pain and loss of dignity for your residents. Facilities with effective pressure ulcer prevention (PUP) programs in place will reap the benefits of better care and life for residents and fewer citations.
Share this information with all your nursing staff—licensed and direct care.
Make sure your staff knows how to properly assess residents for risk using the Braden or Norton. Use this tool at every admission, change in status and post-hospitalization.
Train, train and retrain all your staff to be on prevention, to be on the lookout for skin breakdown and to report this to nursing.
Involve direct care workers and staff from different backgrounds in identifying and solving the problem. Consider forming a multi-disciplinary prevention team.
Remember, as staff come and go, involve the new staff in reviewing systems and continued work on the problem.
Catching the early signs of a pressure ulcer can help you take action that will prevent them from forming. Training all your staff to be alert to these signs and to report them quickly is a pivotal step in this process.
CNA staff are your front line defense against pressure ulcer formation. Praise and reward them when they report any changes to the person’s skin such as bruising, tears, rashes, swelling, excessive dryness or abnormal temperature.
Bath time is a perfect opportunity for staff to evaluate a resident’s skin. Conduct short training sessions that will provide them with the information they need. Require them to use the Comprehensive CNA Shower Review form on every resident. This form could be laminated and placed in the shower area as a reminder. Other opportunities for skin monitoring occur every time a resident is assisted with any ADL.
Make pressure ulcer prevention fun. Drive competition in the facility by tracking the number of reports received by CNA. By empowering your CNAs to report changes in the residents’ skin, you will decrease pressure ulcer formation, enhance quality of resident care and value the work of the CNAs. Further information about pressure ulcer reduction is available on www.primaris.org, www.nhqualitycampaign.org, www.moaha.org, and www.mohealthcare.com.
Action Steps:
Share this with your nursing staff and ask how skin monitoring is done in your facility.
Talk directly with your CNAs to find if it is easy for them to report changes in their residents’ skin.
Use the CNA shower card or develop something for your facility.
If you are not signed up for the Advancing Excellence Campaign, go to www.nhqualitycampaign.org to join or to update your goals if you are a member.
Pressure ulcers hurt everyone. Nearly one in 10 Missouri nursing homes residents develop a pressure ulcer which causes much pain and suffering. For nursing homes, the extra staff hours and medical supplies come at a time when money could be spent in other areas.
This campaign is part of the National Advancing Excellence in America’s Nursing Homes. If you are not a participant in Advancing Excellence go to www.nhqualitycampaign.org to join. If you are a participant please review and update your goals. MoLANE (Local Area Network for Excellence) is the state coalition for advancing excellence. Over the next year our goal is to reduce pressure ulcer suffering and waste of resources. We will share practical tips that will allow you to prevent and treat pressure ulcers through the Pressure Ulcer Prevention (PUP) campaign.
Whenever you see this puppy logo or the word PUP, look for tips from the Missouri LANE.
Most crucial to pressure ulcer prevention is the consistent use of standardized risk assessment tool such as the Braden or Norton. The Braden tool is available at www.bradenscale.com or a shortened version at www.primaris.org/professionals/products.asp under the pressure ulcer topic. Because new pressure ulcers are more common in the first two weeks of admission, it is recommended that the assessment be conducted on every new resident or readmission within at least 24 hours of admission and quarterly thereafter unless there is a change in condition. To supplement the information gained on the Braden, we strongly suggest a visual inspection of the resident’s skin as well as determining their risk for dehydration and skin tears. Forms for these assessments are also available on www.primaris.org.
Using these tools will help your organization decide who needs prevention interventions, allowing you to use your resources for where they are most needed. Further information about pressure ulcer reduction is available on www.primaris.org, www.nhqualitycampaign.org, www.moaha.org, and www.mohealthcare.com.
Action Steps:
Share with information with your nursing staff.
Find out how many of your residents have pressure ulcers or are at risk.
Review your current processes to assess each resident and identify gaps where your process failed.
Be sure to include visual inspection in the process.
January 2009
January 16, 2010
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Primaris Pressure Ulcer Tips of the Month
