Long-Term Care Survey Alert

Published on Sun Aug 31, 2003 PDF

Variation is the enemy of quality, according to quality assurance forefather Edward Deming ... so it stands to reason that a uniform approach to skin care should prevent avoidable pressure ulcers - and F314 tags.
 
By implementing standardized prevention, a facility doesn't have as many "decision points" where staff have to get pressure-reducing surfaces in place when a resident's risk level suddenly changes, says Janet Marron, a nurse and president of Wound Care Solutions Inc. in Baltimore, MD. "Those decision points are where pressure ulcers are likely to occur," Marron emphasizes. A Stage 1 decubitus ulcer can develop quickly and progress to a Stage 2 pressure ulcer within hours or days if you delay getting a preventive mattress, or mattress coverings and other interventions in place.
 
And facilities can eliminate the variance in interfacing pressure on resident's skin without breaking the bank, Marron maintains. "Foam overlays can be purchased for less than $30 per bed," she notes. "High-density foam that holds 8 pounds per square foot is considered good pressure reduction. Many of these high density foam overlays come with a plastic sheath to protect the foam from moisture. Thus, pressure reduction for a 100-bed facility would be less than $3,000 total, as opposed to $10,000 to replace mattresses of no greater efficacy," Marron says.
 
To flag residents at higher-than- average risk for skin breakdown, Marron advocates foregoing the Braden assessment or other comparable tools and asking a simple, but highly sensitive assessment question: Is the resident ambulatory or non-ambulatory? "This question captures a larger risk group, resulting in less variance in nursing assessment - and therefore, less variance in nursing interventions and more stable outcomes," she says.
 
The Braden scale uses triggers based on risk assessment and is designed for an acute-care setting rather than long-term care, according to Marron. "Long-term care residents are so at risk for pressure ulcers that those who are ambulatory may do fine," she explains. "But if they develop a cold or otherwise become ill and get in the bed, they are suddenly much more at risk for developing skin breakdown - and it's hard for a facility to track those changes and react fast enough to prevent skin breakdown." The non-ambulatory classification also encompasses wheelchair-bound residents, which is important because staff sometimes views these individuals as being "up" when they are actually at high risk for skin breakdown.
  
The non-ambulatory residents automatically receive a standardized regimen of turning and repositioning and other more intensive interventions, such as use of a moisture barrier at all times. Tip: Don't overlook preventive measures for wheelchair- bound residents. "CNAs tend to do a good job turning patients who are in bed, but residents sitting in wheelchairs may not get the repositioning and weight shifting they need to provide adequate pressure relief," notes B.J. Collard, a nursing consultant with CTS Inc. in Denver.
 
To ensure the success of their skin care programs, facilities must also eliminate variance in implementation of preventive services. That's where nursing managers go on the floor and determine if staff are turning and repositioning residents and following through with the other interventions.
 
The managers can then focus their teaching on caregivers who aren't complying with the plan of care. Marron suggests providing daily feedback to caregivers to reduce variance in care.
 
Tip: Involve CNAs in peer review programs to assess performance and outcomes in pressure ulcer prevention. (See the skin care management form and the wound care payment tip articles.)