Stopping Pressure Ulcers-Before They Start

Stopping pressure ulcers-Before they start

Zinn: How does ultrasound technology work in detecting potential pressure ulcers and assessing existing ones?

Mogensen: High-frequency ultrasound enables clinicians to view high-resolution images of the underlying few centimeters of the skin’s soft tissue and to detect changes beneath the skin’s surface that indicate that a pressure ulcer is developing. We use a three-phase classification system that shows developing pressure ulcers before they can be detected by sight or touch. At Phase 1, pockets of subcutaneous edema, or fluid, can be seen, starting near the bone (figure, A). Fluid is nonreflective, so it shows up as darker tissue on the scan. At Phase 2, strips of dermal damage, along with increased subcutaneous damage, can be detected (figure, B). At Phase 3, subepidermal inflammation is discernible, along with strips of dermal damage and major subcutaneous damage (figure, C). The next step after Phase 3 is total breakdown, at which time the wound becomes visible on the surface of the skin. The transition from Phase 3 to total breakdown can take just hours or it can take days, but without this technology, pressure ulcers developing below the skin’s surface only can be detected by sight or touch approximately 25% of the time.

Zinn: Some adverse effects have been reported with ultrasound when it’s used for treating wounds. How safe is it when it’s used diagnostically?

Mogensen: The frequency of the ultrasound is higher with diagnostic scanners. Ultrasound equipment used therapeutically is in the low-frequency range-1 to 4 MHz-and at these frequencies, you have to be careful to avoid burns. But scanners used for diagnostic purposes-for example those used for bladder scans, fetal monitoring, and heart exams-are generally in the 4- to 12-MHz range and are not associated with burning or any other adverse effects. The technology we use is noninvasive, operating at 20 MHz. Not only does this high frequency make the scanner safe, but it also provides sharp, high-resolution scans. Because these ultrasound waves can’t penetrate very far-roughly the thickness of five to ten dimes-before they have to come back to the receiver, you could rest it on someone’s skin all day with no adverse effects.

Zinn: What else do these high-frequency ultrasound scans reveal?

Mogensen: A trained radiologist can tell from the images whether a developing wound is actually a pressure ulcer or if it’s a friction ulcer. The radiologist can also pinpoint the source of the developing wound, even when it’s being caused by incontinence.

Zinn: How do the radiologists make these distinctions?

Hertig: These are experienced clinicians who are trained to evaluate the tissue breakdown that’s visible on the scans. Sometimes they can determine the type of wound because of its location-e.g., near the surface just under the epidermis, as with a friction ulcer, versus deep above a bony prominence, as with a pressure ulcer. In other cases they can tell by the composition of injured tissue. This enables them to recommend the appropriate intervention, i.e., correcting an incontinence problem versus providing pressure relief versus removing a source of friction.

With a pressure ulcer, you’re looking at fluid that starts at the bone and works toward the surface. The location and amount of fluid tells the radiologist not only what’s causing the problem, but also how serious that problem is.

Hertig: In addition to facilities’ caregivers using a “shotgun” approach that involves turning every at-risk resident every two hours, they now can target the intervention much more precisely by following our radiologist’s recommendations, which are based on the interpretation of the scans.

Mogensen: Those recommendations consist of a set of preventive protocols [see sidebar, “Soft-Tissue Management Interventions With Use of High-Frequency Ultrasound”]. We worked with nursing homes, reviewing their existing protocols, to develop these.

Hertig: Never before could we see below the skin to detect pressure ulcers in their infancy. So what do you do for a developing wound before it’s even visible? For example, if it’s caused by pressure, what steps do you take to prevent an expensive-to-treat wound? We don’t dictate to facilities that they must adopt our approach rather than doing what they’ve done before. We’re just giving them direction and the confidence to carry out their interventions in a targeted, focused approach.

We learned early on that nursing homes need specific protocols to know what to do when they can’t see a developing wound with their eyes or detect it by touch. We help by saying, “Given past experience and successes, this is a way to address the problem.”

Zinn: What kind of equipment is required to perform the scans?

Mogensen: The scans are obtained with a portable, high-frequency ultrasound scanner, manufactured by Longport, Inc., in Swarthmore, Pennsylvania. It consists of an IBM-compatible personal computer with a Windows« operating system, a custom electronics board that’s placed into the PC, and a custom-designed probe-the handheld device that is held against the skin to obtain a scan-which is connected to the electronics board.

Zinn: How are the scans performed?

Mogensen: The staff member operating the scanner simply puts gel on the probe to ensure good sound transmission between the probe and the skin and positions it over the area to be scanned. The computer captures the images and then they are e-mailed-using secure, HIPAA-compliant encryption technology-to our radiologists’ facility in Pennsylvania, where they are read. After reading and interpreting the scanned images, the radiologist generates a report and sends it back to the nursing home via e-mail within 12 hours, with a hard-copy follow-up.

