From Best Practice to Bed Side: Prevention of Pressure Ulcers. It Can Be Achieved!

By Janusz Kaleta, RN, AAS, BScN (Hon.), IIWCC

If he [patient] has a bedsore, its generally not the fault of the disease, but of the nursing Florence Nightingale (1859) Abstract: This article will discuss practical innovations based on concise treatment protocols focused on early prevention of pressure ulcers. Further the aim of this paper is to demonstrate the essential importance of the front line nursing staff working in long-term care homes which when empowered with knowledge and having access to simple tools can avert risk for development of pressure ulcers among geriatric complex care residents. As the population ages the incidence of pressure ulcers and associated costs will likely increase. There is an urgent need to refocus on real care environments driven innovation to ensure that evidence-based knowledge can be translated into daily practice within the long term care sector. Academic researchers and policy makers must understand real care environments in order to deliver appropriate and cost effective interventions in a proactive rather than reactive manner. The Scope of the Challenge ccording to the Health Quality Ontario (2012) one in 36 LTC residents had a pressure ulcer that got worse, or developed a new, serious pressure ulcer in the preceding three months. Pressure ulcers pose a serious threat to residents in Long Term Care Homes as well as to staff working with increasingly more complex care clients arriving from Hospitals. The incidence and prevalence of pressure ulcers ranges from 0.4% to 38% in acute care Hospitals, from 2.2% to 24% in long-term care and from 0% to 17% in home care (Gupta and Ichioka, 2012). Residents who develop a pressure ulcer are at increased risk of major health complications including infections and death (Thomas, et al 1996). In Canada the current cost of illness, disability and death due to chronic illness is over $80 billion annually and growing (AHS). Pressure ulcer(s) are part of this financial burden on Canadas publically funded Health Care System and in most cases are preventable.

Pressure ulcers are very costly; Prevention is BEST and cost effective Although it has been well established that the cost of treating pressure ulcers is about 2.5 times greater than the cost of preventing them the health care system still often focuses on the costly treatment (OotGiromini et al. 1989). Early identification of risk factors for development of pressure ulcer, team care planning and prompt delivery of correct interventions can not only ensure residents function, independence and prevent pain but also save our publicly funded health system. This challenge also creates fiscal opportunities for each and every LTC home. If a 100-bed healthcare facility achieves a 35% decrease in pressure ulcer, their cost-saving annually could be anywhere from $240,000 to $1.2 million, depending on the degree of trauma and complications (uncomplicated Stage I pressure ulcer: $239,000 to Stage IV: $314,000; and complicated with critical colonization Stage II: $352,000 to Stage III/IV: $390,000; and complicated with osteomyelitis stage II to IV: $1,232,000) (Woodbury and Houghton, 2004).

While treatment of complicated pressure ulcers often requires costly wound products, low air loss (LAL) pressure redistribution surfaces, and antibiotic therapy to treat associated infections (including osteomyelitis) the prevention is based on simple but effective interventions which may be readily delivered by front line staff at the point of care. Such measures include proper hygienic bedside care, regular repositioning, and control of moisture with use of barrier lotions. Pressure ulcers CAN be prevented Pressure ulcer is a localized injury to the skin and / or underlying tissue usually over bony prominence, as a result of unrelieved pressure which in turn leads to a decrease supply of oxygen to the tissue resulting in tissue death (Gupta and Ichioka, 2012). Elderly residents in long term care homes are at high risk for skin breakdown related to: impaired ability to reposition oneself, advanced age, decreased sensory perception, impaired nutrition and excessive exposure to moisture related to incontinence, excessive perspiration, and high body moisture and / or wound drainage. Additionally those at high risk for skin breakdown include: Residents who had experienced recent weight loss (20%) were more likely to have pressure ulcers than those who had not had a recent weight loss (10%) Residents who had experienced high immobility (16%) had an 11% greater occurrence of pressure ulcer than those without high immobility (5%) Residents taking more than eight medications had a greater prevalence of pressure ulcers than residents who were taking fewer medications (13% and 9%, respectively) Residents with recent bowel or bladder incontinence had a higher prevalence (12%) than continent residents (7%) (Park-Lee and Caffrey, 2009). FOCUS on Preventative Skin Care
The Interprofessional Skin & Wound Team will: 1. Identify risk factors for skin breakdown: Level of activity Cognitive ability Pain Impaired mobility Poor nutrition Decreased sensory perception Exposure to excess moisture / incontinence 2. Develop and implement an Interprofessional Plan of Care focused on a Residents needs 3. Encourage resident participation in ROM exercises, assess seating and positioning 4. Ensure hydration of 1500 ml of fluids/24 hour Monitor weight monthly (Involve Registered Dietitian ) 5. Assess the resident for a bowel and bladder Restorative Program (If appropriate) 6. Use protective 3M CAVILON Barriers (e.g. Creams, liquid barrier films, transparent films, Hydrocolloids) or protective padding to reduce friction, maceration and irritation of the integument 7. Manage moisture (e.g., urine, feces, perspiration, wound exudates, and saliva). use protective barrier products, change linens & clothing when damp 8. Minimize shearing and friction on the skin When cleansing, providing care or moving the resident 9. Observe for and respond to resident verbalizations and behaviours indicative of skin discomfort 10. Provide and monitor effectiveness of analgesia

Front line staff needs to be empowered with clear 11. Evaluate, document resident outcome, and information on risk factors to correctly identify update care plan residents at risk. Registered staff requires access to concise and easy to follow treatment protocols in order to initiate needed interventions forthwith.

