Decreasing the Incidence of Heel Pressure Ulcers in Long-term Care by Increasing Awareness: Results of a 1-Year Program

  Extended care involves numerous medical regimens relevant to diverse concerns such as higher patient acuity, rehabilitation, and terminal illness. Some long-term care facilities offer skilled nursing care comparable to subacute units; rehabilitation is a major focus so patients can gain strength and prepare for discharge to a community setting. The development of pressure ulcers not only thwarts the rehabilitation process, but also lengthens stay, causes unnecessary pain, and financially strains the already burdened medical community.   The incidence of heel pressure ulcers has been described to range from 19% to 32% in acute care facilities.¹ Common risk factors for their development include immobility of the lower extremities due to cerebrovascular accident, hip fractures, diabetic neuropathy due to diabetes mellitus, structural deformities resulting in pain, and peripheral vascular disease.² Drennan³ observes that the incidence of sacral and trochanteric ulcers may be decreasing but heel ulcer prevalence appears to be increasing; the heel is the second most common site for the development of pressure ulcers.⁴ Due to the thin layer of subcutaneous tissue in this anatomical location, a heel pressure ulcer can develop when a small amount of pressure is exerted on the heel for a short amount of time.⁴ Ulcers can occur from ill-fitting footwear, friction from rubbing feet across sheets, and direct placement of the heels on a support surface. Heel ulcerations can disrupt residents’ mobilitystatus, strip them of their dignity, cause pain, and in some instances result in the loss of a limb due to osteomyelitis.^2,4

  Reducing pressure ulcer incidence is one of the Healthy People 2010 objectives⁵ and the Centers for Medicare and Medicaid Services (CMS)⁵ has designated pressure ulcers as one of three sentinel events for residents in a long-term care facility who have been assessed as being at low risk using a pressure ulcer risk assessment scale. Only patients who are comatose, malnourished, have end-stage disease, or have impaired transfer or bed mobility are considered as being at high risk by the CMS.

  In the Guideline for Prevention and Management of Pressure Ulcers⁶ published by the Wound Ostomy and Continence Nurses Society, pressure ulcers are defined as areas of localized tissue destruction caused by the compression of soft tissue over a bony prominence and an external surface for a prolonged period of time. The National Pressure Ulcer Advisory Panel (NPUAP)⁶ defines Stage I pressure ulcers as “observable pressure-related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy), and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tone the ulcer may appear with persistent red, blue, or purple hues.”

  In an effort to reduce the 22.5% incidence of heel ulcers on a skilled care unit in a long-term care facility, a 1-year program to prevent their occurrence was implemented and evaluated.

Literature Review

  Few studies on prevalence and incidence rates of heel ulcers exist; those available tend to address patients in acute care settings and compare different offloading devices. A trial⁷ on a surgical ICU in which 140 patients were screened over 4 months found that hydropolymer foam dressings decreased the prevalence of heel ulcers 72% in 2 years. A study⁸ involving experimental balanced factorial design with repeated measures conducted among 52 patients compared the effectiveness of hospital pillows versus a commercial heel elevation device (the Foot Waffle, EHOB, Inc., Indianapolis, IN) in preventing heel pressure ulcers. No significant difference in incidence between groups using either approach to preventing/managing heel pressure ulcers was found; however, patients using the elevation device developed pressure ulcers sooner (10 days versus 13 days) than patients using a pillow. In a 3-year retrospective analysis⁹ of heel pressure ulcer treatment conducted among 100 patients in multiple healthcare settings, the Foot Waffle^® Air Cushion (EHOB, Inc. Indianapolis, Ind) was found to improve outcomes related to wound healing, wound closure, and reoccurrence when compared to the head pillow in all settings.

  Information on the prevention of heel pressure ulcers in long-term care is lacking. However,medical needs are changing, patient acuity is higher, and the elderly population is growing.¹⁰ Studies are needed to document the effectiveness of daily assessments, awareness of ulcer recurrence, and constant education on the development of heel pressure ulcers in long-term care in order to decrease the number of heel ulcers.

Methods

  Setting and participants. The program was conducted among 40 of 42 residents on a skilled care unit of a 470-bed, long-term care facility in Royersford, PA. This unit was randomly selected to represent the population of the 10-unit facility. The two residents who did not participate were bilateral amputees. Initial participants were followed for 1 year unless they were transferred to another unit, discharged from the facility, or deceased. No new residents were added to the initial program population. Thirty-seven staff members (RNs, LPNs, nursing assistants, and restorative aides – specialized aides who work with residents to maintain/improve present level of function) participated in the study.

  Because this was a nonpharmaceutical intervention and did not fall outside of the nursing standard of care, individual consents were deemed not required due to the general consent on admission for authorization for medical and/or surgical treatment. Permission to conduct the study was obtained from the Administrator, the Medical Director and the Skin and Wound Care Committee.

  Assessment and interventions. Participant demographic information was obtained at the beginning of the program and Braden Scale scores¹¹ were calculated on a quarterly basis by the licensed staff working on the unit (see Table 1 and 2). The data were collected, recorded, and maintained by the Certified Wound and Ostomy Care Nurse (WOCN). The Braden Scale scores were used to determine risk status of participants.¹² Regardless of the resident’s risk level, treatment was the same: offloading the heels and a daily assessment by the unit staff.

  An easy-to-use heel assessment form, denoting characteristics of Stage I pressure ulcers, was created by the CWOCN based on the National Pressure Ulcer Advisory Panel’s definition of a Stage I pressure ulcer Please visit www.o-wm.com/current issue for a printable version of the heel assessment form.

