Pressure Ulcers
Introduction
More than one million individuals develop pressure ulcers annually. The prevalence of pressure ulcers is estimated at 11% in skilled-care and nursing homes, 10% in acute care, and 4.4% in home care. In hospitals, the incidence of pressure ulcers ranges from 2.7% to 29.5%. Pressure ulcers negatively affect a patient's quality of life and are associated with an increased incidence of medical complications, infection, and death. Every year an estimated 60,000 people die from complications related to pressure ulcers (2000).
Pressure ulcer is most commonly known as bedsore. Other names for it include pressure sore, decubitus ulcer and trophic ulcer. It is an ischemic necrosis and ulceration of tissues overlying a bony prominence which has been subjected to prolonged pressure against an external object like a bed, wheelchair, cast or splint for example (2003). The condition results to impaired skin integrity related to unrelieved, prolonged pressure (2004).
Such a condition is seen most frequently in patients who have diminished or absent sensation, or are debilitated, emaciated, paralyzed, or otherwise long bedridden. Any patient experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence and/or poor nutrition can therefore be at risk for pressure ulcer development. Tissues over the sacrum, ischia, greater trochanters, external malleoli, and heels are especially susceptible but other sites may be involved, depending on the patient’s position. Pressure ulcers can affect not only superficial tissues, but also muscle and bone.
The prevention of pressure ulcers is a priority in caring for patients and is not limited to patients with restrictions in mobility. Impaired skin integrity may not be a problem in healthy, immobilized individuals but is a serious and potentially devastating problem in ill or debilitated patients. Prompt identification of the high-risk patients and their risk factors aids in prevention of pressure ulcers. The major problem in treating pressure ulcer is that the ulcer is like an iceberg, a small visible surface with an extensive unknown base, and there is no good method of determining the extent of tissue damage.
More advanced ulcers require surgical treatment. Surgical debridement and closure is required for fat and muscle involvement. Affected bone tissue requires surgical removal; disarticulation of joint may be needed. Necrotic tissue can promote pathogen growth and delay healing, so it should be removed. An exception may be eschar or necrotic tissue on a heel ulcer because an open heel wound can easily become infected and lead to osteomyelitis. Several debridement methods are available; the choice depends on the amount of necrotic tissue, absence or presence of infection, patient preferences, and economic considerations (2006).
Risk management Process
Corporate Level
Various health groups in different countries have set up policy and health program developments, and strategic goals in relation to minimizing risk for pressure ulcers. Guidelines for preventing and treating pressure ulcers have been developed in many countries, beginning with the Netherlands and the United States ( 2004).
The National Health Service (NHS) of UK has come up with a clinical guideline for pressure ulcer risk assessment and prevention. The guideline aims to reduce the occurrence of pressure ulcers by providing health care professionals with guidance on the early identification of patients at risk of developing pressure ulcers, the provision of preventative interventions, and by identifying practice that may be harmful or ineffective. The guideline does not cover the epidemiology of pressure ulcers or make recommendations for wound care and/or the surgical management of pressure damage. This guideline does not include treatment of existing pressure ulcers. However in cases where a patient has a pressure ulcer, it will be useful in preventing pressure ulcers on other areas of the body (2001).
Furthermore, in Australia the same measures were being made to help minimize the incidence of pressure ulcers. Guidelines specifically tailored to Australian healthcare were released in 2001 by the Australian Wound Management Association. A major limitation of all these guidelines is the level of evidence on which they are based. Using the evidence-grading system of the National Health and Medical Research Council, only one recommendation in the Australian guidelines achieved level 1 (evidence obtained from a systematic review of all relevant randomized controlled trials) — the recommendation that pressure-reducing or pressure-relieving mattresses or beds be used in place of standard hospital mattresses in high-risk patients. As is common with many guidelines for preventing pressure ulcers, much recommended practice is based only on consensus statements from experts in the field (2004).
