Reducing the Incidence of Pressure Ulcers in Nursing Home Residents: A Prospective 6-Year Evaluation

Abstract:

Despite numerous clinical efforts and regulatory mandates to reduce occurrence, pressure ulcers (PUs) continue to plague up to one fourth of patients in healthcare facilities. In 2003, staff and administrators of a 151-bed skilled nursing facility in the Midwest started a quality improvement project based on 1992 Agency for Health Care Policy and Research guidelines to reduce the incidence of facility-acquired PUs.

Pre-initiative PU data collection suggested a 12% to 25% PU prevalence rate with an average pre-initiative incidence of 5.19% (168 acquired ulcers over 3,234 person-months). During the next 4 years post-initiative, the average incidence was 0.73% (47 acquired ulcers over 6,446 person-months). Implementation of the comprehensive preventive efforts involving an interdisciplinary team with strong leadership, intensive training, use of evidence-based protocols, carefully evaluated support surfaces and wound/skin products, and simplification of processes led to a significant (P <0.0001) and sustained reduction in the incidence and prevalence of PUs. Additional observations included a simultaneous and unexplained reduction in resident falls and an overall cost reduction of more than $124,000 per year. These results confirm that nosocomial pressure ulcers can be significantly reduced in long-term care when well-established standard guidelines are followed.

Please address correspondence to: Aletha W. Tippett, MD, Advanced Wound Team®, 10274 Alliance Road, Cincinnati, OH 45242; email: tippettaw@fuse.net.

This article was adapted from a poster presentation at National Pressure Ulcer Advisory Panel Conference, Tampa, FL, February 25–26, 2005.

     Pressure ulcers (PU) have been documented for thousands of years, with early descriptions in autopsies of Egyptian mummies.¹ Even with modern medical knowledge, attention, and diligence, PUs remain a common health problem worldwide across a variety of healthcare settings.² Exact PU prevalence is not known; estimates range from 2.2% to 23.9% in the US, with persons admitted to healthcare institutions at particular risk.^3,4 Development of a PU can result in serious outcomes including pain, infectious complications, prolonged and expensive hospitalizations, persistent open ulcers, psychological harm, and increased risk for mortality.⁵ In addition to the cost in human suffering, the financial cost of treating PUs in the approximately half-million persons affected in the US⁶ totals more than $1 billion per year by some estimates.⁴ In consideration of the associated increased cost, morbidity, and mortality, one of the goals of the federal program Healthy People 20107 is to reduce PU prevalence by 50%. Despite intense attention, PU prevalence in the past two decades has nearly doubled, increasing overall from 9.2% in 1989 to 15.5% in 2003/2004 and nosocomial prevalence increasing from 5.6% to 10%.⁸

     In 2003, the 151-bed skilled nursing facility in this report had an estimated pre-initiative 12% to 25% prevalence of facility-acquired PUs, similar to the nationally reported nursing home average prevalence of 2.2% to 23.9%,^3,4 and an average incidence rate (number of acquired ulcers per total residents) of 5% per month (range 1% to 12% per month). Just before the program, the facility also had a G-level citation (“actual harm” deficiency).⁹ According to the National Pressure Ulcer Advisory Panel (NPUAP),⁴ although single sites may report pressure ulcer reduction of up to 50% or greater, no evidence of sustained nationwide reduction exists. Plus, although PU prevention guidelines are available and published, there is no consensus concerning best practices for prevention,¹⁰ so even modest reductions in incidence are noteworthy.⁴

     Motivated by state survey deficiencies and citations, in 2003, the facility in this report committed to change and embarked on a multifaceted approach to solving the problem of PUs by establishing a comprehensive, interdisciplinary wound program based on Agency for Health Care Policy and Research (AHCPR) guidelines.¹¹ The vision of the interdisciplinary team was to establish the facility as a recognized leader in the community for excellent wound care and wound care education and to enhance resident well-being by eliminating wounds. The goal was zero facility-acquired PUs. The purpose of this report is to describe: 1) the observed effects of this quality improvement effort, and 2) results of the prospectively collected pressure ulcer incidence data.

Methods

     Resident census, wound type, and size data of all skin wounds were collected weekly for each resident from January 2002 through November 2007, covering 2 years before the November 2003 implementation of the wound program and 4 years post-implementation. All data were collected by the same nurse and recorded according to facility procedures.

