Development of Pressure Ulcers in Patients Receiving Home Hospice Care

P ressure ulcers occur in every setting where healthcare is delivered, but little is known about the prevalence and incidence of pressure ulcers in terminally ill persons who receive home hospice care. The term “incidence” refers to all new cases of an index problem for the period of interest, and “prevalence” refers to all occurrences of a problem for a period of interest, including both preexisting and new cases. It is difficult to draw conclusions about pressure ulcer incidence from published reports because of variations in study methodology, characteristics of the healthcare setting where studies were conducted, and variations in case-mix.¹ According to the National Pressure Ulcer Advisory Panel (NPUAP), reported pressure ulcer prevalence remained relatively stable over the past decade at 10 to 11% with an apparent increase to nearly 15% by the end of the decade.¹ The Panel has called for rigorous studies to determine the “true” incidence of pressure ulcers and both development and study of evidence-based best practices.¹ Since the publication of the NPUAP report, little new evidence has been reported in the literature. The NPUAP President, Dan Berlowitz, MD, MPH, stated in December 2004 that despite the attention to pressure ulcers in recent years, there is a deficiency in “good nationwide data on the prevalence and incidence of pressure ulcers.”² Overview of Pressure Ulcers Pressure ulcers are defined as localized areas of tissue destruction occurring when soft tissue is compressed over bony prominences for prolonged periods of time.³ Tissue destruction occurs when the compressed tissue is deprived of oxygen. Risk factors for development of pressure ulcers include immobility, incontinence, and nutritional deficits. Several assessment tools assist clinicians in identifying individuals who are at greater risk of developing pressure ulcers. Pressure ulcers are painful and difficult and costly to treat. Prevention is clearly the best strategy in settings where it is possible. Published guidelines outlining prevention measures and management strategies are widely available. Pressure ulcer prevention relies on managing or eliminating risk factors, including diminished patient mobility, pressure to bony areas that compromises blood flow to areas of potential breakdown, shearing and friction that occur secondary to prolonged immobility, suboptimal nutritional status, and prolonged skin contact with moisture. While prevention strategies are achievable in some settings, the inevitable physical decline of the hospice patient, the frailty of many familial caregivers, and the potential incompatibility between patients’ comfort-focused goals and generally accepted pressure ulcer management guidelines may present significant challenges for clinicians attempting to reduce the occurrence of pressure ulcers in hospice settings. Goals of Hospice Care Hospice is a coordinated program of interdisciplinary services that has evolved in the past 3 decades as both a philosophy of care and an organized set of services provided by professional caregivers and trained volunteers to patients with life-limiting illnesses. Hospices help patients and families clarify and achieve their goals, maximize patient comfort and quality of life, and provide ongoing support for the patient’s family after the patient dies. While there has been growth in “inpatient” or residential hospice care, most hospice care in the United States is provided at home. In the past 2 decades, hospice care has primarily been utilized by older adults with cancer,⁴ but enrollment of patients with non-cancer diagnoses, such as end-stage heart disease, respiratory disease, dementia, and neuromuscular diseases, is increasing. In 2003, the number of hospice programs in the US was estimated at 3,300.⁵ The increase in the number of hospice programs nationwide and a greater awareness of hospice care as an option have contributed to steady increases in the number of patients who enroll in hospice programs. However, despite widespread availability and increased awareness, most patients are referred very close to the end of life and typically receive hospice care for just 3 weeks before death.⁵ As a result, the typical patient presents at admission to hospice with significant functional impairment and multiple symptoms. Risk Factors for Development of Pressure Ulcers Unsurprisingly, given their advanced illnesses and diminished functional impairment, hospice patients exhibit most or all of the risk factors for pressure ulcer development. However, the patient characteristics predicting pressure ulcer development after admission to hospice have not been well described. In the 2 largest studies examining factors associated with pressure ulcer development among terminally ill patients, older age, compromised mobility, and physical inactivity were identified.