In Queensland, Queensland Health implemented a statewide Pressure Ulcer Prevention and Management Program to reduce the prevalence of pressure ulcers through the implementation of evidence-based guidelines. This involved standardized reporting and monitoring systems for the purposes of benchmarking (2004).
The answer to reducing the prevalence of pressure ulcers lies not in implementing any one strategy, but in providing an institution-wide prevention program. Common to guidelines for preventing pressure ulcers is identification of patients at risk. It is imperative that some form of structured method to identify those at risk is applied to all hospital inpatients (2004).
Assessments need to be repeated regularly throughout a patient’s hospital stay and when there is a significant change in health status. A number of risk-assessment tools can be used, the most common being the Norton Risk Assessment Score, the Braden Scale and the Waterlow Risk Assessment card (2004).
Organization Level
A major challenge in many areas of medical practice is to successfully implement guidelines for clinical practice. A recent review of effective strategies for implementing pressure-ulcer guidelines concluded that active strategies were more successful in reducing ulcer prevalence. The most effective strategies used targeted educational sessions and, in particular, multiple approaches. Such a strategy was recently shown to reduce pressure-ulcer prevalence in a multicentre Australian study. This indicates that developing guidelines alone is not sufficient to influence outcomes, but that they need to be linked to educational strategies to ensure their successful implementation and subsequent influence on clinical outcomes (2004).
The National Institute of Clinical Studies has developed a Pressure Ulcer Resource Guide to provide easy access to evidence-based knowledge and contacts for those individuals and groups implementing strategies to improve pressure ulcer care.
At the University of Western Australia, a national multi-centered study has been undertaken as part of a PhD project, which assessed the effectiveness of implementing the Australian Wound Management Association guidelines for the prediction and prevention of pressure ulcers in tertiary teaching hospitals. As a result of this work, a comprehensive pressure ulcer management resource has been developed (2004).
Fremantle Hospital has also developed reporting and feedback processes, based on Australian Incidence Monitoring Systems, for tracking the occurrence of pressure ulcers in a tertiary hospital. A telephone reporting system has been successfully implemented to support the reporting process and is widely used across all disciplines. The WA Council for Safety and Quality in Health Care has funded a project at Fremantle Hospital to develop and implement a comprehensive education program for nursing staff on assessment, identification of risk and management of pressure ulcers. The project also aims to improve the collection, analysis and reporting of data on the occurrence of pressure ulcers (2006).
Project Level
Healthcare professionals must work together in groups or teams in the care of a patient who is at risk for pressure ulcer or one who already has pressure ulcer.
Nursing director:
The nursing director has the role of getting reports from the head nurse. These reports would include statistics of how many incidents of pressure ulcer are occurring in the hospital and how it is treated according to new research. In addition, the nursing director also have the responsibility of providing qualified nurses and offer them new courses for continuing education.
Head nurse:
The head nurse plays an important role to prevent pressure ulcer. The head nurse has the responsibility of providing the policy and procedure in the unit for all staff; as well as making the staff understand the need and importance of such policies and procedures. The head nurse must also distribute enough staff nurses to cover all shifts in the hospital unit because a shortage of nurses may cause bad care for the patients that could lead to an increase in the incidence of pressure ulcer in the unit.
Clinical instruction:
Education and clinical instruction of patients and their caregivers is an important function of health care professionals, especially of the nurses (2004). There are a variety of educational tools, including videotapes and written materials that can be used by the nurse when teaching patients and their caregivers or family to prevent and treat pressure ulcers. Written materials are available on a variety of topics relating to pressure ulcers. Patient instruction should be individualized for each patient, especially with older patients.
Nurse:
The nurses are responsible for regularly monitoring patients and maintain skin integrity and help the patient change position every one to two hours. The best treatment for pressure ulcers is prevention. Pressure on sensitive areas must be relieved. Unless a full-flotation bed such as a water bed is used, providing even distribution of the patient’s weight. If the patient is using braces or plaster casts, a protective padding at bony prominences should be used under braces or plaster casts, and a window in the cast should be cut over potential pressure sites.
