Only You Can Prevent Pressure Ulcers

Few challenges encountered in long-term care are more daunting, and few conditions to which the elderly or immobile are vulnerable can do more to erode quality of life. They are costly, both in economic and in human terms-and in survey deficiencies and legal exposure. As the old saying goes, the best treatment lies in prevention.

Zinn: How did you, as a plastic surgeon, become interested in the prevention and treatment of pressure ulcers in the nursing home?

Dr. Olshansky: One area of emphasis in a plastic surgeon’s training is wound healing and surgery for wounds-particularly pressure ulcers. For many plastic surgeons this subject gets lost amidst the other aspects of training. In my case, it so happened that a friend who worked for the state got involved with an advocacy group that was working to improve care in nursing homes and asked me to serve on a committee.

Word got around that I was interested in pressure ulcer prevention and treatment, and soon nursing homes were calling me and asking me to see their residents and present staff in-services. Today, pressure ulcer treatment and prevention comprise a good part of my practice.

Zinn: Is surgery commonly used in the treatment of nursing home residents’ pressure ulcers?

Dr. Olshansky: Only rarely. These individuals are usually too sick and debilitated to tolerate surgery. It’s more common in younger residents who are in good overall health and who have had a spinal cord injury or suffer from multiple sclerosis or other diseases that compromise their mobility.

So when it comes to the management of pressure ulcers in the nursing home, the primary emphasis is on prevention, then wound care. When surgical debride-ment is appropriate, it is generally done at the bedside or in the physician’s office.

Zinn: It would seem that an ounce of pressure ulcer prevention is worth several hundred pounds of cure. What can you tell our readers about prevention that they might not have heard before?

Dr. Olshansky: To my knowledge, there has never been a study to prove conclusively whether pressure ulcers are totally preventable. My contention is that, with very few exceptions, they are. If you review the medical literature, for years and years everyone has said that the key factor in the development of pressure ulcers is the patient’s risk profile.

Studies have used measurement instruments such as the Braden scale to look at such variables as immobility, incontinence, nutrition, etc., that put people at high risk of developing pressure ulcers, but they haven’t concurrently measured quality of care. That raises the following question: Are nursing home residents getting pressure ulcers because they’re at high risk or because they’re not receiving adequate care? That question has not been scientifically answered to my satisfaction, but my experience tells me that the greatest variable as to whether a nursing home resident will develop a pressure ulcer is who is caring for that resident.

I think the position that pressure ulcers are primarily attributable to residents’ risk factors is indefensible, because the case mix does not vary widely from nursing home to nursing home, but the quality of caregiving does. We have no real choice about the case mix. We can’t say, “You’re too sick. Sorry.” If they’re sick, we take them.

Here’s a theoretical illustration: Let’s say we have 100 sets of identical twins, all terribly malnourished and with low scores on the Braden scale-individuals considered to be at highest risk. If we put half of the twins into a low-quality nursing home with no specialty beds and the other half into a topnotch facility with specialty beds, where bedridden residents are turned every two hours, common sense would tell us that the latter group would do better, even though both groups had the same Braden scale scores.

To those who say that a resident with poor scores on a Braden scale assessment is expected to get pressure ulcers, I would ask, why? We know how to prevent them: relieve pressure and make sure bedridden residents are moved frequently enough. If someone is identified as being at high risk, that’s all the more reason that he should not get pressure ulcers! In fact, my contention is that it is the lower-risk resident-someone who might be bedridden but is in fairly good general health and able to move about in bed-who suddenly becomes sicker, more dehydrated and slightly obtunded, who’s really at greater risk. That’s the type of person who will be fine one day and the next day will have a pressure ulcer without warning.

Zinn: In light of the impact of quality of care on pressure ulcer prevention, what can facilities do to make sure their caregivers don’t, in effect, become one more risk factor?

Dr. Olshansky: First, we need a core of staff who are knowledgeable about pressure ulcer prevention. This isn’t like cancer or heart disease; there’s nothing mysterious about it.

Quite simply, pressure ulcers are from pressure. And while a healthy resident can stay on his backside a little longer, one who is less healthy needs individualized pressure relief. With the latter resident, there isn’t as much leeway for mistakes as with the former.

So regular in-services on pressure ulcer prevention are essential to keeping staff knowledgeable. Studies have shown that the incidence of pressure ulcers declines immediately after pressure ulcer prevention in-services.

There also has to be a desire to make pressure ulcer prevention happen-in other words, accountability. If the owner of the nursing home conveys to the administrator that nothing but quality care will be tolerated and that pressure ulcers are unacceptable, and the administrator passes that on to the DON, and she in turn communicates it to the nursing supervisors, who then instruct the CNAs, then there is accountability. This creates a culture in which pressure ulcers simply aren’t acceptable.