^6,7 When the patient risk profile is coupled with caregiver frailty, the risk for development of pressure ulcers rises. A dearth of evidence exists in the research literature concerning pressure ulcer incidence in settings where terminally ill patients receive care. A bias toward under-reporting of pressure ulcers has been observed both in acute care and in home hospice care. In a study of 211 hospital inpatients, Benbow observed a significant discrepancy between ward staff’s observation of pressure ulcer risk and prevalence compared to the investigator’s observations of the same patients.⁸ Similarly, Reifsnyder et al. observed an increase in the reported prevalence of pressure ulcers over the course of a 3-month study. In this study, surveillance was increased through pharmacist-initiated telephone interactions with hospice nurses.⁹ The investigators compared prevalence rates at 3 intervals: prior to the surveillance, at the beginning of the surveillance period, and following 3 months of surveillance.⁹ Aggregated pressure ulcer prevalence for the participating hospices was 14.6% in the 6-month pre-surveillance period (based on analysis of medical record abstracts and/or electronic medical records and pressure ulcer logs), which increased to 17.5% at the inception of the study (based on hospice nurse reports for all active patients), and ultimately increased to 26.9% at the completion of the 3-month study.⁹ Risk factors for development of pressure ulcers have been described for patients receiving care in hospitals and nursing homes. For example, risk factors for development of pressure ulcers in nursing homes include fewer nursing care hours per patient day, fewer Medicaid dollars per patient, amount of time spent in bed versus a chair, malnutrition, low hemoglobin levels, age, and diagnosis. Facility resources clearly have an impact on care in the nursing home. Grabowski and Angelelli analyzed nursing home Minimum Data Set (MDS) data, facility-level data, and published state/market data to identify the relationship between Medicaid payment to nursing homes and various measures of nursing home quality.¹⁰ They found that a 10% increase in Medicaid payment is congruent with a 1.5% decrease in risk-adjusted pressure ulcer incidence, supporting a conclusion that development of pressure ulcers is related to available resources in the care setting.⁶ Similarly, reduction in pressure ulcer incidence is associated with increased number of nursing care hours per patient day in hospitals.⁷ Hospitals with more beds (between 200 and 299) are shown to have a greater number of nursing care hours per patient day (14.6 hours per patient day, where the number of beds 11 In a study of hospital inpatients, Olson et al. found that pressure ulcer incidence was higher for patients who spent more time restricted to their beds and less time in chairs and for patients who had lower than normal hemoglobin counts.¹² In addition to these observations, these authors noted that patients who received post-surgical care and those with medical conditions that affect tissue perfusion (eg, respiratory disease or diabetes mellitus) were more likely to develop stage 1 or stage 2 pressure ulcers.¹² Malnutrition has also been described as a significant factor in the development of pressure ulcers in some patient populations. In a study of the relationship between adequate oral supplementation and pressure ulcer incidence, Bourdel-Marchasson et al. found that patients who received adequate oral supplementation 32.6% of the time had pressure ulcer incidences of 26.4%.¹³ In contrast, those who received adequate oral supplementation 86.9% of the time exhibited lower pressure ulcer incidences at 20.2%. In addition, the rate of nosocomial infections in the group that received greater nutritional support was 7.4% lower.¹³ Patient characteristics, including diagnosis, race, and age, may be associated with development of pressure ulcers. As discussed, cancer is one of the most common diagnoses that leads to hospice referral. However, in a study of pressure ulcer prevalence in home hospice, Reifsnyder et al. found that hospice patients with non-cancer diagnoses were disproportionately affected by pressure ulcers.⁹ They reported that central nervous system (CNS) disorders, including cerebral vascular accident and dementia, were associated with the highest incidence with over 51% of CNS patients developing pressure ulcers.⁹ Baumgarten et al. described a difference in pressure ulcer incidence with regard to patient race.¹⁴ These authors reported that Black patients had a substantially higher incidence of pressure ulcers (0.56) compared to White patients (0.35). Even controlling for other resident and facility characteristics, Black patients were still considerably more likely to develop pressure ulcers. However, Black patients had significantly longer nursing home stays, perhaps explaining some of the differential development of pressure ulcers between groups.