Step 2: Risk Assessment
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“An Ounce of Prevention is Worth a Pound of Cure”
Old as it is, this adage wisely sums up one of the major thrusts of efforts to improve pressure ulcer (PU) care in nursing homes. PU prevention can be done, and there are good reasons to do it:
Given these compelling reasons to practice excellent PU prevention, it’s unfortunate that such care is less than optimal in most nursing homes and downright substandard in many. Inadequate staffing is the usual defense against this charge, and it has some merit, for indeed most nursing homes have too few workers to provide proper care of residents (4) and insufficient reimbursement to hire more. But our recent research also suggests that nursing homes can make better use of the staff they have—and improve care—by targeting their services more appropriately and efficiently.
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More PU Risk Re-Assessments Needed
Let’s start with risk assessment, the first step recommended in the PU prevention practice guidelines not to mention a federal requirement for nearly all nursing homes. Nursing homes are required to conduct a risk assessment for each new resident upon admission to determine whether the person is likely to develop a PU.
Practice guidelines recommend the use of a validated risk assessment tool such as the Norton Scale or the more widely used Braden Scale (5,6). Our research indicates that when nursing homes complete this step, and document the results, at-risk residents are more likely to get the preventive care they need (7). Roughly 60% of nursing homes conduct this entrance risk assessment and document it (7, 8), not a great showing given the importance of this step.
Where they really miss the mark, however, is with the corollary to this initial step. Though not a federal requirement, best practice guidelines call on nursing homes to re-assess at-risk residents, particularly those who are unable to reposition themselves or have limited ability to do so.
“The condition of an individual admitted to a health care facility is not static,” notes the guidelines from the Agency for Healthcare Research and Quality (6) “consequently, pressure ulcer risk requires routine re-examination.”
PU prevention guidelines from the University of Iowa Gerontological Nursing Interventions Research Center (5) recommend that at-risk nursing home residents be reassessed “every 48 hours for the first week, weekly for one month, then quarterly, or more frequently if (the resident’s) condition changes.”
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Benefits of Re-Assessments
The rationale for reassessments is that if PUs are going to develop, they will usually develop within the first two to four weeks of a resident’s admission. In one study, for example, of 102 newly admitted nursing home residents, 28 developed PUs, all of them within four weeks of admission (9). In addition, findings from the reassessments can be used as a foundation for the resident’s skin care plan.
The point to understand is if you skip reassessments of at-risk residents, you’ll undermine your own prevention efforts.
It happens all the time. When a study led by Dr. John F. Schnelle included an evaluation of PU care in 16 nursing homes (see Step 1 for background on this study), we called on facilities to conduct weekly reassessments of at-risk residents for four weeks. Any fewer reassessments of these residents equates to substandard care, according to multiple best practice guidelines. Results of this study showed that none of the facilities we evaluated passed this quality indicator. Worse yet, none of them even came close. We lowered the bar to two reassessments within the first four weeks of admission and still all the facilities failed.
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Experiment with New Practice Patterns
Why the dismal failure rate? We can think of two possible reasons:
The first impediment is being addressed by this module. You -for one- now know better.
The staffing problem is considerably more difficult to resolve, and as such, demands an institutional willingness to experiment with new practice patterns. Ask yourself this: Would you rather devote staff time to PU prevention or PU treatment? Indications are that the more you do of the first, the less you’ll do of the second—and vice versa. For all the reasons cited at the start of this section, we recommend devoting adequate staff time to delivering preventive care.
Back to Top
Institute a Triage System
To help with PU prevention, consider implementing our “triage system”.
Be aware that this system has not been tested yet in a rigorous research trial. It is based on expert consensus and best practice guidelines and supported by the best available research and clinical evidence. At its heart is an understanding born of both clinical experience and applied research that many nursing homes, given current staffing ratios and reimbursement levels, simply cannot deliver all that we ask of them (though most can come closer than they do). Failure to acknowledge this may fuel widespread deception, as evidenced by the fact that nursing home workers often record care that they never actually provide (10, 11). This in turn can lead to poor clinical decision-making, for it discourages the use of objective targeting assessments, which strive to make abundantly clear who needs what (and may not be getting it).
Our triage system stands in contrast to the usual care practices in many nursing home facilities. It makes concerted use of objective assessment data so that you can improve clinical decision-making and, at the same time, shape a care process that is actually feasible to implement.