It Can Be Achieved! Prevention by being PROACTIVE rather than Reactive Armed with this knowledge an Interprofessional team was formed at Cedarvale Terrace Long Term Care Home. Front line nursing staff is critical in recognizing the early changes in skin integrity in order to prevent development of pressure ulcers. Cooperation of the entire team including: nurses, physicians, physiotherapists, occupational therapists, dietitians, social worker, activation staff and resident/family within LTC home is required to achieve this goal. Research suggests that when health care providers function as a TEAM, the rates of pressure ulcers may be effectively decreased (Campell et al. 2006).

Interprofessional Team
Nursing [RN/RPN]:

Physician Orders Treatment: Diabetes (HgA1C) HTN, CHF, Renal Failure

Head to Toe Assessment & Initiates treatment protocols

Dietitian Maximizes nutritional status: Vitamin C Zinc & Protein

Social Worker Supports & Assists with psychosocial needs

Focus On Residents Needs & Risk factors

Activity Team Maximizes & Encourages activity, and mobility

PSW/HCA
Control/Prevent

Moisture, Incontinence, Friction & Shear

Rehab (PT/OT) Assesses and eliminates risk for pressure i.e. seating cushion(s)

Staff Educator Educates patient, front line nursing staff & family

By Janusz Kaleta

Program Outcomes
Strategies to relieve pressure from bony prominences: Develop, implement and update an interdisciplinary plan of care. Use pressure offloading devices (e.g., pillows, foam wedges, ROHO cushions, and heel boots). Turn to either side at small increments. Avoid positioning at 90 degrees over the trochanter. Maintain the head of the bed less than 30 degrees. Change angle of reclining chair a minimum of every 2 hours. Avoid any layers of padding between residents skin and relief surface. Maintain clients proper body alignment and position of comfort. Refer to OT/PT for seating assessment and seating devices Evaluate and document preventative interventions and resident outcomes The CVT Team was able to achieve a statistically significant decrease in the incidence of new pressure ulcers as well as worsening of the existing pressure ulcers (see below Q4: Jan., Feb, March) The Interprofessional team at Cedarvale Terrace LTCH was focused on residents complex needs and recognition that the successful approach is one that involves the whole person. Significant outcomes (as much as 50% decreased) in the area of prevention of pressure ulcers were accomplished through active listening and understanding the residents unique risk factors. Implementation of prompt interventions such as control of microclimate, skin moisture, and voiding schedule was recognized as a simple and yet very basic and effective intervention. Significant results included: decrease in newly acquired stage 2 to 4 pressure ulcer from 4.5% to 2% which is under the provincial average of 2.5%. Further the incidence of worsening pressure ulcer stage 2 to 4 was decreased from 5.2% to 2.6% which is also under the provincial average of 2.7%; and existing stage 2 to 4 PU decreased from 11.8% to 7.0%. Data as determined by the Canadian Institute of Health Information (CIHI). As with every Quality Initiative it is imperative not only to work towards improvement but also to sustain it within any given clinical environment. This is often the most challenging phase and one that requires all team members support. Natural Champions emerge often from among the nursing staff as was the case on a specific unit at Cedarvale Terrace. One unit of 42 residents did not have any pressure ulcers for 5 months (Jun. Oct. 2012).
14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% Q4 2010 CIHI Provincial Average Q4 2011CIHI Provincial Average Q4 2010 CVT Q4 2011CVT

Has a New stage II to IV Pressure Ulcer Worsened stage II to IV Pressure Ulcer Has a stage II to IV Pressure Ulcer

Pressure Ulcer Stage

Suggested Treatment
Assess Area / Remove Pressure 1. Cleanse with Normal Saline ( N/S) pat dry 2. Apply skin barrier (CAVILON lotion) 3. Apply OPSITE FLEXGRID (change Q weekly-stretch removable technique) 4. Turning schedule at least Q2hours 5. Prevent: Friction/Shear/Pressure
*Use Barrier Lotion (i.e. 3M CAVILON, SWEEN 24) *Refer to Registered Dietitian *Refer to Skin & Wound Coordinator