  Before starting the program, each staff member was trained by the CWOCN. Elements of training included program rationale, orientation to the heel assessment flow sheet, skin assessment (eg, erythema, bogginess, temperature) using visual and hands-on instructional methods, and proper offloading techniques involving pillows, foam blocks, foam splints, span-aids, and L’nard boots; a variety of options was provided so the offloading method most appropriate for each patient could be selected. Offloading method appropriateness was determined by the CNAs – the key players of the resident care system. Daily heel assessment responsibilities were divided among all three shifts and all nursing staff.

  Increasing awareness. The overall program theme was designed to reinforce the importance of floating heels using the image of kites. Kites were placed at the bedsides of each resident who had a pressure ulcer. Yellow, red, purple, blue, and black kites were used to identify Stage I, Stage II, Stage III, Stage IV, and unstageable heel pressure ulcers, respectively. Posters identifying these symbols and a photo poster to help identify each ulcer stage were displayed on the unit at various locations (see Figures 1 and 2). Pencils engraved with “Float Heels” were supplied for the staff to use. No other changes in overall care were made.

  Procedure. On April 3, 2005, the first day of the program, the CWOCN assessed all residents’ heels on the skilled care unit and the baseline prevalence rate was calculated. Because Stage I pressure ulcer data were not routinely collected before program initiation, the actual onset of Stage I heel ulcers present on that day was unknown so April 3, 2005 was used as the onset date of all existing Stage I heel ulcers. For the remainder of the program, heel assessments were performed by the unit’s staff and the forms were collected at the end of each month by the CWOCN, at which time data were interpreted, incidence rate calculated, and results recorded.

  The incidence rate was calculated using data from the last day of each month – incidence rate was the number of new residents who developed pressure ulcers during the month divided by the number of participants on the last day of the month. The CWOCN also monitored and manually recorded the deaths, transfers, and discharges of participants each month. The CWOCN placed and changed the kites at participants’ bedsides as pressure ulcer stages changed.

Results

  Of the 40 residents who started the program, 19 were men and 21 were women, mean age 67 years (range 16 to 99 years). Daily heel assessment form completion rates averaged 79%. Diagnoses included but were not limited to diabetes mellitus type 1 and type 2, arterial and venous insufficiency, congestive heart failure, anemia, Alzheimer’s disease, myocardial infarction, and cerebral vascular accident (see Table 1). After 1 year, 17 of the original 40 residents remained. At the start of the program, 50% of participants were assessed as being at low risk, 32.5% were considered moderate risk, and 17.5% were considered high risk per the Braden Scale. At the completion of the study, 47% of the participants were considered low risk, 29% were considered moderate risk, and 24% were considered high risk (see Table 2).

  Eleven (11) of the40 participants had a total of 15 heel pressure ulcers when the program started (prevalence rate 22.5%): 13 had Stage I, one had Stage IV, and one had an unstageable heel pressure ulcer. At the end of the program, no participants had pressure ulcers – ulcers present at start of study and ulcers that developedduring study had resolved. All heel pressure ulcers that developed during the study were Stage I (early detection facilitated by daily assessment) (see Table 3).

Discussion

  The results of this program confirm that increased caregiver awareness, staff education, regular assessments, and preventive measures help reduce the incidence of heel pressure ulcers. While the risk of developing pressure ulcers in participating residents changed slightly during the 1-year program, overall, the number of new ulcers decreased substantially.

  Studies have shown that staff education plays an important role in preventing the development of pressure ulcers. Staff numbers also may affect pressure ulcer development by limiting time for care. A statewide survey¹³ involving 8,670 acute care registered nurses implemented in 1999 reflected that workload affects quality of care and plays a role in patient safety (ie, the heavier the workload, the less time for actual one-on-one nursing care). Another study¹⁴ that examined the effects of additional education on 83 baccalaureate students in a Brazilian nursing school found that students who pursued knowledge beyond the classroom setting (eg, through the Internet) scored higher on a pressure ulcer knowledge test.

  Current study results also confirm that Stage I ulcers are most common in the heel area, although this could have been a function of early detection (daily assessment) and prompt intervention. Preliminary results of extensive research by the US Department of Health and Human Services¹⁵ indicate a direct relationship between nursing hours and quality of care. Analysis of data collected as part of the retrospective National Pressure Ulcer Long-Term Study (NPULS) study¹⁶ of 1,376 residents in 82 long term care facilities found that higher staff numbers correlated with the development of fewer pressure ulcers. Even though staffing levels at the author’s facility were at or above minimum levels at all times, during vacation times regular unit staff often were replaced by staff members from other units who were not familiar with the program and had not received the same education and training. In July, some staff members were transferred from the unit and new staff members needed to be trained in the program procedures with a time lapse of approximately 7 days between transfer and program orientation. These findings suggest, again, that education and awareness affect the incidence of pressure ulcers.

  The strength of the program – consistent assessments of residents for a long period of time – also limited the sample size and ability to interpret outcomes for all residents. While program outcomes are very encouraging and confirm earlier published observations, no outcomes data from a non-intervention units were collected. This limits ability to interpret results. Also, should this study be repeated, pain and lack of/intense sensation should be included as part of the daily assessment because these were observed to be harbingers of skin breakdown.

Conclusion

  The results of a heel pressure ulcer awareness/prevention program suggest that the incidence of heel pressure ulcers can be reduced through increased staff awareness, education, daily assessments, and consistent interventions. Program costs were minimal and the results were encouraging. Studies to evaluate optimal heel pressure ulcer prevention strategies in long-term care environments are needed.

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