Zinn: Do long-term care facilities have to purchase the ultrasound scanner, or can it be leased?

Mogensen: We provide the scanners to the facilities. They can buy their own, but this is quite expensive.

Zinn: Is the equipment portable enough to be placed on a cart and wheeled from room to room, so that scans can be performed wherever it’s convenient?

Mogensen: Yes, it is. In fact, as part of our services we provide a cart and all the necessary equipment to permit nursing staff to perform scans at bedside.

Zinn: Which members of the nursing home’s staff would be best qualified to perform these scans?

Mogensen: Anybody can be trained by our wound care experts to perform the scans; it’s not difficult. To help a facility determine which of their staff members should be trained, we try to identify those with leadership skills-people who are quality-of-care advocates who will be likely champions of pressure ulcer prevention. The training course lasts two days, and typically four or five direct care staff from a nursing home are trained. The experts conducting the training proctor a competency test to ensure that the trainees have demonstrated the necessary skills and basic understanding of ultrasound technology to operate the equipment and capture quality scans. During the next few days, the trained staff members practice, and generally by the following week, the quality of their scans is excellent.

When we visit a facility, we can sense whether its nursing staff has the level of commitment needed to get behind a wound prevention program. It’s generally not the administrator who will make using this technology worthwhile, but the direct care staff. Depending on the clinical staff members’ familiarity with computers, there is a slight learning curve because of their initial fear of learning a new, computer-based technology, but they generally absorb the information rapidly. After they’re trained, what motivates them is seeing results. When they hear from our radiologist that a resident has a phase III developing pressure ulcer and needs a pressure-relieving mattress and then act on that advice, they can see for themselves that the wound is prevented before it surfaces. They can see the problem reversing more each week as they do follow-up scans. That spreads a full commitment to pressure ulcer prevention throughout an organization.

Zinn: In how many long-term care facilities have you placed the portable ultrasound scanner for use in assessing and preventing pressure ulcers?

Mogensen: Although the technology has been in development for more than a decade and in use in long-term care for several years, it is just now being incorporated into a nationwide service. There are currently more than 20 skilled nursing facilities in the United States using this technology.

Zinn: Are data available from those facilities that show an improvement in their prevention of pressure ulcers after they began using the equipment?

Hertig: The scanner has been in use in some facilities for as long as five years-for example, at Little Flower Manor in Wilkes Barre, Pennsylvania-and they have been tracking results. That particular facility has been able to show a 40 to 50% reduction in the incidence of pressure ulcers, which is quite significant given the high acuity level of its population.

Also, studies conducted at two Skilled Healthcare LLC facilities (Foothill Ranch, California) in the Southwest have shown that the technology detected and prevented 18 decubitus ulcers during its first 12 weeks of use.

We’ve also seen dramatic results. For example, in one case the scanner identified a significant problem developing on a resident’s heel, and the facility provided pressure relief-before a visible wound developed. They tracked the developing wound’s improvement once the pressure was relieved; the tissue damage reversed and the wound healed and never broke through the skin.

Zinn: In which residents should a scan be obtained, to determine if they have any developing pressure ulcers that are not yet otherwise detectable?

Mogensen: All new admissions should be assessed, to determine whether they are at high, moderate, or low risk for developing pressure ulcers. The Braden scale is incorporated into the scanner’s software, so staff can ask the questions for that scale, which are right on the screen, and input the answers into the computer. If the Braden scale shows that the person is at risk of contracting an ulcer, that person can be scanned then and there. Bony prominences of the body where pressure ulcers could develop can be scanned in approximately five to ten minutes.

Most facilities are doing risk assessments on a regular basis, as well, so when any resident falls into the high-risk category, scans should be done. We also encourage nurses to rely on their own intuition and obtain scans even when they suspect a problem is developing in a resident considered to be only at moderate risk, to confirm or rule out their suspicion.

Scans should also be performed on anyone who’s going to be leaving the nursing home for any length of time; e.g., before hospitalization, to get a baseline. The scans should be repeated when the person returns to the home, to make sure he or she hasn’t started to develop a pressure ulcer.

Hertig: There’s always a concern that nursing homes are inheriting pressure ulcers from hospitals when residents are there for a period of time. This technology takes the subjectivity out of it. If you detect problems on the scan, you can record the fact that these problems developed in the hospital, or in the resident’s home before admission to the nursing home, and you can take action before it becomes a big problem.

Zinn: How often should scans be obtained in residents who have already developed pressure ulcers, to determine whether the treatment they are receiving is working or if it needs to be changed for more effective healing?