     PUs were categorized as either present on admission or facility-acquired (nosocomial) and were graded according to standard NPUAP guidelines¹² as Stage I, Stage II, Stage III, and Stage IV. Unstageable ulcers were designated Stage IV according to facility protocol. All stages of PUs were included in the data for incidence tracking. Because this was an internal quality improvement effort, no IRB involvement was required. Results reported are those generated by the quality improvement efforts.

     The main outcome of interest was the incidence of all stages of nosocomial PUs each month. Data were aggregated for analysis of monthly totals and the rate of nosocomial pressure ulcers (incidence)¹³ was calculated using the occurrence exposure rate equation: rate = number of PU/person-months x 100. Pre-initiative refers to data collected from January 2002 through November 2003; post-initiative (following implementation of comprehensive program) refers to data collected from December 2003 forward. Person-months were the number of residents each month (census for that month) added for the months studied.

     Data analysis. SPSS software (Chicago, IL) was used for statistical analysis. Arithmetic means were used for calculation. Welch’s t test was used to detect differences between pre-initiative and post-initiative nosocomial PU incidence rates in order to account for unequal sample sizes and unequal variances of the pre- and post-implementation populations.¹⁴ Significant differences were assumed when the P value was <0.05.

     Clinical process. The clinical process used to approach the wound problem first involved establishing a wound program based on strict adherence to AHCPR guidelines^11,12 with the following key tenets:

     • Forming an interdisciplinary team with strong leadership. The interdisciplinary team included a physician, the wound coordinator, nurse supervisors from each floor, a director of nursing (DON), a physical therapist (PT), a Minimum Data Set (MDS) nurse, an activities therapist, a nutritionist, a product supply clerk, one nurse aide (a rotating assignment), and a social worker. This group met initially to form goals and direction and has since met weekly. Part of this group — ie, the DON, physician, wound coordinator, nutritionist, and PT — also conducts bedside wound rounds on residents with skin problems. Use of an interdisciplinary team is well-accepted and, some would argue, obligatory^11,12,15-17

     • Providing intensive mandatory training for all staff on wound fundamentals; use of the Braden scale,¹⁸ wound assessment, treatment, and prevention; and use of support surfaces. While all staff were trained initially by the physician consultant, follow-up training has been conducted by the DON and nursing supervisors. The physician consultant has conducted yearly follow-up training sessions, which are mandatory for all staff. Additionally, inservices are provided routinely to keep staff up-to-date. Weekly informal feedback and one-on-one training are provided by nursing supervisors as needed. Effective training has been shown to be the primary tool for improving proper identification, prevention, and treatment of Pus.^19,20

     • Developing simple protocols for prevention and treatment of PU. Prevention protocols were based on Braden scale¹⁸ risk assessment following AHCPR guidelines.¹¹ Table 1 provides a summary of prevention protocols. All residents receive interventions 1 through 5, even if they are low risk on the Braden scale; residents at higher risk receive further interventions, up to 19. Thus, all residents have a preventive plan of care. Treatment is not discussed in this report.

     Protocols for prevention were shared in training classes and incorporated into part of the routine shift reporting and charting. Incentive programs also have been used to keep performance levels high — eg, judged competitions between floors on percent usage of prevention protocols with winners receiving a trophy and a lunch. These competitions have promoted teamwork and interest in the program.

     • Developing a simplified wound care formulary to include only those items used in preventive and treatment protocols, with the ability to use other products on an exception basis

     • Evaluating equipment for pressure management, following guidelines²¹ on types of products. A Delphi process²² was used to compare alternating pressure, foam, low-air-loss, static air, and gel products. Products were selected based on resident acceptance, documented evidence of safety and effectiveness, ease of use, and cost; ultimately, static air was selected. This evaluation was especially important due to the failure of the facility-wide use of alternating pressure pads (APP) to reduce PUs in the pre-initiative period.

     With this initiative, all nursing staff (not just the wound nurse or outside contractor) were made accountable for wound care and documentation. The role of the wound care coordinator was developed to supervise, train, provide clinical support, and track wounds. Before the program, a wound nurse performed all wound assessments; with the new program, this nurse became the wound coordinator. Once the program foundation was established and initial results achieved, preventive strategies evolved to the simplified approach that involved preventive care to all residents with attention to skin lubrication, pressure support for bed and chair, and heel protection.

     A unique focus was universal prevention mandated by the administrator based on results of the first 6 months of the program. Prevention was initiated when residents were admitted to the facility. Retrospectively, this is seen as a simplified stratification approach, with associated simplification of process.

