CMS’s New Guidance for Pressure Ulcers: What It Means

How do you see these changes in the guidance affecting long-term care in general?
Dr. Lyder: The new guidance is much more comprehensive versus the one in place prior to November 12, 2004. In many ways, the document gives surveyors more direction. I think it is much clearer as to what surveyors will be looking for in nursing homes. I think there will be a lot less “wiggle room,” so to speak-fewer gray areas. We’ve tried to make the interpretive guidance much more prescriptive. It also addresses some new areas: For example, it now addresses residents receiving palliative care and what the expectations should be related to their skin care. We tried to use as much up-to-date information as possible. I feel it is a much better working document than the previous guidance.

What was changed that is going to make this new guidance so much better?
Dr. Lyder: I think that the reemphasis we have now placed on prevention is very important-the whole idea of preventing ulcers and identifying residents who are at risk. We wanted to make sure that the surveyors understood some of the main concepts around skin care and pressure ulcer prevention and treatment. The first section focuses on definitions-making sure that the surveyors understand, for example, when a report says “tunneling,” they know exactly what that means. We want everyone to be on the same page with terminology and make sure that everyone is using the terms correctly.

Another big thing is to delineate between the different kinds of ulcers. Quite often, you will see a nursing home mislabel a venous stasis as a pressure ulcer, for example. I think that it is fair to say that in working toward prevention, we spent a lot of time working on accurate assessment as a key. We wanted to make sure that people could identify those factors that may place a specific resident at risk, and to understand that even though there are many nursing homes that use risk-assessment tools, that those tools are limited. Using a risk-assessment tool is great, but users still have to consider other factors that may not be captured in the tool that could place a resident at risk. These factors include history of a previous ulcer and comorbid conditions such as diabetes and coronary artery disease, to name a few.

There are also definitions listed that are not pressure related.
Dr. Lyder: Right. I can’t tell you off the top of my head what the percentage is, but from our observations and based on what the surveyors on our panel said, many times nursing home staff are mislabeling wounds as pressure ulcers. The more educated they are across the board, the better the resident outcomes are going to be.

What are some highlights of the prevention section of the new guidance?
Dr. Lyder: We call special attention to the importance of nutrition and identifying residents who are undernourished, as well as the effects of moisture. These are key risk factors.

We also address advanced directives, which I believe is new to this guidance. We make it a point to specify that just because there is an advanced directive in place, it doesn’t mean that you don’t provide care. We often hear from nursing homes something like the following: “The resident was in the dying process, therefore his ulcer was unavoidable.” And that isn’t right-“palliative care” does not equal “no care.”

What about the treatment section?
Dr. Lyder: Again, we are stressing that you know what type of ulcer you are treating-pressure versus nonpressure, etc. There is quite a bit on staging, but staging only tells you the initial insult. We do also identify much more clearly than in the past what the minimal expectations are for describing the ulcer, i.e., the wound bed, slough or no slough, exudate amount, etc. We now provide clear guidance on monitoring so they are able to describe the ulcer, as well as clarifying some of the characteristics we are looking for in their descriptions.

One of the things that I personally wanted to clarify is that many nursing homes interpret “daily monitoring” to mean that they should be doing daily dressing changes. The new guidance clearly delineates what we meant by daily monitoring. It doesn’t mean that you necessarily remove the dressing, but you can look to see if the dressing is still intact; if there is any drainage; does the area around the dressing appear to be compromised. Some states had previously interpreted daily monitoring to mean, “Remove the dressing and take a look at the wound,” which is counterproductive to healing.

It strikes me that some nursing home staff members may initially think the new guidance is going to create more work for them but, in reality, it is educating them to make their jobs easier. Would you agree?
Dr. Lyder: Exactly. Making a clear definition of daily monitoring is an example of that-the difference between “monitoring” and “assessing.” Wound assessment means you are looking at the wound; wound monitoring means leaving the dressing intact.

In another new item, there is now specific language that says if no progress is made in the wound in a two- to four-week time frame, then the facility should reevaluate the resident and modify the plan of care as needed. That stated time frame is significant. We can’t say what you might need to do, because each individual case is different, but we can say that you should see progress within that time frame.

The other area that we spent a bit of time on was dressings. Moist wound healing is really the optimal way to go. Wet-to-dry dressing is really more for debridement. Many nursing homes still use wet-to-dry as their primary dressing, and we offer a caveat that it may be appropriate in limited circumstances. However, repeated use will slow down the healing process and cause pain.

There are also significant changes in scope and severity. Can you explain those changes?
Dr. Lyder: The big change with scope and severity is that the Level 1 citation-which was “no actual harm, with potential for minimal harm”-has been eliminated. So, for example, if you have a Stage I pressure ulcer, they have to cite you at Level 2.

Beyond that, we give the surveyors more guidance as to what would be appropriate Level 2, Level 3, and Level 4 citations, with more definitions and explanation. For example, we have now added something called Facility Failures. For instance, the failure to recognize or address the potential for developing a pressure ulcer, independent of an ulcer being there, can get you a Level 2 citation. The failure to implement a comprehensive care plan for a resident who has a pressure ulcer can get you a Level 3 citation. Development of an avoidable Stage IV ulcer can get you a Level 4 citation.

Do you forsee any potential problems with implementation of the new guidance?
Dr. Lyder: The reality is that any time you put out a new guidance, there will be some problems. However, I think that CMS did a great job of trying to engage the nursing home community to review the document and have them offer suggestions. Many items were brought up in the two public hearings that we had during the writing phase, and everything that the audience brought up in these meetings was discussed by the committee-pros and cons-and much of it was incorporated into the new document. I would like to think that if facilities aren’t pleased, that it is a small percentage of them, because many of the things we figured into the guidance were directly based on comments we heard from nursing homes throughout the country.

So, in some respects, this guidance was a preventive measure-taking feedback ahead of time as opposed to writing guidance without input and dealing with the complaints later.
Dr. Lyder: Absolutely. We wanted to know what the nursing homes think, and every single comment that was submitted to CMS was reviewed by our group; and after we incorporated these comments and suggestions, we sent the document out a second time to find out, “Did we get this right?” In my opinion, you have to have a workable, realistic document that hopefully is going to provide good care for residents, first and foremost, but also understanding of the fact that there are limitations because there are not an unlimited amount of resources. But you want to produce the best care based on the current environment, and to do that you do have to listen to what the providers and provider organizations had to say. And they had a lot to say on this particular tag.