Mogensen: Once a week is usually sufficient. Without this technology, the way in which wounds are measured is rather subjective; i.e., if three different people measure a wound at one-week intervals, their measurements may not be consistent enough to show whether a wound is really healing or not. Scanning the wounds is an objective way to accurately measure the surface area and depth of a wound and document whether it’s healing.

Zinn: How much do your services cost a long-term care facility?

Mogensen: The cost is calculated for each facility based on the number of residents, the acuity level of the population, and the facility’s current pressure ulcer incidence. Facilities sign an annual contract and then pay a monthly fee that includes use and maintenance of the scanner, hardware and software updates, clinical staff training, and our radiologists’ services.

The average monthly fee is $3,000; it can be less, and it can be more if the home is very large or has an exceptionally high-acuity population. The monthly service fee is all-inclusive and will not vary with the number of scans the facility performs; if the staff want to scan 2 or 20 residents a day, the cost remains the same. Also, the cost of providing the capital equipment is included in that monthly fee.

Hertig: We opted not to charge for our services on a per-scan basis because we didn’t want to create a disincentive. We don’t want to discourage staff from performing as many scans as are needed. The more the merrier, really, because that means they’re applying best practices.

Zinn: Is the cost of using this technology offset by the savings realized from pressure ulcer prevention and possibly providing shorter duration of wound treatment?

Hertig: We hope data will be published shortly in a study conducted by a 140-bed nursing home that’s been using this technology. The researchers collected the hard-dollar costs (i.e., checks written for medications used to treat pressure ulcers, dressings, etc.), but not soft costs, such as nursing time. The facility was able to lower its direct costs of pressure ulcer treatment by 25%. In an average nursing home, those savings would be sufficient to cover the cost of our services.

All the other benefits, such as improved resident care and reduced exposure to litigation and survey deficiencies, weren’t even taken into account. Instead of writing checks to treat pain and suffering, facilities using this technology are writing checks to prevent pain and suffering. As a result, nursing staffs using this technology love it, because it helps them do what they like to do-prevent problems before they occur. It allows them to spend a small amount of their time preventing pressure ulcers instead of a great deal of their time changing dressings on difficult-to-heal wounds.

Zinn: I understand you’re attempting to get CMS to approve Medicare reimbursement for this technology. How is that progressing?

Hertig: It is our understanding that Medicare Part B pays for the use of this technology in mapping a wound prior to surgical debridement, to limit the amount of surgery to precisely what’s needed. We’re beginning discussions with clinical people at CMS, as well as with several of the national associations and state QI organizations, looking for support in expanding Medicare reimbursement to cover diagnostic scans for prevention of decubitus ulcers. Residents of nursing homes won’t need debridement surgery if they don’t develop pressure ulcers in the first place.

Everyone knows that pressure ulcers are a huge problem in long-term care. In fact, the Healthy People 2010 initiative sets a target of less than a 1% incidence of avoidable pressure ulcers; that will be hard to achieve without additional preventive methodologies. We have a great deal of knowledge about the problem; what hasn’t gotten out is that there is now a diagnostic technology that can help to significantly reduce a nursing home’s incidence of ulcers.

Nursing homes have been neglected in terms of technology for a long time, and cost constraints make it even more difficult for them to adopt new technology. Nevertheless, CMS acknowledges that technology can help, so I’m optimistic, and we’re hoping CMS will approve Medicare reimbursement.

With or without Medicare reimbursement, this is a cost-effective approach to pressure ulcer prevention. The latest figures I’ve heard put the average cost of treating one pressure ulcer at approximately $3,500, and it’s been estimated that an average of 23% of all nursing home residents will develop one or more pressure ulcer. That’s a lot of residents who’ll cost the healthcare system a lot of money, not to mention their having to suffer needlessly.

Zinn: Are there any other benefits to using this technology?

Mogensen: Yes, there are. High-frequency ultrasound scanning isn’t limited to detecting potential decubitus ulcers. It also allows us to see other occurrences under the skin. In fact, it was used to prevent a lawsuit at one nursing home when the family of a resident with a superficial bruise was claiming the injury was caused by abuse. Scanning the subcutaneous tissue under the bruise failed to show the deep trauma that would have been consistent with the family’s allegation. When the scans were showed to the plaintiff’s attorney, the claim was dropped.

Hertig: It’s also excellent for documentation. Let’s say you have a resident with a pressure ulcer during a survey and, therefore, you have to document that it’s improving. As mentioned earlier, without this technology that is an extremely subjective process. For one thing, sometimes wounds superficially look like they’re getting worse when actually they’re improving. Other wound-measurement techniques simply are not precise enough.

Mogensen: Better pressure ulcer prevention and assessment also should help to keep skyrocketing liability insurance premiums down. We’re hoping that as this technology catches on, it will help both skilled nursing facilities and their insurance carriers to drive down costs.