Results

     The average monthly nursing home census during the study was 137 (range of 120 to 145; 151-bed capacity). Person-months in the pre-initiative period totaled 3,234; person-months in the post-initiative period totaled 6,446. Average pre-initiative incidence was 5.19% (168 acquired ulcers over 3,234 person-months). Average post-initiative incidence was 0.73% (47 acquired ulcers over 6,446 person-months), an 86% reduction, with an incidence of 0.06% for the program’s fourth year, a 99% reduction. These represent significant (P <0.0001) reductions in the incidence of monthly nosocomial pressure ulcers (see Figure 1). The facility achieved its goal of zero nosocomial ulcers by May 2004, the sixth month of the program, and demonstrated a clear and permanent decline in nosocomial PU incidence following the implementation of the wound program in November 2003.

     All ulcers that developed were Stage I or Stage II and were shown to occur as a result of failure to follow standard preventive measures. Ulcers were treated following AHCPR treatment protocols developed by the wound team¹² and resolved within 2 weeks. This rapid resolution of wounds, in addition to the reduction of wound incidence, reduced wound prevalence.

     Although incidence was the measure tracked, prevalence was easily computed. By definition, prevalence is the “proportion of a given population with a problem”¹³ — ie, the number of residents with a pressure ulcer divided by the number of resident-months at any given point. In the fourth year, only one acquired pressure ulcer occurred in nearly 2,000 resident-months, an almost zero prevalence. Based on the initial estimated 12% to 25% prevalence, this represents >99% reduction in prevalence.

     Ancillary benefit. An unexpected and unplanned corollary benefit of this initiative was a concomitant 37% reduction in falls, discovered during quality review meetings. Falls were reduced significantly (P <0.0001) from an average of 23.1 falls per month during the April through November 2003 time period to a post-initiative average of 14.6 falls per month. How this was related to the wound initiative is not known, but the timing is highly suggestive and the reduction in falls mirrored the reduction in wounds.

     Financial implications. This initiative had two main financial costs: 1) a contract with a physician wound consultant to provide team leadership and technical assistance at $20,000/year for the first three years, then $7,200/year as time-involvement decreased; and 2) purchase of pressure support surfaces for facility-wide use with a one-time expense of $11,000. Pre-initiative expenses for skin care supplies and equipment for preventive care averaged $865/month; these expenses averaged $665/month post-initiative implementation, a yearly savings of $2,400. No changes were incurred in staff costs, other than allowing wound team members to attend weekly meetings and mandating training of all staff. This did not involve any new staff positions or change in overall staff hours. In addition to the reduction in cost for preventive supplies, the cost avoidance due to the reduction in the number of wounds was also substantial. The average number of nosocomial ulcers was reduced from 7.3/month pre-initiative to 1/month post-initiative, an avoidance of 6.3 ulcers per month. Mean cost of treating a patient with a pressure ulcer was reported by Xakellis²³ in 1996 to be $4,467 for 116 days or $1,155 per month. Adjusting with the Consumer Price Index, a conservative estimate of medical cost increases,²⁴ 2008 cost would be $1,617 per pressure ulcer per month, representing a monthly savings of $10,187 and a yearly savings >$122,000. This estimate of cost savings is deliberately understated. More recently, studies published in 2004 reported much higher costs: $2,450 to $4,003 per month in the UK²⁵ and up to $9,000 per month in Canada.²⁶ The unanticipated reduction in falls also yielded cost savings, but these were not included in this calculation.

Discussion

     It is evident that PU incidence and prevalence were reduced remarkably after implementation of the wound program, with virtual elimination of nosocomial PUs. The goal of zero facility-acquired PUs was achieved by the sixth month of the initiative and was maintained at zero or close to zero every month in the nearly four years since with an overall fourth year reduction of 99%.

     Implementation consistency. Although an interdisciplinary approach to preventing PUs is now considered standard care²⁷ and included in the AHCPR guideline,^11,12 its consistent application has been variable and sometimes infrequent, despite mounting evidence that adhering to an interdisciplinary approach can be successful. In 2003, Saliba et al²⁸ reported an overall low adherence to AHCPR guidelines in 35 nursing homes assessed.²⁸ After reviewing the benefits of a multidisciplinary approach to wound care, a report by Gottrup¹⁶ echoed the NPUAP position that “healthcare delivery by individuals rather than teams is not in the best interest of patients”. McInerney²⁹ reported an 81% reduction in hospital-acquired PUs over 4½ years using a focused prevention program with an interdisciplinary team; efforts such as the National Nursing Home Improvement Collaborative³⁰ and the New Jersey Pressure Ulcer Collaborative¹⁷ have shown 69% reduction in severe PUs over 10 months, and 70% overall reduction in 2 years, respectively.

