Pressure ulcers/injuries are significant health issues and one of the biggest challenge’s facilities face on a day-to-day basis. Preventing pressure injuries has always been a challenge, not just in long term care, but for the entire health continuum. The presence of pressure ulcers is a marker of poor overall prognosis and may contribute to premature mortality in some residents, especially those with multiple comorbidities.
Before we discuss prevention, let’s talk risk. Several factors place a resident at risk for developing a pressure ulcer/injury. All residents should be evaluated for pressure ulcer risk with a validated risk assessment tool (i.e. Braden or Norton) periodically through the length of stay including within the first 24 hours of admission/readmission, once weekly for the first four weeks, quarterly, and with a change in condition. While these risk assessment tools generate a total score indicative of risk level, we must review each triggered risk category separately. It is also important to communicate any risks identified that may contribute to pressure ulcer/injury development and the interventions the facility staff will be implementing to mitigate the risk(s) as much as possible. A risk assessment must be used in combination with clinical judgment to assess each resident’s unique pressure ulcer risk(s), so that a person-centered, individualized plan of care based on specific risk factors and comorbidities can be developed.
Pressure ulcer prevention requires an interdisciplinary approach to care. Some parts of pressure ulcer prevention care are highly routinized, but care also must be tailored to the specific risk profile of each patient. Consistent and thorough assessment of skin integrity, including evaluation of current unhealed pressure ulcers is a key process for preventing and/or healing pressure ulcers/injuries. A head-to-toe skin examination should be completed at specified frequencies to identify any impairment to skin or potential complications. No individual clinician working alone can prevent all pressure injuries from developing. Rather, pressure injury prevention requires action among many individuals, including the multiple disciplines involved in developing and implementing the care plan. Best practice dictates that an initial skin assessment is performed within hours of admission as an individual can potentially develop a pressure ulcer/injury within hours of the onset of unrelieved pressure. Following this baseline evaluation, a full skin assessment should be performed no less than once weekly.
The National Pressure Injury Advisory Panel (NPIAP) lists 5 strategies to consider in pressure ulcer prevention:
- Risk Assessment should be considered as the starting point. The earlier a risk is identified, the more quickly it can be addressed. Skin and tissue assessment is important in pressure ulcer prevention, classification, diagnosis, and treatment. The condition of skin and underlying tissue can serve as an indicator of early signs of pressure damage.
- Use a structured risk assessment tool to identify patients at risk as early as possible.
- Refine the assessment by identifying other risk factors, including existing pressure injuries and other diseases, such as diabetes and vascular problems.
- Repeat the assessment on a regular basis and address changes as needed.
- Develop a plan of care based on the risk assessment. Prioritize and address identified issues.
- Skin Care. Protecting and monitoring the condition of the patient’s skin is important for preventing pressure sores and identifying Stage 1 sores early so they can be treated before they worsen. Preventive skin care not only protects the skin and promotes comfort, but also provides an opportunity to conduct a skin assessment and identify areas at risk that may require further preventive care and/or changes to the individual’s overall pressure ulcer prevention plan.
- Inspect the skin upon admission and at least daily for signs of pressure injuries.
- Assess pressure points, temperature and the skin beneath medical devices.
- Clean the skin promptly after episodes of incontinence, use skin cleansers that are pH balanced for the skin, and use skin moisturizers.
- Avoid positioning the patient on an area of pressure injury.
- As it is not always possible to identify erythema on darkly pigmented skin; localized heat, edema, and change in tissue consistency in relation to surrounding tissue (e.g., induration/hardness) are important indicators of early pressure damage to the skin in individuals of darker skin tone.
- Both inadequate nutritional intake and poor nutritional status (malnutrition) have been shown to correlate to the development of pressure ulcers, pressure ulcer severity, and protracted healing of wounds.
- Use a valid tool to assess the patient’s risk for malnutrition.
- Refer at-risk patients to a registered dietitian or nutritionist.
- Assess the patient’s weight regularly, as well as the adequacy of oral, enteral and parenteral intake.
- Provide supplemental nutrition as indicated.
- Positioning and Mobilization. The underlying cause and formation of pressure ulcers is multifaceted; however, by definition pressure ulcers cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in ischemia and inevitable tissue damage.
- Turn and reposition at-risk patients, if not contraindicated.
- Plan a scheduled frequency of turning and repositioning the patient.
- Consider using pressure-relieving devices when placing patients on any support surface.
- Consider the patient’s body size, level of immobility, exposure to shear, skin moisture and perfusion when choosing a support surface.
- Monitoring, Training and Leadership Support. In any type of process improvement or initiative, implementation will be difficult without the right training, monitoring and leadership support.
- Monitor the prevalence and incidence of pressure injuries.
- Educate and train all members of the interdisciplinary team. Make sure they are aware of the plan of care and that all care is documented in the patient’s record.
- Ensure leadership support, oversight and allocation of adequate resources.
Pressure ulcers/injuries also affect more than just the health of our residents. Not only are pressure ulcers/injuries a long stay measure, starting in October 2020, pressure ulcers/injuries became part of the Skilled Nursing Facility Quality Reporting Program (Percentage of SNF residents with pressure ulcers/pressure injuries that are new or worsened). The SNF QRP measures are currently frozen due to the COVID-19 public health emergency, however, facilities are still able to view up-to-date reports in CASPER to monitor outcomes and compliance with the reporting threshold. Because of these QM inclusions, it is important to code pressure ulcers that were present upon admission/entry or reentry correctly. MDS coding of specific items impacts these quality measures and in turn, the CMS quality measures star rating. For example, Section M coding will indicate whether or not a pressure ulcer was present upon admission, developed or worsened under our care. Additionally, if specific ADLs in Section G are not reported accurately, residents may be excluded from your High-Risk Pressure Ulcer QM denominator and obscure the facility prevalence rate. Ensuring your facility has a strong system in place mitigating pressure ulcer development and prevention is critical, as well as ensuring coding accuracy and monitoring quality measures.
- National Pressure Injury Advisory Panel (NPIAP). Pressure Injury Prevention Points (accessed May 4th, 2021). Prevention Points | National Pressure Ulcer Advisory Panel (npiap.com)
- National Pressure Injury Advisory Panel (NPIAP). Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. (accessed May 4th, 2021) NPUAP-EPUAP-PPPIA CPG 2014.pdf (andeal.org)
- Joint Commission. Preventing Pressure Injuries. (2021). Retrieved from: quick_safety_issue_25_july_20161pdf.pdf (jointcommission.org)
- National Pressure Injury Advisory Panel (NPIAP). Unavoidable Pressure Injury during COVID-19 Pandemic (2021) Unavoidable_in_COVID_Pandemi.pdf (ymaws.com)
- The National Pressure Ulcer Advisory Panel (NPUAP) – Educational & Clinical Resources http://www.npuap.org/resources/educational-and-clinical-resources/
- Centers for Medicare and Medicaid Services (CMS). (2020, January 1). MDS 3.0 Quality Measures USER’S MANUAL, 13.0. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIQualityMeasures