Step 3: Preventive Care

Learn about essential early interventions that help prevent pressure ulcers and find out how to target these services to the at-risk residents who most need them.

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Let's Review

In the previous section, we discussed the importance of conducting routine re-assessments of newly admitted residents determined to be at risk of developing pressure ulcers (PU). We recommended that a resident’s initial assessment as well as all re-assessments be conducted using a validated, standardized tool, namely either the Norton Scale or the Braden Scale. We also recommended that re-assessments be conducted weekly for four weeks following admission, largely because PUs, if they are going to develop, will likely develop during this period (1).

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Risk Assessments Help Target Interventions

The risk assessment and the re-assessments serve two purposes. First, they quantify a resident’s PU risk level, so you can monitor whether the person is getting “better” or “worse” over time. Equally important, they help pinpoint the reasons why a resident is at risk, so you can intervene to reduce that risk.

The Braden Scale, for example, assesses six PU risk factors:
  • a resident’s sensory perception 
  • skin moisture 
  • activity level 
  • mobility 
  • usual food intake 
  • exposure to friction and shear
Each time you use this scale to assess a resident, you come to know that resident—and his or her risk profile--better. This knowledge, reflected in the ratings for each risk area, enables you to tailor intervention services to this particular individual. This ability not only can improve clinical care and resident outcomes, it can also save staff time, making good care more affordable. How so? Because when you target intervention services to identified needs you avoid the costly mistake of providing unnecessary care.

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Failure to Target Services Can Create Extra Work

Findings from the evaluation study of PU care led by Dr. John F. Schnelle and conducted in 16 nursing homes (2) suggest that facilities may be creating extra work for themselves. In this study, Dr. Schnelle and his team examined PU care for 329 residents whose most recent Minimum Data Set (MDS) assessment had triggered the PU resident assessment protocol (RAP). This RAP is initiated if a resident presents with one or more of seven PU conditions:
  • limited bed mobility 
  • bed-fastness
  • bowel incontinence
  • peripheral vascular disease
  • a stage 1-4 PU
  • history of PU in the last 90 days
  • use of a trunk restraint daily  
Of our 329 PU risk residents, 90% had documented orders that they be repositioned every two hours as a preventive measure. That’s nearly everyone! Even the best staffed nursing homes would struggle to manage this workload.

Routine repositioning, a costly intervention because it is so labor intensive, is recommended in best practice guidelines for PU risk residents who are (and here’s the key phrase) bedfast or who are unable or have limited ability to reposition themselves (3).
Had nursing home staff followed these guidelines, only 64% of the participating residents would have been targeted for repositioning; that’s the percentage assessed in their MDS as bedfast or immobile in bed. But wait: even this percentage may be too high.

In a related study, also led by Dr. Schnelle, our research team found that nursing home staff tend to over-estimate residents’ dependency levels for bed mobility. We compared nursing home staff MDS bed mobility ratings to our performance assessment ratings for 197 residents in 27 nursing homes (4). Of the 60 residents we rated as “able to move,” 37, or 62%, were rated by nursing home staff as requiring physical assistance to move. That’s 37 residents who may have been getting staff help they didn’t need and possibly didn’t want.

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Failure to Target Services Can Also Short-Change Residents in Need

From a staffing standpoint, overestimating dependency levels, and thus service needs,
can be a costly mistake. From a clinical standpoint, it can be disastrous, for it means that most nursing homes will have targeted more residents than they can provide proper care for. For those who truly need repositioning, the usual upshot is that most will receive substandard care; only a minority will receive services at the level needed.

The PU care evaluation study led by Dr. Schnelle and our research team bore this out (2). We identified a sub-sample of 98 PU risk residents who were unable to reposition themselves independently, based on the performance assessment developed and validated by Dr. Schnelle in a series of studies. All of these residents then were in need of two-hour repositioning to prevent PU development. And all had medical record documentation that they were receiving it. But when we used wireless thigh movement monitors to detect actual repositioning, we found that only 26% of these residents were repositioned an average of every three hours or less. Moreover, their average longest time in one position was 5.6 hours, and ranged from 4 to 12 hours.

Could it be that by trying to do too much for too many, nursing home staff were short-changing those most in need? We think it’s likely.

