The multibillion dollar wound-care industry has brought a myriad of new support surface options as well as dressings and wound treatments, but nothing works like a "back-to-basics" approach, experts say.
Has optimal practice changed in any significant way since the Agency for Health Care Policy and Research (AHCPR) guidelines for pressure ulcer prevention and treatment came out in 1992 and 1994, asked Rita A. Franz, Ph.D. "I don't think so."
Experts are excited by the potential of ultrasound technology that is being pilot tested in nursing homes for early detection of pressure ulcers.
But at this point, most of the advancements made since the early ′90s have been "advancements in the absence of science," or the absence of scientific evidence for efficacy, said Dr. Franz, Kelting dean and professor in the University of Iowa's College of Nursing in Iowa City
Data suggest, for instance, that patients likely to develop a pressure ulcer should be treated with a pressure-reducing surface or device. A 2004 Cochrane review, in fact, showed that compared with standard hospital mattresses, a variety of devices can lower the incidence of pressure ulcers by about 60%but experts have been largely unsuccessful in comparing support surfaces based on meaningful functional characteristics, leaving no one device or type of device scientifically superior.
The science of pressure ulcersetiology, causes, and classificationis still evolving, as is the science of quality measurement. But, despite the change and uncertainties, the vigilance with which nursing homes are attempting to bring the "basics" more consistently and successfully into everyday practice is increasing, and providers are beginning to see results of their efforts.
Certified nursing assistants (CNAs) check patients at Virtua Health and Rehabilitation Centers every day, looking for changes in the skin and reporting such changes immediately to nurses. Nurses also perform head-to-toe skin checks weekly on each patient. In addition, every resident who leaves for a diagnostic test, appointment, or family visit for at least 2 hours receives a full skin check upon returning to a nursing home unit.
Pressure reduction is also thorough: In addition to mattress replacements and overlays for at-risk residents, all residents who cannot reposition themselves have their calves and heels floated on pillows at night, for example. All wheelchairs and geriatric chairs have cushions.
Bed-bound residents are turned every 2 hours, and residents in wheelchairs and geriatric chairs are repositioned every hour. Moisture barriers are used routinely for incontinent patients.
The 2-hour turning/repositioning schedule that is commonly accepted as a standard goal was never subjected to a randomized trial, Dr. Franz notes, but evolved from the results of an observational study done years ago in London on the relationship between amounts of spontaneous nighttime movement and pressure ulcer incidence.
Even without evidence of a casual relationship between good nutrition and pressure ulcer preventionand with disappointing results of nutritional intervention trialsit still seems only logical to promote good nutrition "on the front lines."
Dr. Jeffrey M. Levine of the Cabrini Wound Healing Center and St. Vincent's Medical Center in New York, encourages physicians to "relearn" the art of wound care that physicians used to study and practice. "Unfortunately, wound care has fallen by the wayside for contemporary doctors." He said he hopes to see new standards and techniques both for pressure relief and for the early detection and assessment of skin breakdown that can lead to the development of advanced stages of pressure ulcers.
With Medicare's upcoming reimbursement changes for hospital-acquired pressure ulcers, hospitals will turn to nursing homes for advice as they revamp their skin assessment programs and educate physicians, he said.
"Acute care has a lot to learn from the long-term care environment," he said. "The long-term care community has been far advanced in their skin care" and advanced in the application of basic processes. The back-to-basics approach that Dr. Levine teaches extends well beyond prevention and into management. "We need to evaluate the wound, keep it clean and moist, remove debris, feed the patient, and treat infections," he said.