¹⁴ Age is also a factor associated with pressure ulcer risk. Henoch and Gustafson analyzed pressure ulcer prevalence in a sample of 98 inpatients located at a Swedish hospice and found that age, male gender, physical inactivity, immobility, decreased nutritional intake, incontinence, and poor overall physical condition were associated with development of pressure ulcers in terminally ill patients with cancer.⁷ Similarly, Galvin reported that the 12% of patients admitted to a palliative care unit who developed pressure ulcers during their stay were older and stayed an average of 12 days longer.¹⁵ Thomas noted that patients over the age of 70 account for 70% of all pressure ulcers.¹⁶ Higher incidence tends to be found in the extremes of age; most pediatric patients who develop pressure ulcers are under 1 year of age, and adults tend to be over 64 with the greatest incidence found in patients 64 to 79 years of age.¹⁶ Objectives The purpose of this study was to examine pressure ulcer incidence and prevalence in 4 home hospice programs and to test algorithms for prevention and management of pressure ulcers with currently enrolled and newly admitted hospice patients. The study sponsor, Hospice Pharmacia, Inc., collaborated with wound care experts at East Jefferson General Hospital in Metairie, La, to develop algorithms for prevention and management of pressure ulcers in the hospice population. The guidelines were developed over a 6-month period, during which primary literature was reviewed and drafts were reviewed by a panel of national experts in hospice care and/or wound care. This article reports on incidence findings from the pilot study to test the algorithms. Design and Methods The study was conducted in 4 home hospice programs located in the northeastern US from October through December 2003. Participating hospices were clients of Hospice Pharmacia (HP), a medication therapy management company that provides evidence-based pharmacotherapy counseling, care planning, and pharmaceuticals to hospice programs throughout the US. Hospices that participated in the study had agreed to implement the aforementioned prevention and treatment algorithms for pressure ulcers. Data covering 3 distinct time periods were gathered and analyzed. Each of the 4 programs provided access to historical data related to pressure ulcer prevalence. Prevalence rates were calculated for the 6-month period of January through June 2005 (Time 1). Participating hospices provided patient-level data for each active hospice patient on the day that the study commenced, and these data were analyzed to generate the prevalence rate at study inception (Time 2). Pharmacists located in HP’s pharmaceutical call centers communicated via telephone with hospice nurses to gather data regarding pressure ulcer development, number of pressure ulcers, stage, and wound characteristics (eg, dimensions, exudate, undermining) during the 3-month study (Time 3). Demographic data included age, gender, terminal diagnosis (ie, the diagnosis that supported patient eligibility for hospice), and length of stay (calculated as number of days that the patient received hospice care inclusive of day of admission and day of death or discharge). In addition, pharmacists recorded Karnofsky or Palliative Performance Scale (PPS) scores (prognostic/performance status tools that are commonly used in palliative care and hospice^17,18) and Braden Scale scores, each of which were assessed and reported by hospice nurses. Hospice patients who were residents of long-term care facilities were not included in this study; therefore, the findings reported in this article reflect only those patients receiving home hospice care from one of the participating programs. Data for 980 patients were gathered during the 3-month study period. Period prevalence was calculated as the total number of patients with preexisting pressure ulcers at the time of admission to hospice plus those who developed pressure ulcers during the hospice episode, divided by the total number of patients observed in the study period (with and without pressure ulcers). The prevalence of pressure ulcers during the study period was 26.9%. This article reports on the characteristics of patients who developed new pressure ulcers during the study period. Prevalence findings have been reported elsewhere.⁹ Results Characteristics of the sample. The average age of the hospice patients included in this study was 75 years (n=980). The average length of stay and median length of stay, 84 days and 31 days, respectively, were somewhat longer than the national average of 55 days and median of 22 days.