Note: The wireless thigh monitor technology for assessing the bed mobility of nursing home residents was developed by Dr. Schnelle, in conjunction with Dr. Mark Friedman of Augmentech Inc., Pittsburg, PA, and tested in a series of research studies led by Dr. Schnelle. Unfortunately, these devices are not yet publicly available for use by nursing homes; however, the performance assessment, also developed by Dr. Schnelle, can be used to assess resident’s movement ability.

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So Here are Our Recommendations

It is no accident that so far we have devoted most of this section to repositioning, for of our early intervention recommendations, this care process is by far the most time consuming and the one most in need of improvement.

Our recommendations for prevention are drawn from 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 include three that outline an early intervention process for PU risk residents.

As you review them, keep in mind that these QIs are derived from but are not identical to the recommendations in best practice guidelines. Best practice guidelines, such as those available from the American Medical Directors Association and the Agency for Healthcare Quality and Research, “define optimal or ideal care in the context of complex decision-making” (5).

By contrast, our QIs, developed in conjunction with RAND, a Southern California think tank, “set a minimal standard for acceptable care—standards that, if not met, almost ensure that the care is of poor quality” (5).

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PU Quality Indicators for Intervention
  1. IF a nursing home resident is identified as “at risk” for pressure ulcers, THEN prevention addressing repositioning every two hours, pressure reduction, and nutritional status should be documented, unless intolerance or lack of need is noted.
  2. IF a nursing home resident is at risk for PU, THEN pressure reduction should be implemented unless intolerance or lack of need is noted. 
  3. IF a nursing home resident is both at risk for PU and unable to move independently, THEN repositioning every two hours should be implemented, unless intolerance or lack of need is noted.  
Let’s briefly discussion each of these three quality indicators.

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QI 1: Assess for Prevention Needs

The first one is a bit cryptic, but what it means is that, for any at-risk resident (remember: we defined “risk” in the previous section, you need to assess—and document—whether the resident needs any of three possible interventions:
  • regular repositioning—recommended for residents who are unable to reposition themselves (we discuss this in more detail below) 
  • a nutritional consultation and possibly enhanced feeding assistance to improve food and fluid intake—recommended for residents who are under-nourished or at-risk for it. Our training module on weight loss prevention includes instructions and validated protocols for assessing weight loss risk as well as food and fluid intake
  • use of pressure reduction surfaces on beds and chairs—recommended for all at-risk residents, unless intolerance or lack of need is noted. Pressure reduction surfaces include low air loss beds and foam, air, or gel wheelchair and mattress overlays.
Note that this QI does not recommend automatic implementation of each prevention strategy for every at-risk resident. Each should only be provided to those residents who need it, based on objective, ideally validated, assessment criteria.

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QI 2: Use Pressure Reduction Surfaces

With respect to the second QI, we are happy to report that, for the most part, nursing homes appear to be meeting this standard. In the PU care evaluation study led by Dr. Schnelle, 84% of the 16 participating nursing homes passed this QI (2). Two possible explanations for such commendable compliance are that use of pressure reduction surfaces typically requires a one-time only placement of a pad or overlay and the visibility of these devices make it easy for supervisors to monitor their use.

There remains, however, room for improvement, especially with respect to the use of wheelchair overlays. Our nursing home observations suggest that staff often stop with the use of mattress overlays and low air loss beds, overlooking the fact that some PU risk residents spend a lot of time in their wheelchairs. In fact, the inconsistent use of pressure reduction surfaces often occurs as residents transition from their bed to their wheelchair multiple times per day and the pressure reduction surface remains in only one of the two locations. Consider this in your assessments and take preventive action when indicated.

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QI 3: Reposition Residents Who Need It

We noted it in the previous section, but it bears repeating here: First impressions can be deceptive. And nurse aide reports can be inaccurate. Before you assume that a PU risk resident requires two-hour repositioning, check it out.

Conduct a performance assessment to determine whether residents with mobility limitations are in fact incapable of repositioning themselves independently. Our performance assessment, developed by Dr. John F. Schnelle, presented below and in our forms section, takes about three minutes per resident to complete.

