Fiscal tension driving pressure management reforms

Pressure ulcers are a prevalent and costly yet preventable complication that impacts 2.5 million patients annually in the U.S., according to the Agency for Healthcare Research and Quality (AHRQ). The condition contributes $9.1$11.6 billion per year to U.S. healthcare costs and Medicare estimates that each pressure ulcer adds $43,180 in costs to a patient's hospital stay.1 Recognizing the care and cost implications of stage III and IV pressure ulcers, the Centers for Medicare & Medicaid Services (CMS) has ceased reimbursing healthcare facilities for the condition if it was not present at the time of patient admission.

In today's environment of healthcare reform, where hospitals and health systems are increasingly reimbursed based on the quality of patient care, there is growing demand for products to improve pressure management and reduce the incidence of pressure ulcers. In this article, Healthcare Purchasing News offers expert advice on pressure management and presents some of the latest innovations in this treatment area.

Factors that contribute to pressure ulcers

Pressure management can be an uphill battle for caregivers because there is a broad range of factors that contribute to pressure ulcer formation, including patient conditions, as well as facility staffing and workflow issues.

Patient factors

According to Sarah Cram, PT, DPT, Valley Regional Hospital in Claremont, N.H., attributes and conditions that place a patient at greater risk for a pressure ulcer include:

* Being more than seventy years of age

* Poor nutritional status

* Prolonged periods of immobilization

* Incontinence

* Uncontrolled diabetes

* Circulatory problems

* Fractures

* Dementia

* Spinal cord injury

Catherine Thomas, Senior Marketing Manager, Patient & Resident Safety Solutions, STANLEY Healthcare, adds thinning skin due to advanced age, weight loss and dehydration as additional conditions that increase risk, emphasizing the importance of patient repositioning to avoid stress on the skin while minimizing pressure on vulnerable areas.

Rochelle Froloff, RN, Nurse Consultant from Action Products Inc., adds that shear, heat and humidity are other contributing factors, noting how most facilities focus on mitigating pressure but overlook the need to keep skin cool and dry.

Urinary or fecal incontinence is also a primary contributor to pressure ulcer formation, notes Leighann McDonald, RN, BSN, CWON, Clinical Director, LINET Americas Inc. She points out that while incontinence-associated dermatitis (IAD) differs from that of a pressure ulcer, these conditions often coexist.

"Persons with fecal incontinence are 22 times more likely to develop a pressure ulcer," said McDonald. "Poor nutrition, reduced blood flow due to circulatory disease, loss of sensation in extremities from diabetes and other diseases, cognitive impairment, restraints, medications, dehydration and old age can also be significant factors."

Facility factors

In addition to a patient's physical characteristics and ailments, the environment in which they are treated can also increase their risk for pressure ulcer formation. Because pressure management requires an extremely high level of vigilance, studies have shown that healthcare facilities with nursing shortages tend to have higher pressure ulcer rates.

A study conducted by AHRQ and the National Science Foundation on the correlation between licensed nurse (RNs and LPNs) staffing levels and adverse outcomes among medical and surgical patients in Pennsylvania acute-care hospitals found a lower incidence of adverse events in those facilities with more licensed nurses. For example, there was a 2 percent lower incidence of pressure ulcers in those facilities with a 10 percent higher proportion of licensed nurses.2

"In our conversations with wound care experts across the healthcare industry, STANLEY Healthcare has heard many times that turn management compliance is a serious challenge," said Thomas. "In many instances, staff are simply too busy to consistently adhere to a turn schedule for each patient or resident, may be distracted by emergencies in other areas of the unit, or may either intentionally or unintentionally document a turn that was not actually completed."

Froloff concurs that nursing shortages negatively impact turn management and other key interventions aimed at reducing the risk for pressure ulcer formation. She points out how cuts in nursing staff can result in higher costs for the facility in the long term, stating: "Often there is too large of a patient load for the nurses or primary care network (PCN), so guidelines of turning the patient are minimized. For the facility, infections from open wounds acquired in a hospital are not being reimbursed. This lack of reimbursement has a huge effect on the bottom line."

Complications from poor pressure management

Thomas notes that pressure ulcers cause a wide range of complications for patients, both physical and emotional. These include pain, redness, infections of the skin and bone, social withdrawal and emotional distress.

"Pressure ulcers can prevent full recovery from treatment for other conditions, increase the length of hospital stays, and result in ongoing treatments," said Thomas. "In skilled nursing facilities, an average of 16.7 percent of patients develops pressure ulcers during their stay."3

According to the Mayo Clinic, common complications from pressure ulcers include4:

* Sepsis: Sepsis occurs when bacteria enter the bloodstream through broken skin and spread throughout the body. It is a rapidly progressing, life-threatening condition that can cause organ failure.

* Cellulitis: Cellulitis is an infection of the skin and connected soft tissues. It can cause severe pain, redness and swelling. People with nerve damage often do not feel pain with this condition. Cellulitis can lead to life-threatening complications.

* Bone and joint infections: An infection from a pressure sore can burrow into joints and bones. Joint infections (septic arthritis) can damage cartilage and tissue. Bone infections (osteomyelitis) may reduce the function of joints and limbs. Such infections can lead to life-threatening complications.

Cancer: Another complication is the development of a type of squamous cell carcinoma that develops in chronic, nonhealing wounds (Marjolin ulcer). This type of cancer is aggressive and usually requires surgery.