Back to Top
Consider Risk Assessment Scores and Repositioning Ability
Institute a triage system that ensures that the highest risk residents are the first to receive the four weekly reassessments. This system should take into account two types of assessment data:
Back to Top
We Recommend the Braden Scale
Of these two scales, we recommend use of the Braden scale, largely because it has been more extensively tested in nursing homes. It also is commonly used in nursing home research; so if your facility follows suit, you can compare your results to those reported in published studies. The remainder of this section assumes the use of the Braden scale to assess PU risk.
Back to Top
Target Re-Assessments According to Risk Level
Nursing home residents with a Braden score of 18 or less on admission are considered to be “at risk” for PU (5). Ideally, all these at-risk residents should be re-assessed weekly for four weeks following admission. If the number of residents who meet this criterion and the licensed staff available to conduct the assessments render this task impractical, then target first those residents at highest risk.
New nursing home residents with Braden scores below 11 are considered to be at very high risk for PU. At the very least then, these new residents should be the first to receive the four weekly re-assessments, again using the Braden scale. Results of the re-assessments should guide the residents’ care plans.
Primary risk factors for pressure ulcers are immobility and limited activity levels (6). Given this, the second-tier target group should be new residents with Braden scores between 18 and 11 who are chair-fast, bedbound, or unable to reposition themselves. This second-tier group is likely to include the most residents—and may include more residents than necessary because of a tendency among nursing home staff to underestimate the number of residents capable of independently repositioning themselves. Use our performance assessment, which was developed and validated by work led by Dr. John F. Schnelle, to accurately identify those who are unable to reposition themselves and thus who are at greater risk for PU. This assessment is also discussed in Step 3.
If after targeting residents as noted above, the nursing staff still cannot complete all re-assessments, then reduce the number of weekly re-assessments to two or three within a four-week period following admission. Use residents’ Braden scores to guide the cutbacks, reducing first the number of re-assessments for those with higher Braden scores—or less risk. Thus, you should cut back first for tier 3 residents, then for tier 2 residents, and only as a last resort for tier 1 residents, those at greatest risk.
We recognize that use of this “triage system” may result in substandard care for some at-risk residents. This is truly regrettable but possibly unavoidable. If a facility is seriously short-staffed, as many are, then it is naïve to think that the services provided won’t suffer. In such a case, we believe it is ethically and clinically justifiable to focus first on providing proper care to those most in need, as determined by objective, valid assessments. This triage plan seems preferable to the usual practice in many nursing homes of providing substandard care to all at-risk residents, a system that ensures that none get what they really need.
Back to Top
Targeted Residents Need Early Intervention
Residents targeted to receive routine re-assessments during their first month are at high enough risk that they also need early intervention services to prevent PU development. Strategies for strengthening these services are presented in the next section.
Back to Top
All Other Residents Need Periodic Reassessments
PU risk status is subject to change, so residents who do not meet our tier 1-3 risk criteria nevertheless require systematic re-assessments. We strongly recommend tying these to quarterly Minimum Data Set (MDS) assessments to ensure that they are completed routinely and accurately. IF the re-assessment shows the resident is now at risk of developing a PU (i.e., meets tier 1-3 risk criteria), THEN implement early intervention services.
Back to Top
Your Assignment
Review the medical records of a handful of residents admitted to your facility in the past few months and answer these questions:
Share your findings; please contact us. We plan to report your feedback for the benefit of others in future updates to this site.
Back to Top or proceed to Step 3
- “An Ounce of Prevention is Worth a Pound of Cure”
- More PU Risk Re-Assessments Needed
- Benefits of Re-Assessments
- Experiment with New Practice Patterns
- Institute a Triage System
- Consider Risk Assessment Scores and Repositioning Ability
- We Recommend the Braden Scale
- Target Re-Assessments According to Risk Level
- Targeted Residents Need Early Intervention
- All Other Residents Need Periodic Re-Assessments
- Your Assignment
- References
“An Ounce of Prevention is Worth a Pound of Cure”
Old as it is, this adage wisely sums up one of the major thrusts of efforts to improve pressure ulcer (PU) care in nursing homes. PU prevention can be done, and there are good reasons to do it:
- For starters, most of us would agree that PU prevention is in the best interests of nursing home residents. After all, the clinical consequences of developing a PU are serious: increased morbidity and mortality, increased risk of infection as well as pain, depression, and stress. This should be reason enough to strengthen PU prevention efforts, but if it’s not, consider this:
- PU treatment is costly. A report by LUMETRA (1) cites evidence that PU treatment costs in nursing homes exceed $355 million a year, and that estimate was calculated in 1997. Since then healthcare costs have spiraled up.
- PU prevention is a better buy. Though by no means free, PU prevention can lower treatment costs while improving clinical outcomes (2). Finally…
- We’ve listed it fourth, but some nursing homes may consider it the number one reason to beef up PU prevention efforts: Inadequate PU prevention is one of the top two causes for malpractice litigation against nursing homes. A 1999 study found that adherence to PU prevention guidelines could have saved healthcare defendants $11,389,989 in 20 lawsuits (3).
Given these compelling reasons to practice excellent PU prevention, it’s unfortunate that such care is less than optimal in most nursing homes and downright substandard in many. Inadequate staffing is the usual defense against this charge, and it has some merit, for indeed most nursing homes have too few workers to provide proper care of residents (4) and insufficient reimbursement to hire more. But our recent research also suggests that nursing homes can make better use of the staff they have—and improve care—by targeting their services more appropriately and efficiently.
Back to Top
More PU Risk Re-Assessments Needed
Let’s start with risk assessment, the first step recommended in the PU prevention practice guidelines not to mention a federal requirement for nearly all nursing homes. Nursing homes are required to conduct a risk assessment for each new resident upon admission to determine whether the person is likely to develop a PU.
Practice guidelines recommend the use of a validated risk assessment tool such as the Norton Scale or the more widely used Braden Scale (5,6). Our research indicates that when nursing homes complete this step, and document the results, at-risk residents are more likely to get the preventive care they need (7). Roughly 60% of nursing homes conduct this entrance risk assessment and document it (7, 8), not a great showing given the importance of this step.
Where they really miss the mark, however, is with the corollary to this initial step. Though not a federal requirement, best practice guidelines call on nursing homes to re-assess at-risk residents, particularly those who are unable to reposition themselves or have limited ability to do so.
“The condition of an individual admitted to a health care facility is not static,” notes the guidelines from the Agency for Healthcare Research and Quality (6) “consequently, pressure ulcer risk requires routine re-examination.”
PU prevention guidelines from the University of Iowa Gerontological Nursing Interventions Research Center (5) recommend that at-risk nursing home residents be reassessed “every 48 hours for the first week, weekly for one month, then quarterly, or more frequently if (the resident’s) condition changes.”
Back to Top
Benefits of Re-Assessments
The rationale for reassessments is that if PUs are going to develop, they will usually develop within the first two to four weeks of a resident’s admission. In one study, for example, of 102 newly admitted nursing home residents, 28 developed PUs, all of them within four weeks of admission (9). In addition, findings from the reassessments can be used as a foundation for the resident’s skin care plan.
The point to understand is if you skip reassessments of at-risk residents, you’ll undermine your own prevention efforts.
It happens all the time. When a study led by Dr. John F. Schnelle included an evaluation of PU care in 16 nursing homes (see Step 1 for background on this study), we called on facilities to conduct weekly reassessments of at-risk residents for four weeks. Any fewer reassessments of these residents equates to substandard care, according to multiple best practice guidelines. Results of this study showed that none of the facilities we evaluated passed this quality indicator. Worse yet, none of them even came close. We lowered the bar to two reassessments within the first four weeks of admission and still all the facilities failed.
Back to Top
Experiment with New Practice Patterns
Why the dismal failure rate? We can think of two possible reasons:
- Nursing home staff are unaware of the importance of PU risk re-assessments, and/or
- Insufficient numbers of licensed nurses make it difficult to complete re-assessments.
The first impediment is being addressed by this module. You -for one- now know better.
The staffing problem is considerably more difficult to resolve, and as such, demands an institutional willingness to experiment with new practice patterns. Ask yourself this: Would you rather devote staff time to PU prevention or PU treatment? Indications are that the more you do of the first, the less you’ll do of the second—and vice versa. For all the reasons cited at the start of this section, we recommend devoting adequate staff time to delivering preventive care.
Back to Top
Institute a Triage System
To help with PU prevention, consider implementing our “triage system”.
Be aware that this system has not been tested yet in a rigorous research trial. It is based on expert consensus and best practice guidelines and supported by the best available research and clinical evidence. At its heart is an understanding born of both clinical experience and applied research that many nursing homes, given current staffing ratios and reimbursement levels, simply cannot deliver all that we ask of them (though most can come closer than they do). Failure to acknowledge this may fuel widespread deception, as evidenced by the fact that nursing home workers often record care that they never actually provide (10, 11). This in turn can lead to poor clinical decision-making, for it discourages the use of objective targeting assessments, which strive to make abundantly clear who needs what (and may not be getting it).