     The recently published report by Van Gilder et al⁸ on increasing PU prevalence calls into question the standards used in preventive wound care, especially the mainstays, AHCPR guidelines and the Braden scale. As reported in the current study, these guidelines steered PU reduction; others^15,29,30 have reported similar success. But because guideline implementation has been sporadic,²⁸ efforts might need to focus on correct and consistent adherence.

     Wound assessment and patient characteristic inconsistencies. Potential inconsistencies in performance measurement includes bias in wound assessment and change in patient characteristics. Bias in wound assessment could occur in several ways. First, wound classification — eg, differentiating ischemic from pressure from trauma wounds — can be challenging, especially without specialized training. Additionally, detecting a Stage I PU can be difficult because often the only sign is skin discoloration. Training and inter-rater reliability are critical to proper wound assessment.²⁰ The same nurse assessed wounds for all but the final year of this facility’s evaluation and the nurse in charge of assessments during the last year was trained in the same manner. The physician team member did not change. Thus, measurement/assessment inconsistency was relatively minimal. In a review of records covering a period of 3 months before initiation of the wound program,³⁸ acquired PUs were reported; of these, seven were determined by the physician consultant to have been incorrectly assessed as PUs. If this is representative, it suggests an 18% overstatement of acquired pressure ulcers before implementation of the wound program. This implies an average of 6.1 facility-acquired PU per month instead the calculated 7.4 before beginning the program and a monthly incidence of 4% instead of 5%. A reduction to 0.1 ulcers per month would still be a 98% overall reduction in number of wounds and a 98% reduction in average monthly incidence, not a significant difference.

     Measurement inconsistencies also could occur if patient characteristics changed significantly. For example, changes in the age and frailty of the nursing home population would affect the number of persons at risk for PUs.^31-33 Study residents’ average age was 82 years before the program and remained at 81 years for each of the following 4 years; if age were a surrogate measure for frailty, no significant change occurred. However, assessing frailty is more difficult³¹ and involves hospital admissions, time until death, and ambulatory status, which were not tracked in a manner that could help assess frailty in this study. The facility continued to be a skilled facility (not assisted or independent living) — the facility admissions coordinator estimates that 75% to 90% or more of all admissions were high-acuity, post-hospitalization over the entire 6 years of this study.

     As a sidebar, an important external environmental change that occurred after the implementation of the wound program was the revision of CMS Tag F-314 for PU.³⁴ This revision had no direct impact on the facility, other than to support and confirm the actions that had been taken. State surveys after program initiation were citation-free and included accolades from the surveyors for the wound program.

     Especially successful endeavors. Results were achieved by following AHCPR¹¹ evidence-based protocols for prevention, initially applied to residents identified at risk and after 6 months to all residents admitted to the facility. Although all preventive measures played a role, several efforts seemed particularly important in achieving PU incidence reduction goals.

     Continuous attention by nursing aides and nurses to residents’ skin, including daily inspection, and monitoring, is a standard of care.^11,12,18 However, although skin moisture or dryness is mentioned in evidence-based guidelines,¹⁸ skin lubrication is rarely discussed. Dry skin often is the result of autonomic neuropathy and requires aggressive emollient therapy³⁵; it is more prone to infection, abrasion, and ulceration.^36,37 Facility clinicians believe continuous attention to skin lubrication was key to maintaining a low incidence of facility-acquired PUs in this facility and was relatively easy to monitor and provide. A simple, inexpensive emollient (lanolin/petrolatum-based ointment) was selected and available to all aides at all times, making skin lubrication convenient to maintain.

     In addition to reducing physical factors related to dry skin, the act of touching and looking at the resident’s skin also enhanced total care of that resident, although that benefit is difficult to quantify.

     A second element was the use of pressure-relieving surfaces. Evidenced-based guidelines^11,12,18 endorse use of pressure support surfaces for beds and chairs as well as turning and repositioning immobile, inactive persons to prevent PUs.³⁸ However, there is a paucity of rigorous studies regarding pressure support surfaces and PU reduction. Agostini³⁹ reported results of a Cochrane review⁴⁰ of pressure-relieving devices in 37 randomized controlled trials (RCT); 31 focused on PU prevention. The RCTs included constant low-pressure (water mattress, foam pad, static air mattress, and foam overlays) versus standard foam mattresses and alternating pressure versus standard foam. No significant differences were found when comparing the pressure-reducing devices among themselves; plus, study methodologies in these RCTs were often poor.⁴¹ For example, one RCT⁴² compared alternating pressure mattresses to standard foam and found a 56% reduction in PU frequency but did not specify time frame or setting.