Zinn: Some might say that sounds good in theory, but in the current reimbursement climate and with staffing shortages being such a problem in nursing homes today, how can that culture be attained and maintained?

Dr. Olshansky: Tight money is a reality, to be certain, but it’s not an excuse. If society won’t demand that insurance companies, Medicaid, Medicare and legislatures reimburse at reasonable rates so that we can hire better-quality staff, to some extent we’re going to “get what we pay for.” That’s why it’s so important that once nursing homes hire quality staff, they work hard to keep them.

Staff-retention programs can help. Caring for residents in nursing homes is a tough, and often thankless, job and CNAs bear the brunt of it. If a day goes by and a high-risk resident doesn’t develop a pressure ulcer, someone is doing something right, and we need to acknowledge that.

We need to develop an incentive program. It will not only bolster accountability, but it also will let the staff know that we appreciate how hard it is to succeed at what they do. It doesn’t hurt to tell them that we expect excellence, but when they work hard, an incentive program gives them a thank-you above what’s in their paychecks. As an example, perhaps the nursing home can purchase movie tickets for everyone on the floor if no pressure ulcers occur over a specified period, or gift certificates to a restaurant-something to show its appreciation for a difficult job well done.

Zinn: Has anyone developed a stand-ardized method of assessing caregiving as it pertains to pressure ulcer prevention?

Dr. Olshansky: In 1994, I presented the Pressure Ulcer Predictor Scale (PUPS) as a model to use in assessing the likelihood of pressure ulcer occurrence. [See figure.] This instrument shifts the focus from the resident’s risk level to the quality of care by the facility.

As far as I know, few papers approach pressure ulcer risk from the caregiving perspective. For years the emphasis has been on the high-risk resident, but the incidence of pressure ulcers hasn’t improved very much, despite the fact that we can identify who’s at high risk and that we have the knowledge and technology to prevent them.

I believe that if we were to place a hidden videocamera in every room, we’d find that of all residents who developed pressure ulcers, 99% weren’t adequately turned or relieved of pressure. We know that because of where the ulcers develop: on the sacrum, hips and heels.

Residents rarely get them on the chest or the anterior thighs or calves, for example. They are almost always on bony prominences. Even in a facility with little money and with staffing problems, if residents are regularly turned and if that is all that is done for them, there will be fewer pressure ulcers.

Zinn: When you present pressure ulcer prevention in-services, what else do you emphasize to the staff?

Dr. Olshansky: I talk about the importance of using specialty beds. They’re effective and I highly recommend them, even though they’re expensive.

In addition to the beds and other devices for relieving pressure, there’s another excellent invention: It’s called a chair. If we can get a resident out of bed and into a chair, we’ll relieve pressure on his sacrum, hips and heels.

Ischial pressure ulcers, which develop in patients with spinal cord injuries who sit too long, are seldom seen in the general nursing home population. That’s why I advocate that facilities should have a policy of getting every resident out of bed who can tolerate it, several times a day.

Zinn: At what point in a resident’s care should she be given access to a pressure-relief bed or mattress?

Dr. Olshansky: As soon as she needs one. The underlying issue is this: If you or I send a loved one to a nursing home, what is our expectation? I believe that if a facility is licensed by the state and if someone is paying for my loved one to be taken care of, it’s reasonable to expect that she’ll get good care and not develop pressure ulcers.

That starts with an ini-tial resident evaluation, to determine whether she needs a pressure-relief mattress or bed or other device now, or if she needs to be closely monitored in anticipation of that need. Is she up and walking? Can she perceive pain? Can she turn herself in bed? The important issue is that someone has to make a decision as to what is needed.

If someone is at high risk, we need to feed him, keep him dry and clean, provide physical therapy and turn him every two hours. We have to keep in mind-because schedules aren’t always adhered to perfectly-that for a high-risk resident we need a “hedge.” If we miss a beat, they’re prime targets for pressure ulcers, and specialty surfaces provide that hedge. They’re not a substitute for all the other preventive measures, but they certainly help.

For reducing pressure in residents at moderate risk-for example someone who is a bit weak but can move around in bed somewhat-a heavy foam overlay or something of that sort is suitable. For high-risk residents, low-air-loss mattresses or specialty beds are appropriate.

I should also point out that it’s essential after the initial assessment that resident evaluations be continued periodically, with the frequency based on the condition of the resident. Someone who doesn’t need pressure-relief surfaces or devices today might develop that need later. And these evaluations should be carried out by someone who is experienced and can say, “We have a problem and we need to act now to obtain a bed or mattress.”

