December 2005

Team Solution

By Alice Bell, PT, GCS, and Chuck Smith, PT

An interdisciplinary approach to pressure ulcer prevention results in healthier patients

Pressure ulcers are localized areas of tissue breakdown in skin and/or underlying tissues that result from unrelieved pressure.¹ Risk factors for developing pressure ulcers include prolonged immobilization, circulatory disturbances, poor nutrition, and sensory deficits.²

Pressure ulcers place a tremendous clinical and economic burden on a health care system. Additionally, pressure ulcers significantly impact quality of life and health status on an individual level. For this reason, prevention of pressure ulcers has become a primary focus area particularly in skilled nursing facilities where many of the most vulnerable of the population receive care. Pressure ulcers are believed to be an indicator of the quality of care and are included as one of the reportable quality measures in skilled nursing facilities. Despite a great deal of attention focused on this issue, many facilities have experienced difficulty in reducing the rates of in-house acquired pressure ulcers. This is in part due to the fact that the population in skilled nursing facilities is often at high risk and in part due to a lack of education and information on the most effective way to assess for and manage risk.

MODEL OF CARE
The prevention of pressure ulcers requires both an individual and an organizational approach and commitment. This article will highlight the model established at Genesis HealthCare Corporation (GHCC). Genesis is a long-term care company with 200 nursing centers in 12 states. Genesis Rehabilitation Services (GRS) provides rehabilitation services to 500 sites including nursing centers, assisted living facilities (ALFs), and continuing care retirement communities (CCRCs). GRS is the rehabilitation provider for Genesis. Genesis has had a focused effort to reduce in-house acquired pressure ulcers at their centers. This focused approach has included establishing processes, policies, and resources at a corporate, local, and center level to support caregivers and enable them to provide the highest level of preventable care to an at-risk population. At the corporate level, Genesis established a Skin Integrity Practice Council made up of an interdisciplinary team including nurses, clinical educators, rehabilitation therapists, dieticians, certified wound specialists, and physicians. The role of this group is to identify and implement best practice standards in Genesis nursing centers to ensure optimal prevention and management of pressure ulcers. Accepted standards of care from the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) and the National Pressure Ulcer Advisory Panel provide the blueprint for pressure ulcer prevention and management. Additionally, best practice standards for rehabilitation intervention are identified through ongoing literature review and attendance at continuing education programs.

At a local level, Genesis has identified wound specialists who are board certified in wound care and cover a defined geographical area, providing clinical knowledge to the caregivers through training, education, and consultation. GRS has identified master clinicians in wound care to serve as resources to certain centers or geographical areas and to work closely with the Genesis wound specialists to also provide education, training, and consultation. At the center level, pressure ulcer prevention teams have been formed with representatives from all disciplines working closely with the patient and family to focus on identification of patients at risk and aggressive intervention to mitigate risk factors and prevent development or progression of pressure ulcers.

The first step in ensuring prevention is a comprehensive assessment of risk. Many sites use the Braden or Norton Scale to assess overall risk; however, it is important and, now, mandated to look not only at overall risk but to look at each individual risk factor and how it can best be managed by whom. Assessment must address physical health, medical complications, nutritional status, pain, functional status, and positioning needs. Individuals who are identified as having limitations in any of these areas will require the combined efforts of the appropriate team members to intervene in the specific problem areas. Pressure ulcers are the result of cumulative effects often including an inability to obtain adequate nutritional intake and/or hydration combined with medical complications, decreased strength and mobility, and inadequate pressure redistribution. All of these areas must be addressed in a combined coordinated effort to ensure all areas of risk are managed effectively.

Nurses, therapists, dieticians, and physicians must work closely together with the patient and family to achieve the single objective of ensuring that an individual's skin remains intact and that skin integrity improves to whatever extent is possible. The role of the Skin Integrity Practice Council at GHCC is to provide the most current information and resources to the individuals working in our centers to achieve this goal. This group keeps current on the literature and the regulatory guidelines to ensure that, as an organization, we are meeting and exceeding all standards of care to address this issue. This includes reviewing products for effectiveness such as topical agents and dressings, reviewing modalities and positioning devices, reviewing current literature and establishing best practice standards, and then providing training and resources to staff to implement these standards.

The results of aggressive assessment and preventative measures have been seen and felt throughout this organization, with a significant decline in the incidence of pressure ulcers overall and successful management of those that do develop.

