Pressure Ulcers Etiology
In a small nursing and rehabilitation center serving 102 residents, we have developed an innovative management team who utilizes consistent standards to heal pressure ulcers. Pressure ulcers are a major complication associated with the loss of mobility, activity, increased moisture, poor nutrition, friction, shear, and altered sensory perception. They are caused by unrelieved compression of the blood vessels and tissues resulting in the lymphatic system not filtering waste products. This tension restricts blood circulation causing a lack of oxygen and nutrients over a certain time span resulting in tissue damage to the skin. The elderly resident in a skilled nursing facility is often admitted with or at high risk for pressure ulcers.
Wound Care Team
The skilled nursing facility has interdisciplinary team members. In 2007, the Nursing Director established regular teams for different aspects of care. The skin care team included an educator, a wound care physician, a registered dietitian, a licensed practical nurse, a physical therapist and a certified nursing assistant. This nursing home has established a proactive program to prevent residents without pressure ulcers from developing them, unless unavoidable due to the resident’s conditions. Oceanview promotes the healing of residents who have on admission or have developed pressure ulcers in-house by providing necessary treatment and services, preventing infection, managing pain and preventing new skin breaks.
Establishing Root Cause
This facility identified the root cause of nosocomial and non-healing pressure ulcers to be problematic in that resident’ risk factors were identified but not mitigated by the team. Prior to 2007, the team did not do rounds together, did not include unit staff and had no consistent physician assigned to assess progress on a weekly basis. This inconsistency leads to poor communication between team members. Resident physician orders went unchanged even when pressure ulcers worsened or did not heal due to lack of consistent information. Nurses did report acute symptoms such as vital signs results (i.e. temperature over 100), laboratory values (i.e. elevated white blood count) and acute wound abnormalities (i.e. pus drainage) to the attending not the wound care physician. Attending physicians reviewed four weeks of data, examined resident with monthlies, and occasionally were found inconsistent in documentation.
The plan of correction established by the Director of Nursing and Educator included developing a policy and procedure for skin care based on best community practices. The policy and procedure begins on admission assessing resident for skin breaks and areas at risk for pressure. Each day the nursing assistant validates skin integrity of their residents. The changes in the skin integrity are reported immediately to the unit nurse (the unit nurse informs the RN supervisor). The nursing assistant documents skin integrity findings on the certified nursing assistant accountability record each day. The registered nurse or unit nurse reports any changes to the physician on-call immediately.
For any new skin break an investigation (quality assurance audit is completed by the nursing supervisor) is initiated to determine causality (scratch, skin tear or pressure site). The unit nurse follows the chain of command and report findings. Audits are trended and reported into the Infection Control Committee (a sub-committee of performance improvement committee). The unit nurse informs the physician and obtains a treatment order on day of discovery. This investigation determines if the skin break was avoidable or unavoidable; and root cause of the condition or problem.
When a wound is present, weekly skin care team evaluations occur and the residents’ response to treatment is documented on a flow sheet. Interventions will show a team collaboration to reduce pressure, eliminate or lower risk factors and provide appropriate treatments according to residents’ conditions and circumstances. Interventions are carefully tailored for each individual through weekly rounds and care plan updates.
Quarterly care planning meetings often include the resident or designated representative (when they can attend), caregiver and interdisciplinary team members. Many of our residents have various wounds, other than due to pressure. Residents with arterial/ venous insufficiency (peripheral vascular disease/ stasis ulcers), diabetic, or surgical wounds are younger than the population with pressure ulcers. Utilization of a local hospital’s wound center for vascular, diabetic and surgical wounds are made when pertinent to diagnosing or evaluating treatment options. Management of these other wounds are more challenging as residents often do not wish to raise legs, wear special hose, follow diets, or have dressing changed, per physician orders for frequency. This mixed population demands weekly education with physician present. Important considerations include residents’ mental competency, danger to self or others with refusal, prior life style preferences and resident’s goals and objectives for his/ her health and happiness. The team feels that appropriate care is a balance between what is needed and safe versus individual rights and preferences.
Mitigating Risk Factors
The comprehensive care plan is established to include risk, skin break reasons,
resident’s strengths or weaknesses, goals, time frames, measurable objectives, interventions and periodic evaluations. Care plans must mitigate and lower risk factors that support appropriate interventions (e.g. - high risk due to immobility might lead to interventions that include (not limited to) exercise rehabilitation program, turning and repositioning, and/ or toileting schedule. The team monitors plan for needed change at least quarterly (and more often to add or delete interventions). Outcome of the pressure ulcer healing progress is noted. A high percent (above 98%) of residents with pressure ulcer were admitted with their skin breaks. The skin care team concentrated more on the risk factors and healing rates rather than the quality indicators of high risk pressure ulcers.
1. Rates for high-risk pressure ulcers:
Observed Percent Range
From 57% to 0%
From 50% to 8.3%
From 30% to 0%
15% (thus far, 10 months)
2. Healing rates:
Not measured consistently
Unable to determine
From 7 to 0
From 7 to 1
In 2007 the new program was created and its implementation depended on proper recruitment and much education. The healing average per month increased from 1.8 to 3.9 over the two-year span. This calculates to an average of 2.1 more pressure ulcers that were healed each month of 2009 compared to 2008. In 2009, both units had improvements in healing rates and both units won awards for pressure ulcer healing rates.