Hospital administrators should take note of the program implemented by Texas Arlington Memorial Hospital to reduce hospital-acquired bed sores.  The program implemented by Texas Arlington resulted in a 63% reduction in pressure sores.  This hospital accomplished this by taking the following steps:

• Identifying decubitus ulcers on all new admissions
• Reducing use of diapers amongst patients
• Encouraging all staff to look for and document decubitus ulcers, even in their earliest stages
• Paying extra attention to patients who are bed bound or who’s skin comes into contact with medical equipment like oxygen masks or tubing
• Implementing daily skin checks and intensive, hospital-wide skin checks on a quarterly basis to help the facility keep accurate tabs on how well its wound prevention program is working
• Empowering all staff to bring the early signs of bed sores to the attention of physicians and supervisors

Reduction of Hospital-acquired Pressure Ulcers at Texas Health Arlington Memorial Hospital

Turning should be completed at intervals set forth by a physician.  However, turning of patients at least every two hours is usually considered to be the minimally accepted interval.  In bed-bound residents, the staff should rotate the patient to their sides.  In residents who spend most of their time in wheelchairs, staff need to lift the residents out of their chairs.

Despite its prevalence, incontinence is often treatable.  Any resident who has been deemed incontinent should be evaluated by a physician to determine if the cause of the incontinence is physical or psychological.  Once the cause is identified a combination of behavior modification and staff assistance may be of some help.  In other cases, medication or surgery may also help alleviate the incontinence issues.  Diapers or similar undergarments should only be used as a last resort.

Incontinent patients have an increased vulnerability for developing bed sores (also called: pressure ulcers, pressure, sores or decubitus ulcers) because when urine or fecal material is held against the skin, the damp, acidic nature of the wastes cause the skin to become weakened and susceptible to cracking and peeling–literally eroding the bodies natural defenses.

Proper maintenance of the skin, requires the skin to be kept dray and sanitized.  To minimize development of pressure sores, facilities should take the following precautions for incontinent residents:

• Have adequate staffing levels: encourage patients, who are able, to use the toilet and those who are unable to notify staff as soon as a change of sheets or clothing is required
• Clean patients regularly with mild soap and lukewarm water
• Moisturized patients daily, the lotions help create a barrier on the skin
• Use proper turning techniques to minimize time spent in one location
• Keep the bed elevation (in other words, keep the head even as possible with the rest of the body)- this reduces pressure on the sacrum

Related Article:

Incontinence Amongst The Nursing Home Population, Nursing Homes Abuse Blog

• Skin should be inspected for discoloration
• Skin and tissue should be examined for any temperature change (warm / cold)
• The consistency of the skin should be assessed to see if the area has become firm or softened

Each person’s tissue tolerance is different.  In order to provide the most effective bed sore prevention measures, staff should figure in the tissue tolerance when composing an individuals care plan / turning intervals.

Turning is especially important in patients who are in a sitting position (the head above 30 degrees) because all of their weight gets pressed into the buttock area.  Consequently, many patients who are confined to wheelchairs should be moved into a bed (with their head even level with their body) to help alleviate pressure build up.

Many situations where a resident develops a bed sore at a hospital or skilled nursing facility, stem from the fact that the staff failed to properly turn the person.

F-Tag 314 (codified as 42 C.F.R. 483.25(c)), relates to bed sores (also referred to as: pressure sores, pressure ulcers or decubitus ulcers):

Based on the comprehensive assessment of a resident, the facility must ensure that:

(1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable; and

(2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.

When focusing on the individuals who developed bed sores, 39.5% were determined to be malnourished according to their BMI, compared with just 2.5% of people who were determined to be well nourished.

Consequently, establishing good nutrition in long-term settings is one of the most important areas to concentrate in to prevent development of bed sores.

Source:

“Nutrition Status and Pressure Ulcer: What We Need for Nutrition Screening”, Journal of Parental and Enteral Nutrition, Vol. 31, No. 4, 288-294 (2007) Authored by Susanne Hegstermann, Andreas Fisher, M.D., Ph.D., Elisabeth Steinhagen-Thiessen, M.D., Ph.D. and Raid-Joachim Schulz, M.D., Ph.D.

A numerical score is assigned to category depending on the individuals needs and level of assistance.  In general, the scores correlate the likelihood of development of bed sores and dictate what preventative tools should be implemented.  The lower the individual scores on the Braden Scale for Predicting Pressure Sore Risk, the more likely the individual is to develop bed sores.  A Braden Score of 12 or less is considered to be ‘high risk’ for development of bed sores.

The goal behind implementation of the Braden Scale for Predicting Pressure Sore Risk is that it can assist medical professionals with varied experience and judgment to consistently identify patients at risk for developing bed sores and to quantify the severity of risk.  The Braden Scale for Predicting Pressure Sore Risk is completed on admission to a facility and should be updated quarterly to help provide the best care to a residents changing physical condition.

A completed Braden Scale for Predicting Pressure Sore Risk becomes part of the residents chart and can be used a reference for all care givers to address medical needs.  In a busy nursing home or hospital setting, the Braden Scale serves as a reminder to busy nursing staff to attend to this aspect of patient assessment and care with the consistency necessary to influence outcomes.  The Braden Scale for Predicting Pressure Sore Risk also helps direct the attention of the nursing staff to six specific risk factors so that preventive care can be appropriately prescribed.

Below is the Braden Scale for Predicting Pressure Ulcer Risk. Copyright.  Barbara Braden and Nancy Bergstrom, 1988.  Reprinted with permission.  All Rights Reserved.

Under the terms of Bill S-1517, nursing home operators would have to switch from regular mattresses to pressure-relief mattresses within three years. Nursing home owners would have one year from the bills enactment to begin phasing in the use of pressure relieving mattresses.

“While pressure redistribution mattresses may cost more up front than the standard spring mattresses, we cannot put a price on the continued health and wellness of our state’s most vulnerable senior citizens,” said bill co-sponsor Sen. Bob Gordon (D-Bergen). “While these new mattresses alone won’t make bed sores an ailment of the past, they will greatly reduce the incidence of bed sores, and make their treatment much easier on the dedicated nursing home staff.”

If this law proves effective in New Jersey, it will be interesting to see if other states, or even Medicare, passes similar legislation.

The second component of a nursing home’s bed sore prevention program includes the development of a care plan.  In developing a care plan, members from the nursing home staff, the resident’s family, and sometimes the resident him- or herself meet and put together a care plan to address the resident’s needs.  A care plan sets forth with specificity what preventative measures are to be completed and the frequency with which they are to be completed. Specific preventative measures include turning and re-positioning, use of pressure relieving mattresses, heel boots, special nutritional supplements, and specialized skin care.

The third element of a nursing home bed sore prevention program is the implementation of the care plan.  This implementation of the care plan requires skilled workers who are competent in following the instructions set forth in the care plan.  Additionally, implementation of the care plan also requires that changes in the resident’s skin condition (development of new bed sores) be noted as the issues arise.