Step 1: Overview
Click on one of the following topics to skip to that section:
What We Know About Pressure Ulcer Care - A Lot
A current count shows there are seven clinical practice guidelines on pressure ulcer care:
In addition, there is an evidence-based wound assessment tool:
Back to Top
What We Don't Know About Pressure Ulcer Care in Nursing Homes - A Lot
Nationally, the prevalence of PU among nursing home residents is 14% (2) for high-risk individuals, but go up to 24% (3), both unacceptably high rates for a serious health problem often considered preventable. Not surprisingly, this costly, too common problem has fueled a rise in PU-related litigation. A report by LUMETRA (4) cites evidence that claims per occupied nursing home bed have increased at an annual rate of 14% while the average court settlement has risen to $250,000.
The incidence and prevalence of pressure ulcers in nursing homes is high enough to have sparked concern among regulators, who consider PU rates a measure of the quality of care in nursing homes. As a result, publicly reported quality measures now alert consumers to nursing homes with high PU prevalence rates. The problem is that, for all we know about ideal PU care, we do not yet know enough about how it actually is delivered in nursing homes.
Back to Top
We Decide to Investigate
We know how to prevent, treat, and manage PUs. So where exactly is that care process breaking down in nursing homes? We decided to find out. The results of this investigation (5,6) and the recommendations they point to constitute the basis of this training module. We present this information in subsequent sections, but first we describe key features of the methodology we used, for as you will see, these strategies are echoed in our recommendations.
Back to Top
We Conducted Our Own Assessments
Although we used some secondary data sources, usually medical records, to evaluate PU care in nursing homes, we primarily collected information using our own eyes and ears (and then often used these data to verify information in the medical charts).
We conducted skin assessments, checked at regular intervals to see whether PU risk residents were lying or sitting on pressure reduction surfaces, used wireless thigh movement monitors to find out how often at-risk residents were repositioned, directly observed mealtimes, and asked residents about the incontinence care they received.
Although medical records and especially information from Minimum Data Set (MDS) assessments are widely used to evaluate quality of care in nursing homes, we have repeatedly found this information to be inaccurate. Consequently, we try to use it sparingly, and then only in conjunction with data gleaned from other assessment strategies, such as resident reports and direct observations.
Back to Top
We Used Quality Indicators to Evaluate Care
We used a series of 11 quality indicators (QI) related to PU care for nursing home residents. Presented as a series of if/then statements, these QIs outline the PU assessment and treatment process, thereby providing a basis for evaluating actual care practices.
It should be noted that these QIs are not, technically speaking, practice guidelines, though they are based closely on existing guidelines. Practice guidelines “aim to define optimal or ideal care in the context of complex decision-making,” writes RAND, the southern California think tank that helped us develop the QIs. In most nursing homes, however, optimal care is virtually synonymous with impossible care: it almost invariably requires more staff time than most nursing homes can afford and consequently cannot be implemented under usual conditions. So with a nod to real life, the QIs lower the bar. Explains RAND (7): They “set a minimal standard for acceptable care—standards that, if not met, almost ensure that the care is of poor quality.”
Based on expert opinion and existing best-practice guidelines, all of our QI-associated PU care tasks are both related to positive outcomes for residents and feasible for nursing home staff to implement.
Back to Top
Overview of Findings
The study was led by Dr. John F. Schnelle and conducted in 16 nursing homes in Southern California. These facilities comprised two groups: Six of them had scores among the lowest on the MDS quality indicator (QI) “prevalence of PU,” and the remaining 10 had scores among the highest on this QI. Presumably, differences in QI scores are explained by differences in the quality of care provided. Thus, low-prevalence homes supposedly provide better PU care than high-prevalence homes.
The results of this study disproved this assumption, however. The only difference between the two groups—and it was a small difference—is that the supposedly “bad” nursing homes were doing a better job of documenting wound characteristics and using pressure-reduction surfaces to prevent PU.
But what struck us as more important than the differences between these two groups were their similarities. All 16 nursing homes performed poorly on screening and preventing PUs, though they did better at management once a PU was present.
In the next section, we show you how to target pressure ulcer (PU) risk reassessments to residents at highest risk.
Back to Top or proceed to Step 2
A current count shows there are seven clinical practice guidelines on pressure ulcer care:
- “Pressure Ulcer Prevention” and “Pressure Ulcer Treatment,” both available from the Agency for Health Care Research and Quality
- “Pressure Ulcers” and “Pressure Ulcer Therapy Companion,” both available from the American Medical Directors Association
- “Prevention of Pressure Ulcers,” by and available from the Gerontological Nursing Interventions Research Center, Research Dissemination Core
- “Guideline for the Prevention and Management of Pressure Ulcers,” by and available from the Wound, Ostomy, and Continence Nurses Society, Glenview, IL.
