Wound Care: Winning the Battle over Pressure Ulcers

Understanding the seriousness and complexity of pressure ulcers relating to continuum of care requires addressing government regulations, legal responsibility, appropriate medical practice guidelines and financial responsibility.

Pressure ulcers remain an area in medicine where worst practices are more common than best practices. With that said, it is paramount that clinicians understand their fiduciary responsibility to the patient.

To follow the appropriate standard of care, the caregiver must recognize the problem, understand the problem and then address the problem. For years in the medical industry, many people within a medical setting have recognized the problems of pressure ulcers and have addressed the problem, but do not understand the pathophysiology of a pressure ulcer. In addition to the pathophysiology, many people lack the understanding of the basic science of products being utilized for pressure ulcer prevention and treatment. This lack of proven problem-solving technique has led to little, if any, decrease in pressure ulcer development.

Patients at risk of developing pressure ulcers and those who had existing pressure ulcers are often under-treated.

With stress growing for quicker hospital discharges and increasing patient acuity, pressure ulcer assessment and management are important areas for education and quality improvements in home care. Patients at risk of developing pressure ulcers and those who had existing pressure ulcers are often under-treated.

Once the awareness of the problem has been noted, then an understanding of the problem must be addressed. A pressure ulcer is a mechanical stress (pressure, shear, friction) that causes ischemic necrosis of at risk soft tissue. Candidates are predominately nutritionally deficient and have mobility limitations and are using support surfaces. Little is known about predicting pressure ulcer development in home health care patients. The few studies conducted in this setting found that urine or fecal incontinence, altered levels of activity and mobility, recent discharge from an institutional setting or more functional impairments were associated with the presence of a pressure ulcer.

In understanding the relationship between soft-tissue injury and support surfaces, we must accept that the human body is three-dimensional and when a support surface delivers a gradient pressure or shear mechanical stress, the soft tissue will then become distorted. This distortion causes a change in the velocity and flow pattern of the circulation, causing endothelial cell damage. This damage can result in ischemia and possibly infarction of the soft tissue at risk that is trapped between the bony prominence of the skeletal press and the extrinsic support surface. When this ischemic event is combined with reperfusion injury and lack of reactive hyperhemia reserve in an at-risk patient, one now better understands the concept of deep tissue injury and necrosis. Most importantly, it is important to have an understanding that there is a time delay of up to three to seven days for pressure ulcers to be clinically recognized from time of the causive event. This understanding enables the clinicians to better recognize and document medical conditions that can and cannot be modified allowing one to be able to determine avoidable versus non-avoidable pressure ulcers. This has tremendous clinical outcome, regulatory, legal and public relations ramifications.

When one understands the pathophysiology of pressure ulcer formation, the basic science relating to the support surface should be addressed. The various basic science disciplines of chemistry, physics, mechanics and others can help the clinicians understand the mechanical stresses that will be delivered to the patient at risk for pressure ulcer development. The media from which the support surface is made must be evaluated based upon scientific facts and studied by three-dimensional, not two-dimensional means. Pressure mapping relies of a two-dimensional measurement. For a more accurate evaluation, three-dimensional volumetric measuring techniques such as CT scanning or MRI scanning should be conducted on the soft tissue at risk.

Volumetric support can only be delivered by a static fluid (gas, liquid, sol) media within an appropriate container that is properly filled or inflated and is pliable yet durable. Mother Nature has chosen a static fluid environment for the development of the fetus and life in an atmosphere (gas) or water (liquid). A properly made and used static fluid product creates an equalized distribution of the body?s weight. This allows the patients physiologic system to auto regulates itself to the best obtainable level of health. If homeostasis is maintained, the patient has a better chance not to develop a pressure ulcer. Selection of a proper support surface is a modifiable factor when trying to prevent or treat a pressure ulcer. No one product type is appropriate for every patient?s needs. Knowledge about how products work and how they affect the at-risk patient is imperative.

The lower extremity cannot be protected from pressure ulcer development nor relied on for treatment of an existing pressure ulcer with use of a support surface alone at all times. With the recumbent physiological changes resulting in homodynamic variations, coupled with the anatomy of the ankle/heel/foot complex, creates a very difficult prevention/treatment scenario of pressure ulcers of the lower extremity. Additional devices may be required depending on various factors such as mobility and ambulation along with other general medical problems such as the cardiovascular health of the patient.

The usage of pressure reducing devices alone can cause an increase in the incidence of pressure ulcer development while protocols decrease the incidence by 50 percent or greater. Protocols are crucial in developing and implementing a seamless continuum of care. Protocol should be able to be individualized so a care plan can be developed and followed for each individual patient. Factors to be considered for developing a standardized protocol might include nutrition and hydration, mobilization and ambulation, support surface selection, lower extremity protection, incontinence care, wound care, care of other general medical conditions and continuum of care responsibilities. For the continuum of care to be properly implemented, the individualized care plan based on the standardized protocol must be understood and followed by all caregivers combined with a timely assessment and risk analysis upon admission. The care plan must continue after admission with scheduled assessments throughout the patients stay and discharge to the next level of care.

One must remember that health-impaired people are susceptible to pressure ulcer development as long as the risk factor remains. Prevention and treatment strategies for pressure ulcers were found to be limited before admission to homecare. Since pressure ulcers can occur on any surface in a short period of time, support surface protection should occur immediately and be maintained throughout the continuum of care within a facility as well as inter-facility transfer.

The problem remains that only 54 percent of patients with pressure ulcers were placed on a pressure reducing device upon discharge and only 18 percent of those at risk for developing new pressure ulcers were receiving pressure reduction devices at time of discharge. A care plan should follow a patient to the next level of care. To accomplish this appropriately, adequate medical staffing levels with appropriate abilities must be combined with appropriate material resources. The need to inform, educate and help the patient or caregiver about the risk of pressure ulcer development or the requirements to heal an existing pressure ulcer is not only appropriate medical care, but is required by governmental regulations. This seamless continuum of care compares to a well-trained relay race team that practice and communicate with each other so as not to drop the baton.

Appropriate staffing levels and skills have been studied to determine the appropriate levels needed to decrease the risk of pressure ulcer development. The selection of appropriate products is difficult at times due to profit motivations by some facilities to use low price, ineffective products or expensive products that are reimbursed at higher levels with no proven improvement in care. Difficult requirements to obtain insurance reimbursements, even though there is a medical necessity for the use of specific products, creates a disconnect in care if products can not be obtained at a reasonable cost. A new medical product delivery system utilizing patient direct sales will evolve as the medical industry goes from a reimbursement-driven system to a consumer-driven system for purchasing of products period.

In conclusion, the pressure ulcer problem must be addressed by an individualized care plan that considers multiple risk factors. This care plan must be the glue to a seamless continuum of care for that patient. Continuum of care must have appropriate staffing levels with adequate skill as well as having access to products and services that are cost-effective, not the cheapest or the best profit generating. Until this seamless approach is accomplished, avoidable pressure ulcer development, patient morbidity and death, citations, civil penalties and litigation will continue.

This article originally appeared in the March 2005 issue of HME Business.

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