Skin inspection is also an important thing that a nurse should perform. Pressure points should be checked for erythema or trauma at least once/day in an adequate light. Able patients, mobile or immobile, and their families must be taught a routine of daily visual inspection and palpation of sites for potential ulcer formation. Exquisite skin care for neurologically damaged parts is necessary to prevent maceration and secondary infection. Maintaining cleanliness and dryness helps to prevent maceration. However, nurses have to make plan and provide care that prevents pressure ulcer.
The nursing staff also serves as a vital link to the dietitian and/or physician by communicating those patients at nutritional risk. This first line of defense helps to identify early patients at nutritional risk who would benefit from a comprehensive nutritional assessment performed by a dietitian and nutritional interventions (2000).
Physical therapist:
Physical therapists also play a role in the prevention and treatment of pressure ulcers. Physical therapists can we evaluate areas to see where the weight-bearing pressures are and in a way prevent the development of pressure ulcers. They can improve the patient’s ability to move and make exercise plans for patients. Thru the help of physical therapists, range of motion activities can be done by the patient and can help avoid development of pressure ulcers.
Wound care:
When caring for patients who have impaired skin integrity and chronic wounds, the nurse must integrate knowledge from nursing and other disciplines, previous experiences, and information gathered from clients to understand the risk to skin integrity and wound healing. Knowledge of normal musculoskeletal physiology, the pathogenesis of pressure ulcers, normal wound healing, and the pathophysiology of underlying diseases enable the nurse to have a scientific basis for care (2004).
Dieticians:
Nutritional factors play a significant role in the ability to maintain and attain skin integrity because proper nutrition is very important for prevention and treatment of pressure ulcers. A well-balanced diet, high in protein, is also important in the treatment of pressure ulcers (2004). Nutrition assessment techniques and nutritional interventions for patients at risk for developing a pressure ulcer or who currently have pressure ulcers are essential components of quality patient care.
However, dietician determine patient’s nutritional status by assessing the nutritional risk factors, give dietary support, advice and help patient to maintain ideal body weight. When dealing with patients that already have pressure ulcers, nutritional assessment is essential for identifying individuals whose nutritional status may compromise healing. Assessment also serves as a basis for planning nutritional support (2005).
Individual Level
All health care professionals should receive relevant training or education in pressure ulcer risk assessment and prevention. Health care professionals with recognized training in pressure ulcer management should cascade their knowledge and skills to their local health care teams. An inter-disciplinary approach to the training and education of health care professionals should be adopted.
Not only should health care professionals be the only ones who should be educated regarding pressure ulcers. Patients and their caregivers as well should be educated or provided information regarding pressure ulcers.
Scope of the risk according the following categories:
Patient care:
A variety of factors can predispose a patient to pressure ulcer formation. These factors can be directly related to disease, such as decreased level of consciousness, related to the aftereffects of trauma, the presence of a cast, or secondary to an illness, such as decreased sensory input following a cerebrovascular accident. These factors are divided into intrinsic and extrinsic factors.
Both intrinsic and extrinsic factors precipitate pressure ulcers. Intrinsic factors include loss of pain and pressure sensations that ordinarily prompt the patient to shift position and relieve the pressure, and the thinness of fat and muscle padding between bony weight-bearing prominences and the skin. Disuse atrophy, malnutrition, anemia, and infection play contributory roles. The most important of the extrinsic factors is pressure. Its force and duration directly determine the extent of the ulcer. Pressure severe enough to impair local circulation can occur within hours of an immobilized patient, causing local tissue anoxia that progresses, if unrelieved, to necrosis of the skin and subcutaneous tissues.