Sound like extra work? In the long run this assessment will likely save staff time. The reason is that, in the absence of an objective assessment, nursing home staff tend to overestimate the number of residents who are unable to reposition themselves, thus creating more work for themselves. In a recent study led by Dr. Schnelle, for example, we found that, of 144 residents whom nursing home staff had identified as in need of repositioning, 46 residents—about 32%--could in fact independently reposition themselves (4).

Our performance assessment, presented next and in our forms section, can be used to both target PU risk re-assessments and determine who needs routine repositioning. Residents who are capable of independently repositioning themselves are at lower risk of developing PUs.

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How to Conduct the Performance Assessment

To conduct our performance assessment, a licensed nurse should ask residents lying in bed to turn to one side, and then the other side. For each turn, be prepared to offer the resident the minimum level of human assistance possible, according to a standardized graduated assistance protocol:
  • Level 0: Request only, no physical assistance required
  • Level 1: No physical assistance but encouragement, verbal cues, prompting, or instructions on how to perform the activity (e.g., “Reach for the siderail, pull yourself over”)
  • Level 2: Verbal cues required plus minimal manual guidance to start the movement (e.g., “Please move your hand towards the siderail”)
  • Level 3: Partial physical assistance (e.g., take arm and move to side rail to turn)
  • Level 4: Unable to turn to the side without complete physical assistance 
Residents are rated “able to move” if their performance falls within Level 0 or 1 on both sides.

Please note: Some of these residents, especially those rated Level 1, will need verbal cuing or reminders to turn (though they don’t need time-consuming physical help). Remember also to provide verbal reminders as needed when residents are in their wheelchairs. Be sure to share performance assessment results with fellow staff workers so they, too, can provide appropriate care.

If residents are rated at higher levels (2-4) on either or both sides, they are considered “unable to move independently” and thus, require physical help from staff with repositioning every two hours.

Use our Performance Assessment Form to document resident results.

This assessment takes about five minutes per resident to conduct (about three minutes per side). Inter-rater reliability is excellent and stability of results is good (4).

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Take Action Based on Residents' Abilities

Once you have more accurate information about residents’ abilities to move independently, you can design more effective movement care plans. For example, try the following movement care plans:
  1. Use verbal reminders to move for those residents judged able to independently move but who required verbal cues or encouragement to do so. Be sure staff know that they should remain with the resident until the resident has repositioned him/herself, as opposed to simply providing a verbal reminder and then leaving.
  2. Remember to reposition those residents who are unable to move independently both when in bed and when up in a chair.
  3. Use verbal reminders for residents who are able to independently move one side of their body (e.g., scored level 0 or 1 when turning to one side but levels 2-4 when turning to the other side). Again, be sure the resident actually repositions him or herself following a verbal reminder. Provide physical help when moving these residents to the impaired side of their body.  
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Additional Recommendations for Optimal Care

Again, our QIs represent minimal standards for acceptable care. Best practice guidelines include additional recommendations for improving mobility, enhancing incontinence care, performing regular skin assessments, and conducting other preventative interventions. Ready to review these recommended steps with an eye toward implementation? Then check out these resources:
  • Our training module on incontinence management presents instructions and protocols for accomplishing each of the four steps required to implement an effective prompted-voiding program, a behavioral management intervention that has been shown to significantly improve continence.
  • Our training module on mobility decline prevention presents instructions and protocols for implementing a fitness program that maintains or improves mobility among even the most functionally impaired residents.
  • Best practice guidelines for PU care, including early intervention to prevent PU development, are available from several agencies. We list them on our links page.


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Coming Up: Wound Assessment

What action is required if a resident is admitted with a PU or, despite your best efforts, develops one? The next section discusses procedures for completing an important assessment that is often left incomplete in nursing homes: PU evaluation. Data from this evaluation helps guide interventions, provides a basis for later comparison to evaluate healing, and helps predict time to healing.

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Your Assignment
  • Identify a handful of residents who have documented orders for two-hour repositioning.
  • Use our Performance Assessment Form to evaluate their ability to reposition themselves.

How did they do? Did you find that some were able to reposition themselves independently? And how did you do with our standardized assessment? Let us know; please contact us. We plan to report your feedback for the benefit of others in future updates to this site.

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