Rationale for Intervention

Normal Saline not harmful to tissue 3M CAVILON Durable barrier cream / pH balanced, concentrated protects skin / affected area from moisture / friction and irritants. OPSITE FLEXGRID A moisture vapor permeable, transparent film with measuring grid to assess wound size Update Care Plan / Q Weekly Notes Resident Centered Assessment to determine etiology of the pressure ulcer and: vascular assessment, relevant diagnosis. CAVILON No Sting ETOH free, barrier film, protects intact or damaged skin from urine, feces TEGADERM Ag mesh antimicrobial silver dressing /nonwoven with silver sulfate. Silver ions create effective antimicrobial barrier for up to 7days. Refer to ET Nurse for Assessment Risk for bacterial burden Infection /Pain Assessment/Assess Exudate for: amount/colour/& odour TEGADERM Hydrogel Wound FillerNon-cytotoxic / preservative-free. Promotes moist wound environment Indicative for autolytic debridement TEGADERM Foam highly absorbent reduce risk for skin maceration Refer to MD to rule out bone involvement (osteomyolytis) Refer to ET Nurse for Assessment Assess for Infection A/B Treatment Surgical evaluation may be indicated (debridement of eschar) Low Air Loss Air Mattress if available should be provided forthwith Irrigation of wound bed with N/S and 25cc syringe to cleanse wound

Assess Area /Pain/ Remove Pressure 1. Cleanse / irrigate with N/S pat dry 2. CAVILON No Sting to periwound 3. Apply TEGADERM Ag Mesh (cut to size of the crater) 4. Cover with TEGADERM Hydrocolloid Thin Dressing 5. Change Q M-Thu-Sun + PRN
*Refer to: RD, Skin & Wound Coordinator *Refer to RPT if resident uses w/c or cushion

Assess for Infection/Remove Pressure 1. Cleanse / irrigate with N/S pat dry 2. CAVILON No Sting to periwound 3. TEGADERM Hydrogel Wound Filler to base of the wound 4. Apply TEGADERM Ag Mesh 5. Cover c TEGADERM Foam 6. Secure with TEGADERM roll tape 7. Change Q Mon-Thu-Sun +PRN Assess for Infection/Remove Pressure 1. Cleanse / irrigate with N/S pat dry 2. CAVILON No Sting to periwound 3. TEGADERM Hydrogel Wound Filler to base of the wound 4. Apply TEGADERM Ag Mesh to tunneling and / or undermining 5. Cover c TEGADERM Foam 6. Secure with TEGADERM roll tape 7. Change Q Mon-Thu-Sun +PRN

References: 1) RNAO Nursing Best Practice Guideline for Assessment and Management of stage I to IV pressure ulcers (2007) 2)
Sibbald RG, Williamson D, Orsted HL, Cambell K, Keast D, Krasner D, Sibbald D. Preparing the Wound Bed Bacterial Balance, and Moisture Balance. Ostomy/Wound Management 2000; 46(11):14-35 3) 3M Products description 2011, 4) Pictures KCI Medical Canada, Inc. Janusz Kaleta 2011

References: Bennett G, Dealey C, Posnett J. The cost of pressure ulcers in the UK Age Ageing 2004; 33(3):230-5. Blumenthal S, Skefos C, Oppenheimer J, Clarke A. Putting Prevention into Practice in Health Care Reform. Available at: http://www.huffingtonpost.com/susan-blumenthal/putting-prevention-intop_b_239260.html European Pressure Ulcer Advisory Panel Development of International Pressure Ulcer Guidelines Available at: http://www.pressureulcerguidelines.org/ Gupta S, Ichioka S. Optimal use of negative pressure wound therapy in treating pressure ulcer. Int. Wound J 2012; 9 (Suppl. 1):8-16 International Guidelines Pressure Ulcer Prevention: Prevalence and incidence in context. A consensus document London: MEP Ltd, 2009. Registered Nurses Association of Ontario (RNAO) Nursing Best Practice Guideline: Assessment and Management of Venous Leg Ulcers Toronto: RNAO. 2005. Available online at www.rnao.org/bestpractices/ Sibbald RG, Orsted HL, Schultz GS, Coutts P, Keast D. Preparing the wound bed 2003 Ostomy/Wound Management 2003:49(11):24-51. Sibbald RG, Cameron J. Dermatologic aspects of wound care. In Krasner DL, Rodeheaver GT, Sibbald RG, (Eds.). Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, Third Edition Wayne, PA: HMP Communications. 2001. Organization for Economic Co-operation and Development OECD Countries Spend Only 3% of Healthcare Budgets on Prevention, Public Awareness. Available at: http://www.oecd.org/document/0/0,2340,en_2649_33929_35625856_1_1_1_1,00.html Woodbury MG, Houghton PE. Prevalence of pressure ulcers in Canadian health-care settings Ostomy/Wound Man 2004; 50(10):22-38. Quality Monitor, Health Quality Ontario. 2012 Report on Ontarios Health System