Dr. Olshansky: There is one factor that is largely outside the control of the nursing home and caregiving staff: family involvement. If families are constantly visiting and checking up on their loved ones, those loved ones will get better care. In essence, the family holds the facility accountable by their frequent presence.

Staff might think of these families, at times, as the biggest pains, but they also know that these families have expectations and that they, the staff, had better toe the line. Also, families need to be kept informed. If a resident is at risk or becomes at risk of developing pressure ulcers, her family needs to have her care needs explained, and you might need to discuss insurance issues with them and figure out how to get a specialty bed if her insurance doesn’t cover one.

I’d also like to emphasize the importance of preventing contractures, which falls within the venue of the PT/OT department or consultants. Once a resident becomes bedridden, it’s imperative that PT/OT help with stretching exercises and therapy, because once contractures develop, it might be too late. Residents with contractures in their legs can’t lie on their backs.

They can only lie on either hip in the fetal position, and therefore they’re extremely prone to developing ulcers on their hips and feet. These individuals have to be provided with pressure-relief beds; if not, many will develop pressure ulcers.

Zinn: What is your response to administrators who say, “We’re doing the best we can, but we can’t afford more staff, and we can’t afford pressure-relief beds and mattresses”?

Dr. Olshansky: Nursing homes are licensed and are expected to fulfill certain standards and pass inspection by surveyors. Those that don’t meet the standards are putting themselves at a tremendous legal disadvantage, because answers like “not enough beds” or “not enough staff” don’t hold up very well in court.

The plain truth is that maintaining adequate staffing and adequate pressure relief equipment is part of the cost of doing business as a nursing home. In keeping with that, it’s advisable for administrators or their financial officers to calculate the cost-benefit ratio for the prevention of pressure ulcers versus their treatment. They need to examine the cost of purchasing versus renting specialty beds, and they need to take into account ancillary expenses, such as wound care costs-and legal fees and settlements, which are inevitable if they get sued because a resident develops pressure ulcers.

I would certainly advise nursing homes, if they haven’t done so already, to consider purchasing top-quality beds with a service contract and making them available for their higher-risk residents. Obviously, this is important from a quality-of-care viewpoint, but it’s also important from a legal perspective. If a resident has access to a pressure-relief surface and deteriorates anyway, you’re standing on much firmer ground.

I would also recommend that every facility have a staff or consultant wound specialist who will make daily rounds and head off problems before they develop. That person can also be the in-service coordinator for wound care.
Finally, I’d strongly urge that we document, document, document-and do so honestly. I know this is a mundane task, but it will be time well spent. NH

Kenneth Olshansky, MD, is a clinical pro-fessor of plastic surgery at Virginia Commonwealth University/Medical College of Virginia, Division of Plastic Surgery, and chief of staff at St. Mary’s Hospital, Richmond, Virginia. He has lectured frequently on the subject of pressure ulcers and consults in nursing homes and hospitals in the Richmond area. For more information, phone (804) 282-7965; fax (804) 282-7986 or write Kenneth Olshansky, MD, 5875 Bremo Road, Suite 212, Richmond, VA 23226.

Additional Reading

Olshansky K. Essay on knowledge, caring and psychological factors in prevention and treatment of pressure ulcers. Advances in Wound Care 1994;7:65-8 [correction published in Advances in Wound Care 1995;8:7].
Olshansky K. Nursing care and development of pressure ulcers [letter]. JAMA 1995;274:1014-5.
Olshansky K. Pressure ulcer risk assessment scales-The missing link. Advances in Wound Care 1998;11:90.
Olshansky K. Pressure ulcers: No more excuses-Assess institutions instead of patients. Advances in Wound Care 1995;7:8,12.
Olshansky K. Pressure ulcers: A preventable American tragedy. Advances in Wound Care 1996;9:8.
Olshansky K. Rethinking our approach to pressure ulcers [guest editorial]. Ostomy Wound Management 2001;47:6.

1. Facility (Hospital/Nursing Home) has an active skin care team with Clinical Specialists, MDs, Therapists (PT/OT), etc., and reports regularly to Administration.

2. Facility has regular Staff in-service training programs for pressure ulcer prevention.

3. For any given individual resident, rate the knowlege andcommitment of his/her caregiving team.

4. Facility is able to provide its residents with pressure-relieving beds or other devices as needed.
5. Facility reports and investigates all occurrences of pressure ulcers,and appropriate education and counseling are given.
6. schedule for each high-risk resident.
7. Facility has an aggressive policy where all residents, when possible,are gotten out of bed several times a day.
8. Facility has active physical and occupational therapy consultants available to maintain range of motion and prevent contractures.
9. Facility has an active nutritionist/dietitian who assures that every resident is receiving adequate nutrition.
10. Facility assures that patients and families are involved and educated regarding pressure ulcer prevention.