Hertig: It certainly should help keep premiums from rising, since pressure ulcers have so often been the culprits in litigation. We’re hoping that the long-term care insurance industry will become aware of this technology. I’d think it would be of great interest to them to insure facilities that use it. It helps everyone, from the residents and their families to staff to owners to insurers to third-party payers. It allows information that was previously unknown to be managed much more closely.

Nursing homes have been dealing with this problem forever. Wouldn’t the best solution be for pressure ulcers never to develop? Many products are available for managing pressure ulcers after they occur. We want to shift the approach from treatment to prevention, allowing nursing homes to take control and improve their residents’ quality of life.

The following protocols may be used in response to the phasing classification supplied with the Longport High-Frequency Ultrasound Scanner. In the event that an ultrasound procedure results in the collection of a scan that reveals the interpretation of a Phase 1, 2, 3 developing pressure ulcer, or Phase F (friction ulcer), the following protocols may be followed.

PHASE 1 PRE-ULCER

• Pre-albumin level (serum albumin levels accepted if available).
• Prescribe multivitamin and mineral supplement.
• Granulex or skin prep to bilateral heels qd with soap-and-water wash between applications.
• Moisture barrier cream to buttocks after each brief change.
• Bowel and bladder program for incontinent patients.
• Heels floated with pillows when in bed.
• Evaluate support surface for “bottoming” with hand check.
• OT or PT to provide appropriate wheelchair and wheelchair cushion.
• May be up in chair in a.m., back to bed after therapies completed in p.m., up again for supper.

Rescan on post-assessment day 14. If this shows no deterioration, continue with Phase 1 interventions and rescan again on post-assessment day 28 and one (1) time per month for two (2) more months, then D/C. If condition has worsened, go to Phase 2 interventions.

PHASE 2 PRE-ULCER

• Pre-albumin levels (serum albumin levels accepted if available).
• Prescribe multivitamin and mineral supplement.
• Granulex spray or skin prep to heels bid with soap-and-water wash between applications.
• Moisture barrier to buttocks after each brief change.
• Bowel and bladder program for incontinent patients.
• Float heels with popliteal wedges or heel-lift boots.
• Evaluate support surface for “bottoming” with hand check and adjust accordingly.
• OT or PT to provide appropriate wheelchair and wheelchair cushion.
• Patient up in chair in a.m. for breakfast, remain up for therapy in a.m., back to bed after lunch in p.m. Up for supper.

Rescan in one (1) week; if stable, rescan every two (2) weeks for two (2) months. If condition remains stable, rescan every three (3) months and then D/C. If condition has worsened, go to Phase 3 protocols.

PHASE 3 PRE-ULCER

• Pre-albumin level (serum albumin levels accepted if available).
• Prescribe multivitamin and mineral supplement.
• Prescribe dietary supplements (i.e., Ensure, Boost, etc.).
• Granulex spray or skin prep to heels once per shift with soap-and-water wash between applications.
• Popliteal wedge or heel-lift boots when in bed.
• Evaluate support surface and order accordingly (alternating pressure, low-air-loss, etc.).
• Barrier cream to buttocks at each brief change.
• Bowel and bladder program for appropriate patients.
• OT, PT, and Speech consult for positioning, swallowing, mobility, etc.
• Patient up in a.m. after breakfast, back to bed after lunch, up in late p.m. for any remaining therapy and supper, back to bed after supper.
• q2h turning schedules when in bed.
• OT, PT to provide appropriate wheelchair and wheelchair cushion.

Rescan in 72 hours and then weekly for six (6) weeks. If condition persists, continue protocols and rescan every two (2) weeks until condition improves, then change to Phase 2 protocols.

PHASE F PRE-ULCER
Implement all measures as for Phase 3 PLUS:

• Consider using Xenaderm« ointment (prescription) on buttocks or aggressive moisture barrier ointment to provide longer-lasting protection.
• Evaluate for yeast infection and treat accordingly.
• Implement aggressive incontinence procedures (Foley cath, bladder training, etc.).
• Consider bladder ultrasound scan.
• Once-per-shift skin checks to affected area by treatment nurse, wound nurse, or unit manager.
• If ischials are the area of concern, limit sitting to 2-3 hours/day and ensure good wheelchair cushion support.
• If sacrum or coccyx is area of concern, limit lying supine in bed.
• Ensure that turning schedule is in place. Minimize friction and shear by keeping head of bed as low (30 degrees or less) as possible.
• Evaluate for “nervous foot” movements and address additional protection as necessary.

Rescan 72 hours after initial scan and one (1) time per week for two (2) weeks. If condition persists, continue weekly scanning for four (4) weeks and then biweekly for two (2) months. If condition improves, scan on a biweekly basis for one (1) month and then monthly.

Reprinted with permission of Advanced Clinic Services. This form may not be reproduced without express written permission.