An individual's potential to develop pressure ulcers may be influenced by the following intrinsic risk factors which therefore should be considered when performing a risk assessment: reduced mobility or immobility; sensory impairment; acute illness; level of consciousness; extremes of age; vascular disease; severe chronic or terminal illness; previous history of pressure damage; malnutrition and dehydration (2004). The following extrinsic risk factors are involved in tissue damage and should be removed or diminished to prevent injury: pressure; shearing and friction. An individual's potential to develop pressure ulcers may be exacerbated by the following factors mentioned, which therefore should be considered when performing a risk assessment: medication and moisture to the skin.
Identifying Individuals at Risk
The assessment an individual’s risk of developing pressure ulcers should involve both informal and formal assessment procedures. Risk assessment should be carried out by personnel who have undergone appropriate training to recognize the risk factors that contribute to the development of pressure
ulcers and know how to initiate and maintain correct and suitable preventative
measures.
The timing of risk assessment should be based on each individual case. However, it should take place within six hours of the start of admission to the episode of care. If considered not at risk on initial assessment, reassessment should occur if there is a change in an individual’s condition which increases risk.
All formal assessments of risk should be documented or recorded and made accessible to all members of the inter-disciplinary team.
There are several instruments for assessing patients who are at high risk for developing a pressure ulcer. Patients with little risk for pressure ulcer development are spared the unnecessary and sometimes costly preventive treatments and the related risk of complications.
Clinical staff:
Incident of pressure ulcers could have negative effects on health care professionals. Take for example the nurse could be punished if his or her patient has developed pressure ulcers under his or her care. Punishment may include banishment the nurse from the department or worse from the hospital. The nurse could also be given a warning letter and kept in his or her file, creating a bad personal reputation. At the worst, the nurses or other health care professionals could face litigation from complaints of patients and their caregivers.
Other employees:
No risk to other employees.
Property:
No risk on the property.
Financial:
It has been widely established that pressure ulcers represent a significant cost to health care system anywhere in the world. However, estimates of costs vary widely, and to date there has been no analysis of the cost of pressure ulcers in medical versus surgical patients. The estimated costs associated with the estimated 1 to 1.7 million annual pressure ulcers is between $5 billion and $8.5 billion (1999).
In addition, litigation related to pressure ulcers is also a growing financial problem due to several factors. These factors include closer scrutiny of care by the patient, the patient's family, government agencies, and the media. Many facilities have been found liable in civil lawsuits for poor pressure ulcer management.
A review of medical malpractice cases regarding patients at risk for pressure ulcers in long-term care facilities indicated that the patient achieved a verdict or settlement in 68% of cases, and the median monetary recovery was $250,000. Another recent study in hospitals and long-term care facilities reported that the patient achieved a verdict or settlement in 78% of cases involving pressure ulcers. They also found that the monetary recovery for patients whose pressure ulcers were caused by poor nutrition alone was almost five times higher than the monetary recovery for patients whose pressure ulcers were caused by poor pressure management alone (2000).
Corporate governance:
With the increasing incidence of litigations due to pressure ulcers, the medical condition in itself is being used as an indicator of quality of care by various regulatory agencies. When the incidence of pressure ulcers increase in a certain hospital or health care institution, that would mean that the hospital or health care institution have inadequate medical care and doesn’t provide good quality care for the patients. As a result, the hospital or health care institution will lose reputation and money.
Other risks:
No other risk.
Conclusion
The incidence of pressure ulcers had created high costs for hospitals and health care institutions. Various health care agencies are therefore creating programs that could identify high-risk individuals and at the same time lower the incidence of risks that pressure ulcer generates to other aspects.
Pressure ulcer prevention and treatment must encompass all aspects of patient care including nutritional intervention, pressure relief and management, incontinence management, and wound care. Perhaps the most effective intervention for problems with skin integrity and wound care that would both predispose to pressure ulcers is prevention. Prompt identification of high-risk patients and their risk factors aids in prevention of pressure ulcers.
Care given to patients with pressure ulcers must be of high quality since this could affect the overall image of a hospital. To be able to provide the best quality of care, a variety of factors is essential. Most important of which is the continuing education of health care professionals.
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