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A recent study by the University of California found that an increasing number of people are entering the home care environment with pressure ulcers. Does this mean that more health care professionals are tuned into what constitutes a pressure ulcer or does it mean that there are more people getting them? And in either event, what can be done to stop this from happening?
"The accepted number in 1966 was that at any time about 1% of the general population had pressure ulcers," says Ramon Carter, a principal in WoundHEAL, an Albuquerque, NM, research and education partnership between Meditrend Inc., R. Carter & Co., and its Medical Resource Group.
"The best number today is about 1.1%, but it’s generally accepted that about 1.5% of population at any one time has pressure ulcers," he says. "The question that flows from this is that we know what causes pressure ulcers, how to prevent them and how to successfully treat them, yet the increase is up between 10% and 50%. That’s between 60,000 and 80,000 people, depending on which source you use, who are dying annually as a direct result of bedsores. That’s a 737-plane crashing every day, and no one’s doing anything about it," Carter explains.
Ben Peirce, RN, CWOCN, national wound care manager for Sunrise, FL-based Gentiva Health Services, says there are a host of factors that have contributed to this rise, but among the most significant is that the population is getting older "by the hour, by the day, and by the year, so when you increase the number of older people, and as older people they are more at risk for pressure ulcers, you have more cases crop up."
He explains, "Another factor is shorter hospital stays. People might be going home sooner, but they are sicker than before they left and still need watching. And lastly, I think a major contributing factor is a knowledge deficit on the part of consumers as to the importance of the issue. People aren’t very often aware that there is a lot that can be done that is critical to preventing pressure ulcers," he adds. "Even long-term care programs need to keep up the nutrition level of the patient and address the issue of incontinence."
Carter sees a more insidious reason. "We have known what causes [pressure ulcers] for 40 plus years. We have solutions available, and Medicare has approved them for 30 years. . . . So why aren’t we stopping them? If you’re dealing with hospitals or certain medical service providers, they love surgery and a good mechanical sharp debridement is worth $20,000; a plastic closure is $40,000; and a flap is about $60,000.
"The bulk of these cases occur in Medicare patients in nursing homes," continues Carter. "There are two places where patients get them: An elderly person falls, breaks a hip, and goes to the hospital, and by the time they are out of hospital, they have a skin breakdown. And when nursing homes transfer patients from skilled nursing divisions to a Medicaid bed, as far as I’m aware, I’ve never seen one of these patients on a Class 2 support surface. The minute a patient gets two Stage 2 ulcers or one Stage 3 ulcer, you are required to put them on a certified Class 2 support surface, but no one does that. Instead, they get put on a nonrated foam that has no value other than comfort. Medicare declared years ago that they have no therapeutic value."
Aside from a person’s age, there are several factors that contribute to the incidence of pressure ulcers, notes Peirce. The most critical are a patient’s nutritional status, incontinence (short- or long-term), the patient’s activity level, and their level of sensory perception. Especially at risk in the latter category are those patients who have had strokes or are paraplegic or diabetic, he says. "Often these factors compound with each other. You’ll have [patients] who get ill and wait before going to the doctor until they are so very ill that their nutrition is not good at all. Then, if they are in the hospital for short while, they won’t move around much and their ability to be continent may be borderline. Give them some medication that makes them sedated and disoriented on top of that, and all these are ripe for a pressure ulcer."
If a patient is determined to be at risk, says Peirce, home care aides should give both written and verbal instructions on pressure ulcer prevention. Included in these instructions, as well as a patient’s care protocol, should be:
• Conducting a systematic inspection of the skin at least once a day with special attention to the bony parts of the pelvis.
• Cleansing susceptible areas as thoroughly and as frequently as possible — and at routine intervals thereafter — if the patient is incontinent. Peirce cautions that caregivers should avoid using hot water and stick to special moisturizing soaps such as Dove; to minimize skin trauma, cleansed areas should be patted dry.
• Applying moisturizing agents to dry skin but with caution to avoid massaging the bony areas of body.
• Providing a means of improving a person’s mobility and providing for padding over any bony prominence for patients with limited mobility.
Aside from looking at the areas mentioned above, Peirce places a strong emphasis on the issue of friction and shear: "You don’t want to drag or push patients in a way that will cause these forces on the skin." Don’t pay enough attention to these areas, he says, and "the best wound care in the world won’t heal them."
To reduce these two factors, when patients are turned or transferred from bed to chair and back again, there are some devices and tricks that home care aides and other caregivers should utilize. For starters, he says, patients should be repositioned every two hours with foam wedges or pillows used to protect bony prominences from pressure. "When you turn [patients] on their side, avoid turning them all the way so that the pressure on their hip is reduced. You want them to be 30 degrees from being flat on their backs," he explains. "Also, keep the head of the bed as low as possible unless indicated for another medical condition. If the head is elevated and the patient is sweating, [the] skin will stick to the sheets and as [the] skeleton slides to foot of the bed you’ll be creating a shear condition.
"One way to help is to use a lifting device like a trapeze positioned over the bed that allows patients to help move themselves up in bed rather than you dragging them up. And anyone at risk should be placed on pressure-reducing devices like foams, mattress replacements, static air-filled overlays, or alternating air or gel devices," Peirce explains.
But devices aren’t the only weapons in the battle against pressure ulcers. There are a lot of basic preventative and healing measures the family and home care aides can implement. "Adequate nutrition is so important for anyone who is frail. You want to keep them well hydrated, and, if they have reduced mobility, it’s so important to get them involved in rehabilitation efforts. Whether it’s the family, the home care aide, or the doctor or therapist, get them involved and let the patient know they need to start moving," Peirce states.
"If pain is a barrier, then get that addressed. What you don’t want is them in bed, not moving. Ulcers are often difficult to heal because the very things that are leading to the pressure ulcers are also leading to their lack of mobility. You want your loved one to realize that they don’t want to have a skin breakdown that will place them at risk for bone infections."
Just as patient education is vital to reducing the incidence of pressure ulcers, so is educating health care professionals. Peirce recommends that employees ask that the subject of pressure ulcers be added to an organization’s list of educational programs for the year, especially programs geared to the home health aide, because as he believes, "the most important members of the health care team when it comes to pressure ulcers are the home health aide."
Web sites (such as: www.ahcpr.gov and www.woundheal.com) provide a good source of information, as do subscriptions to medical journals. Peirce also recommends that health care professionals join state home health care associations where there will be more information and educational opportunities than they might be able to get through their agency alone.
WoundHEAL.com, explains Carter, was set up with the goal of educating patients and their families to the causes and treatment of pressure ulcers, along with providing some good advice on their prevention. "We hope we’ve provided the information in such a way that will enable either a family caregiver or service provider to solve the their problems, because most pressure ulcers are preventable. There’s just no excuse for most of them."
[For more information, contact:
• Ramon B. Carter, Principal, WoundHEAL.com@Meditrend Inc., 4820 Eubank Blvd. N.E., Albuquerque, NM 87111. Telephone: (505) 292-9358.
Ben Peirce, RN, CWOCN, Gentiva National Wound Care Manager, Gentiva Health Services, 1551 Sawgrass Corporate Parkway, Ste. 410, Sunrise, FL 33323. Telephone: (954) 851-1022.]