     In the current study, the selection of static air surfaces was a deliberate and careful decision but it is not known if this selection is optimal in other situations. The facility’s results suggest that choices made were adequate. Although it may be tempting to infer that use of static air devices was an important reason for PU reduction, this cannot be verified due to the number of other changes instituted.

     Because of the low program costs and excellent outcomes observed, implications for cost reduction and cost effectiveness in care deserve to be evaluated further, especially in light of a recent meta-analysis⁴² reporting no differences in benefit of powered versus static pressure support surfaces in the treatment of pressure ulcers.

     The third key element of prevention strategy was heel protection. No support surface by itself is adequate to offload the heel; some can contribute to increased risk of ulcer development.^43,44 The patient lying supine is at increased risk of PUs on the heel due to anatomy and the physics of increased pressure and decreased circulation.^45,46 This facility primarily used pillows, found to be an inexpensive and effective option,^47-49 to elevate the legs to offload heels. A second approach, used when pillows were not optimal for the patient, involved static air heel elevators,⁵⁰ again an inexpensive and effective option. Whether other products would work as well is unknown.

     Ultimately, the most unique and important aspect of this facility’s program is providing prevention measures to all residents, simplifying risk stratification. According to recent literature,⁸ the prevalence of acquired PUs in long-term, acute, and long-term acute care facilities ranges from 15% to 27% and the Braden scale predicts risk in only 52% of cases. Initially, the administrator’s decision to apply prevention across the board was perceived as a bold, innovative step, but consistent with previous action to put APP pads on all beds. Retrospectively, the decision to universally apply prevention appears to be based on sound evidence, using a systems approach. If up to 25% of the persons entering a facility will develop pressure ulcers, and the best prediction tool only predicts risk half the time, providing preventive measures for all persons entering the facility is sound logic and good economic reasoning. This decision simplified the process, making training and implementation easier while enhancing consistency. Several hospitals report use of simplified risk stratification in specific departments, including University of Alabama at Birmingham emergency department,⁵¹ New Jersey Community Medical Center emergency department,⁵² and Columbus Regional Hospital, IN, orthopedic department,⁵³ but results, while favorable, reflect only 2 years or less of data to date.

     The unexpected reduction in falls needs further evaluation. Because no other action plans were in place to reduce falls, it would seem that actions related to the wound program were responsible for the reduction in falls. Whether this is actually the case remains unknown.

Conclusion

     The overall impact of a PU-reduction project reduced PU prevalence and incidence of facility-acquired PU by 99%, a virtual elimination of the problem in this facility. Although this was a quality improvement program with prospective data collection procedures, a design that cannot be used to establish causality, the number of data points (nearly 10,000) make the outcomes compelling.

     Program results at this facility demonstrate that the incidence of PUs can be significantly reduced and reductions sustained by changing the culture of an organization and adopting evidence-based prevention strategies. Duplicating these results in other nursing facilities seems feasible, but would require several key elements. First and foremost is commitment on the part of the facility to make a change. This facility committed financial resources by providing support surfaces and staffing resources for weekly meetings, mandatory training, and hiring a physician wound consultant. Gaining facility and administration commitment may be a key barrier to replicating the efforts described in other facilities.

     A second element is a team approach, with strong leadership, a finding supported by DeLaat and others.^11,12,37 Facilities frequently try to solve wound problems by appointing a wound nurse or contracting with an outside wound nurse or wound care group. This may help document and treat wounds but does not address underlying problems that cause acquired PUs. Wounds need to be the shared concern of all healthcare providers, not just the appointed nurse. This can best be accomplished using a team approach, capitalizing on the diversity of team members’ skills and experience. The leader of the team needs to be knowledgeable and empowered to make changes.

     The third key element for successful replication of these results is the adoption of evidence-based preventive measures. In this facility, prevention was based on the Braden scale,¹⁸ AHCPR guidelines,^11,12 and clinical experience, with special focus on support surfaces, heel protection, and skin care. Procedures were also in place to ensure that these measures were used consistently. Risk stratification cannot be overlooked in analysis of these results. This facility did not stratify risk; preventive strategies were provided to every resident. Given the success at this institution, further elucidation of such a systems approach is needed and may offer solutions to the PU problem.

     Determining how to replicate these results at other nursing homes and healthcare facilities should be a focus of future efforts using this or other models in order to alleviate human suffering and reduce the cost of medical care.

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