"Pressure ulcers are painful to the patient and can be very upsetting to the patient's family and caregivers," adds McDonald. "If a pressure ulcer occurs, it can take a week to months to heal depending on the severity, thus extending the length of stay of the patient. In some severe cases, septicemia can result which is a life threatening condition. Patients can develop osteomyelitis, which leads to long term and costly intravenous antibiotic therapy. Stage III or Stage IV pressure ulcers may require surgical debridement or muscle flap grafts to help close the wound. Furthermore, once a severe pressure ulcer heals, there is still potential for recurrence at the wound's site due to decreased tensile strength of the tissue."

Froloff points out that complications from poor pressure management programs are seen in the unrelenting infection rates throughout the healthcare system, stating that, "patients will leave the hospital without realizing an ulcer has formed, only to later be readmitted for costly treatments. The prolonged healing process is painful and expensive, and for the most part could be preventable with adequate nursing care and devices."

Processes and products to reduce the risk of pressure ulcers

Because there are many contributing factors to pressure ulcer formation, nursing staff and other caregivers are challenged with continuously monitoring patients for the various signs and symptoms of the condition, and rapidly intervening when they believe someone is at risk.

Froloff offers the following tips to help healthcare facilities in their efforts to minimize pressure ulcers:

* Institutions should re-evaluate their staffing parameters to ensure that there is adequate personnel to care for patients on the different units.

* Skin assessments should be done frequently to catch ulcers before they progress.

* Product selection to prevent decubitus ulcers should be tested and validated. Pressure management protocols need to meet all factors that contribute to pressure ulcers (pressure, shear, heat and humidity) in order to be effective.

Action Products offers a variety of pads and positioners to provide maximum pressure distribution and shear qualities to support pressure ulcer management and safety protocols. Constructed from the company's Akton viscoelastic polymer, these products include operating room replacement table pads, overlays, positioners for the head, arms, legs, chest and heels, along with a large selection of padding for specialty frames.

The company also offers white papers and other resources to help healthcare facilities achieve "zero tolerance" of pressure ulcer formation. One such resource is a free CE course entitled, "Basic Principles of Patient Positioning." It can be found on the Action Products website: http://www.actionproducts.com/ resources/continuing-education.html.

Turn management

Because pressure ulcer prevention requires nursing staff to be vigilant for risk factors and proactive in measures to inhibit ulcers from forming, medical product suppliers have developed technologies to aid them in these efforts. Studies have shown frequent manual repositioning of patients at risk for pressure ulcers can significantly reduce incidence of the condition, with the National Pressure Ulcer Advisory Panel (NPUAP) recommending bed-bound persons are repositioned at least every two hours and chair-bound persons every hour, consistent with overall goals of care.5

To address this issue, STANLEY Healthcare launched its Patient Safety Monitoring solution (PSM), the company's newest in proactive and dignified monitoring of a facility's patients or long-term residents. Caregivers are empowered to reliably and discretely monitor individuals at a risk of developing pressure ulcers by tracking and reporting on turn management practices. PSM contributes to a better quality of life with non-invasive and touchless monitoring, while improving safety and clinical outcomes through continuous capturing and reporting of: position changes, bed exit/ entry, sleep patterns, and vital sign trends.

Caregiver safety

According to McDonald, one challenge in the manual repositioning of patients is that it poses a risk of occupational injury for the caregiver. The Occupational Safety & Health Administration (OSHA) website notes that musculoskeletal disorders (MSDs) are a major source of injury to healthcare workers, with nursing aides, orderlies, and attendants having the highest rates of MSDs. In 2010, there were more than 27,020 cases of MSDs among healthcare workers, which equates to an incidence rate of 249 per 10,000 workers, more than seven times the average for all industries.6

To minimize the risk for injuries among healthcare workers as they manually reposition patients, LINET offers the Multicare LE acuity-adaptable Med-Surg bed and the Multicare Critical Care bed, both of which are equipped with the company's unique Lateral Tilt functionality. Lateral Tilt significantly reduces the mechanical load on tissue and vastly improves the task of repositioning a patient. Turning a patient with Lateral Tilt lessons the stress to the caregiver and patient with a controlled, gentle rotation. The ease of positioning promotes dignity for the patient with quicker cleanups for incontinence and also ensures Q2 turn schedule compliance by reducing the number of caregivers required to tum a patient. The outcome is improved skin care and reduction in mechanical load, which ultimately results in helping reduce pressure ulcer incidence.

In addition, LINET's support surface portfolio features a diverse range of pressure redistribution surfaces, including surfaces that are integrated with microclimate management. Microclimate management therapy provides a flow of air within a support surface to help wick away heat and moisture from a patient's skin, keeping them cool and dry which in turn helps maintain skin integrity and reduce IAD through decreased maceration. Optimal immersion, envelopment and microclimate management increase patient comfort and aid in the prevention and treatment of pressure ulcers through the management of tissue loads while also controlling the heat and humidity (microclimate) of a patient's skin. HPN

References

1. http://www.ahrq.gov/professionals/systems/long-term-care/ resources/pressure-ulcers/pressureulcertoolkit/putooll.html

2. http://www.ahrq.gov/research/findings/factsheets/services/ nursestaffing/index.html

3. Wulffson, Robin. "New UCLA study reports bedsores can be fatal." http://www.examiner.com/article/new-ucla-study-reportsbedsores-can-be-fatal

4. http://www. mayoclinic.org/diseases-conditions/bedsores/basics/ complications/CON-20030848

5. http://www.npuap.org/resources/educational-and-clinicalresources/pressure-ulcer-prevention-points/

6. https://www.osha.gov/SLTC/healthcarefacilities/safepatienthandling.html