Best Practices in the Prevention and Treatment of Pressure Ulcers

With health care reform, staff downsizing, and the lengths of hospital stays decreasing, it is inevitable that the incidence of wounds will increase. The Joint Commission of Accreditation of Hospital Organizations (JACHO) suggests the appearance of a pressure ulcer may indicate the quality of care provided by a hospital. Of course the patient’s complex condition must be viewed before it can be related to inferior quality-of-care (Hall, Schumann, 2001).
Best Practices in the Prevention and Treatment of Pressure Ulcers

With health care reform, staff downsizing, and the lengths of hospital stays decreasing, it is inevitable that the incidence of wounds will increase. The Joint Commission of Accreditation of Hospital Organizations (JACHO) suggests the appearance of a pressure ulcer may indicate the quality of care provided by a hospital. Of course the patient’s complex condition must be viewed before it can be related to inferior quality-of-care (Hall, Schumann, 2001).
Preventing the incidence of a wound is one of the most important responsibilities that nurses have. Recognizing the stages of a pressure ulcer is a basic competency for nurses, however the National Pressure Ulcer Advisory Panel (NPUAP) identified, based on research, that nurses did not have the skills to identify even stage 1 pressure ulcers (Ayello, Baronoski, Salati, 2006). Regulatory bodies set guidance for staging pressure ulcers, depending on the care setting, which may determine how the same pressure ulcer is staged. Providing the best possible nursing care means staying current with the development of better products and prevention techniques that support better healing (Ayello, et. al., 2006).
The quality of wound care education received in school affects the knowledge and competence of the clinician’s wound care management. The contents of many textbooks are either incomplete or inaccurate and only provide a brief description of wound care and prevention of pressure ulcers. The caregiver’s ability in providing wound care and their knowledge about the skills needed in preventing wounds may be shown to have greater importance even than assessing the patient’s risk factors. Medical and physical conditions, environmental sources and iatrogenic causes are the three major risk factors that contribute to the failure of wound healing. Pressure ulcer development may now be determined not by how sick the patient is, but by the clinician’s knowledge and abilities which can have direct impact on outcome of healing (Hall, et. al., 2001).
The Centers for Medicare and Medicaid Services (CMS) track pressure ulcers in acute care as medical errors through the Medicare Patient Safety Monitory System (MPSMS) (Ayello, et. al., 2006). In their sister publication, Nursing 2006, Ayello set out to examine if the latest nursing wound care practices reflected the current best practice standards. According to the results of the survey, older nurses with many years of experience knew a lot about wound care where as the newer, younger and less experienced nurses needed more wound care education.
Identifying patients at risk for pressure ulcers led to the development of The Braden risk assessment tool. Overemphasis on documenting risk based on The Braden scale is important upon admission and or when the patient’s condition begins to change no matter the location of the care setting. The implementation of prevention protocols at any of the six subscales must be done rather that relying to the total risk score (18 or below) (Ayello, et. al., 2006).
In providing guidance and clinical decision making, algorithms, guidelines and clinical pathways are tools that should be used along with clinical expertise in preventing delays and enhancing appropriate treatments. The United States Department of Health and Human Services (USDHHS) has provided a list of six areas that are used to develop pressure ulcer treatment plans such as 1) a complete history and physical, 2) identification of complications and comorbid conditions, 3) nutritional assessment, 4) pain assessment, 5) psychosocial assessment, and 6) evaluation of the individual’s risk for the development of additional pressure ulcers (Hall, et. al., 2001).
Lewis, Pearson, and Ward (2003) recognize the need for straightforward guidelines for treatment and prevention of pressure ulcers. It is believed that the duration and magnitude of pressure exertion on a particular body part or region can increase the variations of pressure ulcers making it difficult to be successful with treatment.
However, practices in staging of pressure ulcers may vary from care setting to care setting; wound prevention and treatment has evolved over the years. Benbow (2006) indicates that an ‘all-in-one’ guideline on pressure ulcer prevention and management was published by the National Institute for Health and Clinical Excellence (NICE) in 2005. It is published in two parts The Management of Pressure Ulcers in Primary and Secondary Care is the first part and the second part is on risk assessment and prevention which also includes the use of pressure-relieving devices. The guideline highlights what healthcare professionals should do to prevent and treat pressure ulcers using evidence-based best practice (Benbow, 2006).

a. Intervention 1 - Continuing education for nurses in the prevention of pressure ulcers
i. Disadvantage 1 – knowledge deficit
1. Although not all pressure ulcers are preventable. Patients
with multisystem failure are particularly at risk despite the aggressiveness of
interventions. Knowledge deficit amongst nurses is a key factor in the
prevalence of pressure ulcers.
2. Education and training of healthcare professionals must be an
interdisciplinary approach. With technological and therapeutic advances
systematic implementation and updates systematic implementation needs
to be adaptable. Ultimately this education should be easily accessible to
both nurses and patients in the form of resource manuals and brochures
and easily comprehended.
Source: Lewis, M., Pearson, A., & Ward, C. (2003, April). Pressure ulcer
prevention and treatment: transforming research findings into
consensus based clinical guidelines. International Journal of
Nursing Practice, 9(2), 92-102. Retrieved November 14, 2007,
from CINAHL database.

ii. Disadvantage 2 – Not keeping up with current standards and technology
1. Management of wound care is constantly evolving. As technology
advances keeping up with the changes plays a major role in wound
healing.
2. If clinicians do not keep current with the standards and
guidelines as they become updated even the most aggressive interventions
may not be useful in preventing pressure ulcers. Knowledgeable staff
performing the initial assessment and accurate staging is essential.
Source: Caliann, C. (2007, May). Pressure ulcers a quality issue. Nursing
Management, 38(5), 42-51. Retrieved February 6, 2008, from
Academic Search Premier database.
b. Intervention 2 – Treatment options for already existing pressure ulcers
i. Disadvantage 1 – Socioeconomic status
1. Socioeconomic status affects both healthcare institutions as well as the
patients. It is important to be aware of the costs involved in treatment of
pressure ulcers which should be a good motivator for reducing the
incidence.
2. Hall and Schumann state that only one half of 1% of the aggregate health
care dollar is spent on wound care in the United States. A total national
cost of treatment has been estimated to exceed $1.36 billion dollars per
year. The average cost to heal a single pressure ulcer ranges from $1,951
for a leg ulcer to $29,373 for a diabetic ulcer. An independent study of
Medicare claims data shows that more than $20,000 is spent per patient,
per ulcer episode.
Source: Hall, P., & Schumann, L. (2001, June). Wound care: Meeting the
challenge. Journal of the American Academy of Nurse
Practitioners, 13(6), 258-268. Retrieved November 4, 2007,
from CINAHL database.

References:


Ayello, E., Baranoski, S., & Salati, D. (2006, September). Best practices in wound care
prevention and treatment. Nursing Management, 37(9), 42-48. Retrieved November
4, 2007, from CINAHL database.

Benbow, M. (2006, September 6). Guidelines for the prevention and treatment
of pressure ulcers. Nursing Standard, 20(52), 42-44. Retrieved November 4, 2007,
from CINAHL database.

Hall, P., & Schumann, L. (2001, June). Wound care: Meeting the challenge. Journal of
the American Academy of Nurse Practitioners, 13(6), 258-268. Retrieved November
4, 2007, from CINAHL database.

Lewis, M., Pearson, A., & Ward, C. (2003, April). Pressure ulcer prevention and
treatment: transforming research findings into consensus based clinical guidelines.
International Journal of Nursing Practice, 9(2), 92-102. Retrieved November 14,
2007, from CINAHL database.