- “Pressure Ulcer Prevention and Treatment following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals,” by and available from the Paralyzed Veterans of America, Washington, D.C.
In addition, there is an evidence-based wound assessment tool:
- PUSH Tool 3.0, available for free from the National Pressure Ulcer Advisory Panel.
Back to Top
What We Don't Know About Pressure Ulcer Care in Nursing Homes - A Lot
Nationally, the prevalence of PU among nursing home residents is 14% (2) for high-risk individuals, but go up to 24% (3), both unacceptably high rates for a serious health problem often considered preventable. Not surprisingly, this costly, too common problem has fueled a rise in PU-related litigation. A report by LUMETRA (4) cites evidence that claims per occupied nursing home bed have increased at an annual rate of 14% while the average court settlement has risen to $250,000.
The incidence and prevalence of pressure ulcers in nursing homes is high enough to have sparked concern among regulators, who consider PU rates a measure of the quality of care in nursing homes. As a result, publicly reported quality measures now alert consumers to nursing homes with high PU prevalence rates. The problem is that, for all we know about ideal PU care, we do not yet know enough about how it actually is delivered in nursing homes.
Back to Top
We Decide to Investigate
We know how to prevent, treat, and manage PUs. So where exactly is that care process breaking down in nursing homes? We decided to find out. The results of this investigation (5,6) and the recommendations they point to constitute the basis of this training module. We present this information in subsequent sections, but first we describe key features of the methodology we used, for as you will see, these strategies are echoed in our recommendations.
Back to Top
We Conducted Our Own Assessments
Although we used some secondary data sources, usually medical records, to evaluate PU care in nursing homes, we primarily collected information using our own eyes and ears (and then often used these data to verify information in the medical charts).
We conducted skin assessments, checked at regular intervals to see whether PU risk residents were lying or sitting on pressure reduction surfaces, used wireless thigh movement monitors to find out how often at-risk residents were repositioned, directly observed mealtimes, and asked residents about the incontinence care they received.
Although medical records and especially information from Minimum Data Set (MDS) assessments are widely used to evaluate quality of care in nursing homes, we have repeatedly found this information to be inaccurate. Consequently, we try to use it sparingly, and then only in conjunction with data gleaned from other assessment strategies, such as resident reports and direct observations.
Back to Top
We Used Quality Indicators to Evaluate Care
We used a series of 11 quality indicators (QI) related to PU care for nursing home residents. Presented as a series of if/then statements, these QIs outline the PU assessment and treatment process, thereby providing a basis for evaluating actual care practices.
It should be noted that these QIs are not, technically speaking, practice guidelines, though they are based closely on existing guidelines. Practice guidelines “aim to define optimal or ideal care in the context of complex decision-making,” writes RAND, the southern California think tank that helped us develop the QIs. In most nursing homes, however, optimal care is virtually synonymous with impossible care: it almost invariably requires more staff time than most nursing homes can afford and consequently cannot be implemented under usual conditions. So with a nod to real life, the QIs lower the bar. Explains RAND (7): They “set a minimal standard for acceptable care—standards that, if not met, almost ensure that the care is of poor quality.”
Based on expert opinion and existing best-practice guidelines, all of our QI-associated PU care tasks are both related to positive outcomes for residents and feasible for nursing home staff to implement.
Back to Top
Overview of Findings
The study was led by Dr. John F. Schnelle and conducted in 16 nursing homes in Southern California. These facilities comprised two groups: Six of them had scores among the lowest on the MDS quality indicator (QI) “prevalence of PU,” and the remaining 10 had scores among the highest on this QI. Presumably, differences in QI scores are explained by differences in the quality of care provided. Thus, low-prevalence homes supposedly provide better PU care than high-prevalence homes.
The results of this study disproved this assumption, however. The only difference between the two groups—and it was a small difference—is that the supposedly “bad” nursing homes were doing a better job of documenting wound characteristics and using pressure-reduction surfaces to prevent PU.
But what struck us as more important than the differences between these two groups were their similarities. All 16 nursing homes performed poorly on screening and preventing PUs, though they did better at management once a PU was present.
In the next section, we show you how to target pressure ulcer (PU) risk reassessments to residents at highest risk.
Back to Top or proceed to Step 2