Although pressure ulcers result from many known causes, each patient has individual problems and needs and the weighting of the individual issues is unique to each patient. The prevention of a pressure ulcer in an at-risk individual must be a highly dynamic and integrated process. Two of the most critical issues requiring coordinated efforts include addressing nutritional and positioning needs. Studies have shown an inverse relationship exists between body mass index (BMI) and peak seat interface pressure.⁴ Restoring nutritional status for patients who are not receiving adequate nutritional intake and/or have experienced a recent decline in weight is an immediate need combined with identifying the most effective pressure redistribution device(s).⁵

Selecting an appropriate support surface is important to promote adequate blood flow to tissue in order to prevent or optimally treat a pressure ulcer. There are many choices available, and it is important to select the most appropriate surface. For individuals who require pressure relief or reduction in sitting, a cushion should be selected based on the individual patient's needs. When determining the most appropriate bed or mattress, the following general guidelines may be helpful. Pressure reduction support surfaces include gel and foam and are indicated for prevention and early treatment of stage I and II pressure ulcers. Pressure relief surfaces include low air loss, alternating air, and nonpowered mattresses and are indicated for patients with stage III or IV ulcers. The Department of Health and Human Services provides some additional guidelines. A static surface such as visco foam, which is designed to mold to the body and provide pressure relief, is indicated when:

• a patient can assume a variety of positions without weight bearing on a pressure ulcer and without fully compressing or "bottoming out" on the support surface.

A dynamic surface such as a low air mattress is indicated when:

• a patient cannot assume a variety of positions without weight bearing on a pressure ulcer, or
• a patient has stage III or IV pressure ulcers on multiple turning surfaces, or
• a patient fully compresses "or bottoms out" on a static support surface, or
• there is no sign of pressure ulcer healing within 2 to 4 weeks.

Treatment priorities may shift quickly. For example, the initial priority may be to get that person stabilized medically and to improve nutritional intake. This requires the combined efforts of the physician, nursing staff, and dietary. Additionally, if the person is experiencing difficulty with feeding or with swallowing, occupational and/or speech therapy may be indicated. At the same time, the fact that the person is immobile or has limited mobility necessitates addressing positioning and pressure redistribution needs. This would include evaluating the most appropriate pressure reducing or relieving device for a patient in a wheelchair and the most appropriate support surface to be used in bed.

A variety of positioning devices are available for off-loading of actual or potential pressure areas. It is helpful to develop a resource manual or formulary to assist staff in determining the most useful device(s). These needs are best addressed through the combined efforts of nursing, physical therapy, and occupational therapy. Once the individual has become medically stable and is better able to participate in rehabilitation to improve mobility, the nutritional requirements must be reevaluated to ensure that the intake is meeting the new demands.

Collaboration between physical therapy, occupational therapy, dietary, nursing, and the physician is necessary to ensure energy and activity demands are being balanced against nutritional intake. As strength and mobility improve, the need for certain positioning or pressure-redistributing devices may decline. Nursing and therapists must be working closely together and communicating regularly to ensure devices are modified, added, or discontinued based on the patient's changing status. Additionally, as the individual becomes more active, medications may need to be adjusted particularly for patients with diabetes. This type of management requires close interdisciplinary communication and management between therapy, nursing, dietary, and the physician.

At Genesis, experience has demonstrated that with a strong and supportive interdisciplinary culture, skilled clinicians who are given the information and resources they need, and a patient-centered model of care that focuses on comprehensive and individual needs, many pressure ulcers—as well as the pain and disability associated with them—can be prevented.

Alice Bell, PT, GCS, is director, clinical practice, physical therapy at Genesis Rehabilitation Services, and Chuck Smith, PT, is a clinical specialist at Genesis Rehabilitation Services, Andover, Mass.

REFERENCES

1. American Pressure Ulcer Advisory Panel. Pressure ulcers prevalence, cost and risk assessment: consensus development conference statement. Decubitus. 1998;2:24-28
2. Kanj LF, Wilking SV, Phillips TJ. Pressure ulcers. J Am Acad Dermatol. 1998;38:517-536.
3. Bouten CV, Oomens CW, Baaijens FP, Bader DL. The etiology of pressure ulcers: skin deep or muscle bound? Arch Phys Med Rehabil. 2003;84:616-619.
4. Kernozek TW, Wilder PA, Amundson A, Hummer J. The effects of body mass index on peak seat-interface pressure of institutionalized elderly. Arch Phys Med Rehabil. 2002;83:868-871.
5. Lewis CB, ed. Aging: The Health Care Challenge. 3rd ed. Philadelphia: F.A. Davis Co; 1995.

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