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Fighting Pressure Ulcers Requires a Team Effort

February 20, 2008

Published in the New York Times on February 19, 2008

To understand why some doctors and nurses take bedsores so seriously, it helps to call them by their clinical name: pressure ulcers.

An area of skin breakdown that occurs when sustained pressure cuts off blood circulation ”” usually in patients confined to their beds in hospitals and nursing homes ”” a bedsore can result in a wound so deep and painful that some patients require narcotics. If a bedsore becomes infected, the complications can be fatal.

“They are not just little sores,” said Susan D. Horn, senior scientist at the Institute for Clinical Outcomes Research in Salt Lake City. “If you’ve ever seen a very bad one, frankly, it would make you sick. You see a very reddened outer area, then you see, depending on how deep it is, just this hole in the skin, and it goes right down to the bone.”

Experts estimate that two million Americans suffer from pressure ulcers each year, usually through some combination of immobility, poor nutrition, dehydration and incontinence. The Centers for Disease Control and Prevention does not keep statistics on fatalities, but one prominent victim was the actor Christopher Reeve, who died of a bedsore infection in 2004 in the middle of a heroic battle against paralysis.

New research is suggesting that the battle against bedsores requires a team approach, enlisting everyone from nurses and nursing assistants to laundry workers, nutritionists, maintenance workers and even in-house beauticians.

In a study of a collaborative program involving 52 nursing homes around the country, The Journal of the American Geriatrics Society reported last August that team efforts had reduced the number of severe pressure ulcers acquired in-house by 69 percent.

“Preventing pressure ulcers is a 24/7/365 kind of job,” said Jeff West, a clinical reviewer at Qualis Health in Seattle, who helped to set up the collaborative in 2003. “It’s not as if one person can get it all done. And if it fails just a little bit, just during the weekends, for instance, you’re not going to get the results. It takes tremendous consistency.”

At the Lutheran Home in Fort Wayne, Ind., for instance, “the laundry workers helped us see that some clothes weren’t fitting the residents properly and were restricting their skin,” said Jeanie Langschied, a registered nurse there.

The kitchen staff began putting protein powders in cookies to boost nutrition. They added buffet dining, so residents would not remain in one position for so long, compressing fragile skin.

Even the beauty shop “realized that wait times needed to decrease,” Ms. Langschied said, and residents should be repositioned while getting their hair done. “It was all departments looking at everything, and it was just amazing the information that flowed through.”

Lutheran Home was one of the 52 facilities that took part in the collaborative, sponsored by the Centers for Medicare and Medicaid Services. Dr. Joanne Lynn, who helped begin the project when she was a senior natural scientist with the RAND Corporation (she has since joined the Medicare centers), said the goal was to educate nursing home workers in bedsore prevention and to encourage them to come up with creative, low-tech solutions of their own. “It was a combination of education, cheerleading and something like systems engineering,” Dr. Lynn recalled.

The number of superficial bedsores did not decrease to a statistically significant degree, for reasons that are unclear.

At David Place, a nursing home in David City, Neb., staff members say they focused on assessing each resident’s risk for bedsores, and noted this risk on the assignment sheets used by nursing assistants.

“The residents at highest risk,” said Dan Smith, director of nursing, “would be the last up for meals and the first down after meals so they would not be in their wheelchairs for long periods of time putting pressure on their bottoms.” Residents at risk from weight loss were given yellow plates, so that staff members would remember to encourage them to eat more.

David Place also bought new mattresses made of high-density foam to reduce pressure in key areas. Staff members say they redoubled efforts to keep feet elevated with pillows so that bedsores would not develop on the heels. And they began to use new moisture barrier creams with residents who were incontinent, since lingering moisture can speed the development of sores.

Staff members at Palatka Health Care Center in Palatka, Fla., initiated a similar blend of measures. They created a “skin-watch action team,” or SWAT, to identify vulnerable residents and to make sure that their heels were floated, that they were given pressure-reducing cushions and that they were repositioned frequently, said Carol Jones, a risk manager at the center.

“We got the grass-roots level, the certified nursing assistants, much more involved, and they were held accountable,” Ms. Jones said. If a bedsore began to develop, she said, “we’d ask them, how did this happen?”

Initially, as the collaborative collected data from participating facilities, the incidence of pressure ulcers did not appear to change, Dr. Lynn said. It was only when researchers focused on data for the most severe bedsores that they saw an improvement.

Clinicians document four stages of pressure ulcers, in which Stages 1 and 2 are superficial sores and Stages 3 and 4 are deep wounds that result from death of the skin and underlying tissues.

“In good care, almost all new stage 3 or 4 pressure ulcers show up fully formed,” Dr. Lynn said, meaning that they do not begin as superficial bruises that then go deeper. The injury, she said, “appears to be in the deep tissues from the start, though it can take a few days for the extent of dead tissue to become apparent.”

The deeper sores may have different underlying causes than the superficial ones, she said. But it is unclear why the less severe ones did not respond as well to the practices instituted by the collaborative.

Dr. Horn, of the Institute for Clinical Outcomes Research, praised the collaborative as “the first major national effort driven by Medicare to reduce pressure ulcers.” But she said that better outcomes could be achieved if more nursing homes improved their documentation, so that all of the information on a given resident, including details on eating, urinary and bowel function, appeared on a single sheet, with key reminders to nursing assistants and other staff members about best practices.

Institutional change and work-flow redesign are critical, she added, given the high rates of turnover in nursing home staff across the country.

The changes need to become hard-wired in an organization, said Mr. West, of Qualis. “A lot of places do well when they have a lot of support,” he said. “But it’s hard to keep that momentum going. That’s the real challenge.”

Statewide efforts to reduce pressure ulcers are also under way in California, New Jersey, New York and elsewhere.

Bedsores are “a major quality-of-life issue, and a self-esteem issue,” said Joanie Jones, a nurse at David Place in Nebraska. “No one wants to have sores on their bottom. I don’t care how old you are. You still want your skin intact.”