⁵ The mortality rate during the 3-month study period was 81.2%. Incidence of pressure ulcers. Incidence was calculated as the number of patients who developed new pressure ulcers divided by the total number of patients observed in the study period (with and without pressure ulcers). Ninety-nine patients developed pressure ulcers during the study period, yielding an incidence rate of 10%. Thirty of those patients had preexisting ulcers and developed one or more additional ulcers after hospice admission. Patients who developed pressure ulcers were significantly older (p=0.006). The average age of patients included in the total sample was 75 years (range 10–105 years; SD=13.9). In comparison, the average age of those patients without pressure ulcers was 74.46 and 76.43 (range 43–97; SD=11.9) for those who developed pressure ulcers during the hospice episode (Table 1). Nearly one half of patients who developed pressure ulcers during the study period had diagnoses of cancer. After cancer, the next most frequent diagnosis was CNS disorder/dementia (18.2%) followed by cardiovascular disease (13.1%), unspecified debility (9.1%), and end-stage lung disease (7.1%). While most patients in the sample had diagnoses of terminal cancer (62.6%), those with non-cancer diagnoses were disproportionately affected by pressure ulcer development. For example, patients with CNS disorder/dementia comprised 9.2% of the sample by diagnosis, yet they accounted for nearly 20% of the new pressure ulcers. Similarly, patients with diagnoses of unspecified debility comprised just 4.2% of the sample, yet they accounted for approximately 9% of new pressure ulcer cases (Figure 1). Braden Scale scores. Braden Scale scores were documented weekly for patients enrolled in the study. The Braden Scale is a summated rating instrument consisting of 6 subscales. Lower sum scores indicate higher risk for development of pressure ulcers. Patients who developed pressure ulcers exhibited lower Braden Scale scores as compared to those who never developed pressure ulcers (Figure 2). Nearly 50% of the patients with pressure ulcers exhibited Braden Scale scores of less than 9 or 10–12, compared to just 15% of those without pressure ulcers. While the intent of this study was not to validate the Braden Scale in a sample of hospice patients, these findings suggest that the Scale is predictive of pressure ulcers for this group. Karnofsky/PPS scores. The PPS is a prognostic measure used in palliative care settings based on the Karnofsky Performance Scale, a tool used to classify patients receiving cancer treatment according to their level of functional impairment. Like the Karnofsky Scale, PPS is scored 0 (death) to 100 (no limitation) in 10 unit increments. The 2 scales are scored similarly and are often used interchangeably in hospice settings. Generally, patients with Karnofsky/PPS scores lower than 70% would be considered eligible for hospice care.¹⁹ A score of 40% indicates that the patient spends most of his or her time in bed; a score of 30% indicates that the patient has increasing debility and requires total care.¹⁹ The patients in this study were quite ill, as evidenced by the mean Karnofsky/PPS scores. However, the mean score for patients with pressure ulcers was significantly lower at 30, compared to a mean of 40 for patients without pressure ulcers (p3 The Guidelines do not specifically address patients approaching the end of life.³ It is unclear whether measures taken in other care settings to prevent or treat pressure ulcers are feasible in hospice and palliative care settings or that pressure ulcers will occur in hospice settings regardless of preventative efforts.²⁰ There is some evidence in the research literature that systematic risk assessment to determine the application of support surface type²¹ and application of standardized dressing protocols²² reduces pressure ulcer incidence in hospice. Conclusion This study was undertaken to describe incidence and prevalence of pressure ulcers in home hospice care, a setting where the typical patient is extremely ill and whose condition is expected to deteriorate. The findings from this study suggest that older patients, those with non-cancer diagnoses, and patients with lower performance scores (30 or less) are at higher risk for development of pressure ulcers after admission to hospice. Research is needed to identify the relative contribution of discrete risk factors in this population, the most appropriate risk assessment tool, and treatment strategies that are consistent with palliative goals of care. The NPUAP has called for large, multisite studies to examine prevalence and incidence of pressure ulcers in hospice patients, research into the feasibility of prevention in this population, and development and testing of patient-sensitive prevention and treatment protocols.¹ It is clear that more study of this vulnerable population is needed.