Preventing & Managing Pressure Sores

by Duncan S. MacLean, MD, CMD

Caregivers have contended with pressure sores throughout history, and still do today. Mummies of Egyptian noblemen dating back 5,000 years have pressure ulcers. Up to 29% of US hospital patients, 33% of critical care patients, and 66% of elderly hip fracture patients also have them. At the time of death, 24% of Americans have at least one stage-2 or greater pressure ulcer, according to a 1989 National Funeral Directors Association (NFDA) study (Eckman KL. Decubitus 1989;2:36-40).

Nationally, 9.8% of nursing home residents have pressure ulcers. The prevalence of pressure sores in individual facilities ranges from 2.5% to 24%, depending on facility characteristics.

Pressure sores are largely, but not entirely, preventable. Every day, caregivers in US nursing homes protect their high-risk residents from pressure sores through diligent pressure-reduction efforts, incontinence care, and feeding. If it weren't for this care shift-by-shift, day in and day out, the skin of frail residents would break down rapidly.

Sometimes, pressure sores develop despite caregivers' preventive efforts. Many of these sores can heal readily, if detected promptly and treated at an early stage.

Other pressure sores are not preventable because of intractable patient factors. For example, the terminal pressure sores in the NFDA study probably reflected a lingering death among subjects, and thus were an inexorable part of their dying process. The National Hospice and Palliative Care Organization (NHPCO; www.nhpco.org) lists intractable pressure sores as one indicator of a terminal prognosis that qualifies non-cancer patients for admission to hospice programs.

In some cases, however, pressure sores may at least partially relate to "substandard care." In the year 2000, Tag F 314 (Pressure Ulcer Prevention and Healing) was the fourth most common category of deficiencies cited in annual nursing home inspections. The Centers for Medicare and Medicaid Services cited almost 19% of facilities for inadequate skin care--failure to assess risk, plan appropriate care, execute the plan consistently, or monitor the plan's effectiveness. Some nursing homes countered that only documentation was lacking, not care. However, documentation of pressure ulcer treatment is essential, both to facilitate clinical care as well as to reduce liability.

CMS's Conditions of Participation, which are based on the 1987 OBRA regulations, require nursing homes to prevent pressure sores whenever possible and to provide necessary treatment to existing sores. How do facilities and surveyors know which pressure sores can be prevented and which ones cannot? What treatments should be given? What are the responsibilities of attending physicians? How can the medical director help the facilities prevent and treat pressure sores? How should unavoidable and incurable pressure ulcers be documented to avoid "substandard care" citations? Which standards should be included in medical policies, and which should be put into guidelines?

Preventing Pressure Sores

The Agency for Healthcare Research and Quality (formerly AHCPR) has identified several basic principles for pressure-ulcer prevention:

Use a validated tool to assess risk
The Braden Scale and Norton Scale are the most widely used risk-assessment tools. These scales score alertness, mobility, incontinence, and nutritional status. Nurses should reassess risk using one of these tools or another comparable one at regular intervals.

Implement a preventive plan for residents at risk
The care plan should focus on avoiding friction and shear trauma to skin regions at risk, avoiding maceration from moisture, and addressing nutrition and mobility. High-risk residents may need an individualized plan to reduce pressure, such as frequent repositioning.

Inspect skin daily for high-risk residents
Skin and deep-tissue damage can occur in as little as two hours. Thus, high-risk residents may need daily skin examination.

In most cases, nursing staff can independently identify high-risk residents and effectively plan, implement, and monitor a preventive program. The 1996 AMDA clinical practice guideline on pressure ulcers highlights additional responsibilities of physicians to help prevent pressure sores (see Resources):

• Identify and manage underlying medical risk factors, some of which may not be reflected in the Braden score, including disease states, nutritional compromise, skin disorders, and drugs that affect skin, such as corticosteroids.
• Identify and treat modifiable causes of decreased alertness, incontinence, and immobility.
• Identify and manage acute changes in condition that may increase the risk of skin breakdown, such as delirium; also identify subacute changes that increase risk, such as weight loss or progression of dementia.
• Clarify overall condition, prognosis, and realistic goals; if appropriate to the resident's situation, discuss orders to limit or withhold treatment with the resident or responsible party.

Physicians should document when residents have significant risk factors for skin breakdown, and review the preventive care plan regularly. They should encourage nurses and caregivers' perseverance in trying to prevent pressure sores.

Treatment

When a shallow (Shea stage 2) pressure sore develops, the physician may be tempted merely to prescribe pressure relief and a protective dressing. In some cases, this simple approach is enough to heal the wound.

However, many other wounds will not respond to such simple measures. A seemingly simple pressure sore may be the "tip of the iceberg." After all, pressure ulcers, like many geriatric syndromes, often result from a complex set of interacting factors that render the older individual unable to maintain homeostasis. A comprehensive approach to uncovering all contributing factors from the outset has the best chance of avoiding a cascade of chronic non-healing wounds, complications, and even death.