Our triage system stands in contrast to the usual care practices in many nursing home facilities. It makes concerted use of objective assessment data so that you can improve clinical decision-making and, at the same time, shape a care process that is actually feasible to implement.
Back to Top
Consider Risk Assessment Scores and Repositioning Ability
Institute a triage system that ensures that the highest risk residents are the first to receive the four weekly reassessments. This system should take into account two types of assessment data:
- The resident’s score on a standardized risk assessment conducted upon admission, and
- The resident’s ability to reposition him- or herself.
Back to Top
We Recommend the Braden Scale
Of these two scales, we recommend use of the Braden scale, largely because it has been more extensively tested in nursing homes. It also is commonly used in nursing home research; so if your facility follows suit, you can compare your results to those reported in published studies. The remainder of this section assumes the use of the Braden scale to assess PU risk.
Back to Top
Target Re-Assessments According to Risk Level
Nursing home residents with a Braden score of 18 or less on admission are considered to be “at risk” for PU (5). Ideally, all these at-risk residents should be re-assessed weekly for four weeks following admission. If the number of residents who meet this criterion and the licensed staff available to conduct the assessments render this task impractical, then target first those residents at highest risk.
- Tier 1: Residents with Braden scores below 11
New nursing home residents with Braden scores below 11 are considered to be at very high risk for PU. At the very least then, these new residents should be the first to receive the four weekly re-assessments, again using the Braden scale. Results of the re-assessments should guide the residents’ care plans.
- Tier 2: Residents with at-risk scores and limited mobility
Primary risk factors for pressure ulcers are immobility and limited activity levels (6). Given this, the second-tier target group should be new residents with Braden scores between 18 and 11 who are chair-fast, bedbound, or unable to reposition themselves. This second-tier group is likely to include the most residents—and may include more residents than necessary because of a tendency among nursing home staff to underestimate the number of residents capable of independently repositioning themselves. Use our performance assessment, which was developed and validated by work led by Dr. John F. Schnelle, to accurately identify those who are unable to reposition themselves and thus who are at greater risk for PU. This assessment is also discussed in Step 3.
- Tier 3: All other residents with at-risk Braden scores
If after targeting residents as noted above, the nursing staff still cannot complete all re-assessments, then reduce the number of weekly re-assessments to two or three within a four-week period following admission. Use residents’ Braden scores to guide the cutbacks, reducing first the number of re-assessments for those with higher Braden scores—or less risk. Thus, you should cut back first for tier 3 residents, then for tier 2 residents, and only as a last resort for tier 1 residents, those at greatest risk.
We recognize that use of this “triage system” may result in substandard care for some at-risk residents. This is truly regrettable but possibly unavoidable. If a facility is seriously short-staffed, as many are, then it is naïve to think that the services provided won’t suffer. In such a case, we believe it is ethically and clinically justifiable to focus first on providing proper care to those most in need, as determined by objective, valid assessments. This triage plan seems preferable to the usual practice in many nursing homes of providing substandard care to all at-risk residents, a system that ensures that none get what they really need.
Back to Top
Targeted Residents Need Early Intervention
Residents targeted to receive routine re-assessments during their first month are at high enough risk that they also need early intervention services to prevent PU development. Strategies for strengthening these services are presented in the next section.
Back to Top
All Other Residents Need Periodic Reassessments
PU risk status is subject to change, so residents who do not meet our tier 1-3 risk criteria nevertheless require systematic re-assessments. We strongly recommend tying these to quarterly Minimum Data Set (MDS) assessments to ensure that they are completed routinely and accurately. IF the re-assessment shows the resident is now at risk of developing a PU (i.e., meets tier 1-3 risk criteria), THEN implement early intervention services.
Back to Top
Your Assignment
Review the medical records of a handful of residents admitted to your facility in the past few months and answer these questions:
- How many residents had an initial pressure ulcer risk assessment?
- What assessment instrument was used?
- How many residents had weekly re-assessments within the first month following admission?
- Of those residents who did not receive re-assessment, should some have been reassessed based on risk status according to their initial assessment?
- Based on this review, does your facility need to strengthen PU reassessment procedures?
Share your findings; please contact us. We plan to report your feedback for the benefit of others in future updates to this site.
Back to Top or proceed to Step 3
