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Preventing Pressure Sores in the Nursing Home

Can pressure sores be prevented among nursing home residents?

The development of new pressure sores declined 30 percent over a five-year period among residents of 107 nursing homes affiliated with a national nursing home chain, suggesting improved quality of care.

Slide For Preventing Pressure Sores in the Nursing Home


Why is this important?

The development of pressure ulcers (bed sores) among nursing home residents is one measure of patient quality-of-life and is closely linked to general quality of care in nursing homes (Berlowitz et al. 1997; Mukamel 1997). Pressure sores are often preventable with appropriate care (Lyder 2003).

Findings

The development of new pressure ulcers among residents of one national nursing home chain declined by 30 percent (risk-adjusted rate) over a five-year period from 1991 to 1995 (Berlowitz et al. 2000).

  • As a result of this improvement, 127 fewer residents developed a pressure ulcer in six months of the last study year than would have if the rate had remained unchanged at these facilities.
  • Reduction in pressure ulcers saved an estimated $800,000 in treatment costs in just six months among the 107 nursing homes included in the study.

Implications

Prevention of pressure ulcers suggests improved patient care within these nursing homes. This improvement may be a result of regular assessment of residents, greater attention to this issue within the medical community, and among regulators, implementation of guidelines and the threat of malpractice suits (Berlowitz et al. 2000).

A more recent study in 100 nursing homes found that the following factors were associated with a lower incidence of pressure sores: nutritional interventions, fluid orders, use of disposable briefs, use of antidepressant medication, and higher staffing levels of registered nurses and nurses aides (0.25 hours and two hours per resident per day or more, respectively) (Horn et al. 2004).

Improvement Ideas and Resources

Comprehensive interventions involving risk assessment, turning schedules, pressure reduction surfaces, nutritional support, and staff education have reduced the development of pressure sores (Lyder et al. 2002; Regan et al. 1995), although continuing effort is needed to sustain improvements (Xakellis et al. 2001). Tracking resident assessment information in an integrated fashion can facilitate care planning and timely feedback (Horn 2006).

The federal government recently issued revised guidance for state and federal inspectors to follow when examining the adequacy of nursing home pressure sore prevention and treatment practices. Clinical experts interpret the guidance to be "clear in its intent to encourage all long-term care facilities to adopt evidence-based pressure ulcer protocols of care" (Lyder and van Rijswijk 2005).

Measure:

This study was based on 144,379 observations recorded between 1991 and 1995 on resident assessments for 30,510 residents of 107 National HealthCare Corporation nursing homes located in nine states. Six-month rates of pressure ulcer development were calculated as the proportion of residents without an ulcer who had a stage 2–4 ulcer on a subsequent assessment (stage 1 ulcers are difficult to detect and often do not worsen). Rates were risk-adjusted to control for changes in resident characteristics. Residents with a readmission during any period were excluded from the analysis in that period to ensure that any pressure ulcer developed in the nursing home. The temporal decline in pressure ulcer development was statistically significant (Berlowitz et al. 2000).

Limitations:

The details of specific interventions or improvements were not described. The definition of a pressure ulcer used here differs from that used in the current Nursing Home Compare measure, so rates are not comparable.

Source:

Data were collected by nursing home staff using the Minimum Data Set. The study was conducted by researchers at the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Mass., Boston Medical Center, and the Boston University Schools of Medicine and Public Health (Berlowitz et al. 2000).

References:

* Indicates source of data used in the chart(s).* Berlowitz, D. R., H. Q. Bezerra, G. H. Brandeis et al. 2000. Are We Improving the Quality of Nursing Home Care: The Case of Pressure Ulcers. Journal of the American Geriatrics Society 48 (1): 59–62.

Berlowitz, D. R., G. H. Brandeis, J. Anderson et al. 1997. Effect of Pressure Ulcers on the Survival of Long-Term Care Residents. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 52 (2): M106–10.

Horn, S. 2006. Partnerships for Quality: Preventing Pressure Ulcers in Long-Term Care. Translating Research into Practice and Policy Conference, July 10–12, Washington, D.C.: Agency for Healthcare Research and Quality.

Horn, S. D., S. A. Bender, M. L. Ferguson et al. 2004. The National Pressure Ulcer Long-Term Care Study: Pressure Ulcer Development in Long-Term Care Residents. Journal of the American Geriatrics Society 52 (3): 359–67.

Lyder, C., and L. van Rijswijk. 2005. Pressure Ulcer Prevention and Care. Preventing and Managing Pressure Ulcers in Long-Term Care: An Overview of the Revised Federal Regulation. Ostomy/Wound Management Supplement 2–6.

Lyder, C. H. 2003. Pressure Ulcer Prevention and Management. Journal of the American Medical Association 289 (2): 223–6.

Lyder, C. H., R. Shannon, O. Empleo-Frazier et al. 2002. A Comprehensive Program to Prevent Pressure Ulcers in Long-Term Care: Exploring Costs and Outcomes. Ostomy/Wound Management 48 (4): 52–62.

Mukamel, D. B. 1997. Risk-Adjusted Outcome Measures and Quality of Care in Nursing homes. Medical Care 35 (4): 367–85.

Regan, M. B., P. H. Byers, and H. N. Mayrovitz. 1995. Efficacy of a Comprehensive Pressure Ulcer Prevention Program in an Extended Care Facility. Advances in Wound Care 8 (3): 49, 51–2, 54–5.

Xakellis, G. C., R. A. Frantz, A. Lewis et al. 2001. Translating Pressure Ulcer Guidelines into Practice: It's Harder than It Sounds. Advances in Skin & Wound Care 14 (5): 249–56, 258.