AMDA's guideline on pressure sores in nursing homes advises starting with a thorough assessment (see Resources), using an assessment checklist that focuses on:

• General medical stability and prognosis
• Specific comorbidities affecting wound healing, including underlying ischemia
• Nutrition
• Functional status
• Infection
• Pain
• Wound assessment and management
• Psychobehavioral factors
• Ethical considerations

Because of the many issues involved, it is difficult to create simple policies and procedures to cover all treatment options. Although in some facilities, policies outline the appropriate steps and offer different options, in my opinion, medical policies on pressure sores should address general principles only. The facility should instead use clinical practice guidelines to describe the step-by-step details of managing pressure sores, allowing flexibility for clinicians (see "Clinical Practice Guidelines: Simpler May Be Better," in the July 2001 Caring, p. 33-34).

Several other authors and organizations have published detailed guidelines on managing pressure sores. Nursing home physicians and other practitioners should refer to guidelines authored by Patterson and Bennett and by AHCPR, as well as to the AMDA guidelines (see Resources). These guidelines discuss currently accepted principles of treatment, which include the following components:

• Relieve pressure.
• Debride necrotic tissue.
• Treat infection.
• Keep the wound moist to promote granulation.
• Protect surrounding skin.
• Manage the patient's overall condition.
• Track wound-healing progress accurately.

Effectively tracking wound healing requires the use of a consistent, reproducible format, especially if different nurses are involved in monitoring the progress of a given wound. How else can the physician and team know whether the current treatment is working or not?

Medical Policy

What aspects of pressure-ulcer management should the medical policy address? I recommend four elements for the policy:

• Physician assessment of any prior history of pressure sores and other underlying risk factors, on admission and periodically.
• Review of the preventive care plan periodically, including management of treatable medical conditions, optimizing function, and reduction or elimination of potentially detrimental drugs, in accordance with facility (or generally accepted) guidelines.
• Management of actual pressure sores according to facility (or generally accepted) guidelines, including appropriate involvement of ancillary disciplines--dietitian, wound-care nurse specialist, physical therapist, and others.
• Documentation of the physician's exam, estimation of prognosis, and treatment goals.

Physicians can be cued to record a detailed wound description using a standard checklist, such as one found in AMDA's 1999 practice guideline.

Under this policy, attending physicians should systematically address each risk factor, regardless of a resident's Braden scale score. For example, the physician should seek treatable causes for all residents with urinary incontinence. They should recommend a preventive skin-care plan for all residents with peripheral vascular disease or contractures, even if no other risk factors are present. Or, they should document when a risk factor is not readily modifiable.

Medical directors should also ask attending physicians to review the efforts made by the staff to prevent skin breakdown, and document when they believe that a patient's pressure sore was not preventable despite reasonable efforts.

On the other hand, if a physician believes a pressure sore was preventable, he or she should report this to the medical director and nursing staff so that they can investigate. The physician should not use the medical record to speculate about reasons why a pressure sore has occurred or has not healed as predicted.

Medical Director Issues

Medical directors may be asked to address several other issues related to wound prevention and management and about oversight of the facility's wound management.

Some treatments are controversial. For example, manufacturers are heavily promoting platelet-derived growth factors. But randomized controlled trials (RCT) in diabetic foot ulcers have been evenly divided between those showing no benefit and those showing improved healing rates, with numbers-needed-to-treat of 2 to 7 (Hunt D, Gerstein H. Clinical Evidence. London: BMJ Publishing Group, 2001, p. 452). Growth factors are FDA-approved so far only for diabetic ulcers, not for pressure sores.

Use of low-air-loss and air-fluidized beds to prevent and treat pressure sores has also been controversial. Clinical Evidence cited two RCTs showing improved healing of established sores using these beds, but four showing no advantage compared with egg crate foam overlays (Cullum N, Nelson EA, Nixon J. Clinical Evidence. London: BMJ Publishing Group, 2001, p. 1497). The Cochrane Library concludes that there is "good evidence of efficacy" of special beds for treatment, but not for prevention, of pressure sores (Cullum N, Deeks J, et al. Cochrane Library, Issue 3, Oxford: Update Software Ltd., 2002).

Another issue for the medical director is quality monitoring. I recommend monitoring standard incidence and prevalence rates. Incidence reflects the formation of new ulcers, and prevalence reflects the non-healing of existing ulcers. Since published rates for pressure sore incidence vary by almost 50-fold from 0.3 to 14 per 1,000 resident-days, each facility should calculate its own upper and lower control limits rather than rely on published benchmarks.

Yet another issue is the wound treatment product formulary. The Patterson and Bennett review and the 1999 AMDA guideline both contain similar tables of product categories. Generally, each facility needs only one product from each category, which can be chosen on the basis of cost, since the various products in each category are otherwise generally comparable.

With a systematic approach guided by appropriate policies and guidelines, nursing homes and long-term care physicians can prevent preventable pressure sores and document those that are not preventable.

Dr. MacLean is Medical Director of Delaware's state-operated system of nursing homes. He was founding President of the Pennsylvania Medical Directors Association and served as an Issue Expert on Long-Term Care for the 1995 White House Conference on Aging. He has directed a private non-profit nursing home, a hospital-based subacute unit, and a private personal care facility. He has served on AMDA committees, presented at the AMDA Annual Symposium, and conducted Symposium discussion groups.

The opinions expressed by Dr. MacLean are his own and not necessarily those of the American Medical Directors Association.

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