Quality Indicators for Prevention and Management of Pressure Ulcers in Vulnerable Elders

Pressure ulcers can lead to pain, disfigurement, and slow recovery from comorbid conditions. They interfere with activities of daily living, predispose to osteomyelitis and septicemia (1), and are strongly associated with longer hospital stays and mortality. Frailty and chronic illness, both common among older adults, predispose to pressure ulcers (13). The prevalence of pressure ulcers is 10% to 14% among hospitalized patients of all ages (4, 5) and up to 24% among patients in nursing homes (2). One goal of Healthy People 2010 is to reduce the prevalence of pressure ulcers in nursing home patients by 50% (6). Prevention and treatment of pressure ulcers are an important aspect of care for vulnerable elders. This paper presents quality indicators for the prevention and care of pressure ulcers among vulnerable elders and the evidence supporting these indicators. Methods The methods for developing these quality indicators, including literature review and expert panel consideration, are described in detail in another paper in this issue (7). For pressure ulcers, the structured literature review identified 177 titles, from which abstracts and articles that were relevant to this report were identified. Fifteen potential quality indicators were proposed on the basis of the literature and the author's expertise and files from previous reviews of the subject (8, 9). Results Of the 15 potential quality indicators, 10 were judged to be valid by the expert panel and 1 additional indicator was created by the panel (see the quality indicators). One indicator was merged with an accepted indicator, and 4 were not accepted. The literature supporting each of the indicators judged to be valid by the expert panel process is reviewed below. Quality Indicators 1 and 2: Pressure Ulcer Prevention Risk Assessment IF a vulnerable elder is admitted to an intensive care unit or a medical or surgical unit of a hospital and cannot reposition himself or herself or has limited ability to do so, THEN risk assessment for pressure ulcers should be done on admission BECAUSE risk assessment can predict pressure ulcer formation in such high-risk groups and forms the basis for intervention. Positioning Needs and Pressure Reduction IF a vulnerable elder is identified as at risk for pressure ulcer development or a pressure ulcer risk assessment score indicates that the person is at risk, THEN a preventive intervention addressing repositioning needs and pressure reduction (or management of tissue loads) must be instituted within 12 hours BECAUSE reduction or elimination of risk factors can prevent pressure ulcer formation. Supporting Evidence. Several cohort and prospective studies and various expert groups provide evidence supporting timely risk assessment. Braden and Bergstrom (10) studied the predictive validity of risk assessment for pressure ulcers in 102 newly admitted nursing home residents. Using the Braden Scale (Figure) with a cutoff score of 18, they demonstrated that the sensitivity, specificity, positive predictive value, and negative predictive value of the admission assessment for subsequent development of pressure ulcers were 75%, 59%, 41%, and 86%, respectively. Of the 28 residents who developed pressure ulcers, the ulcer developed within about 2 weeks after admission in 71%, and all ulcers developed less than 4 weeks after admission (10). Figure. The Braden Scale for predicting risk for pressure ulcers. A multisite cohort study of 843 patients who were followed for 4 weeks found that the Braden Scale was predictive of pressure ulcer development in tertiary care centers, Veterans Affairs medical centers, and skilled nursing facilities (11). As part of the study, prescription of preventive interventions for turning and pressure reduction were evaluated in all three health care settings. Regardless of setting, turning schedules and pressure reduction were prescribed less frequently (7.7% and 34%) for patients at no risk or low risk (Braden Scale scores 16) than for patients at moderate or high risk (Braden Scale scores 15; 51% and 69%) (12). In another prospective cohort study of 200 newly admitted nursing home residents, the best predictor of all stages of pressure ulcer formation was Braden Scale score (13). Other investigators also found an association between preventive interventions and Braden Scale scores, in particular the subscale scores for mobility, friction, and shear (14). Prevention interventions are ordered and seem to be used more frequently for people with high-risk Braden Scale scores. However, data showing the effectiveness of the interventions themselves are lacking. Various expert groups, including the National Pressure Ulcer Advisory Panel (NPUAP) (15), the Agency for Health Care Policy and Research (AHCPR) Panel for Prevention and Prediction of Pressure Ulcers (2), and the American Medical Directors Association (AMDA) (3) recommend performing risk assessment in persons who cannot reposition themselves or have limited ability to do so. Quality Indicator 3: Pressure Ulcer Prevention Nutrition IF a vulnerable elder is identified as at risk for pressure ulcer development and has malnutrition (involuntary weight loss of 10% over 1 year or low albumin or prealbumin levels), THEN nutritional intervention or dietary consultation should be instituted BECAUSE poor diet, particularly low dietary protein intake, is an independent predictor of pressure ulcer development. Supporting Evidence. Studies have shown a relationship between risk factors for malnutrition, such as involuntary weight loss, anorexia, gastrointestinal illnesses, cancer, low caloric intake, and low albumin level and pressure ulcer formation; some studies have found a relationship between ulcer severity and severity of malnutrition (1618). Furthermore, several studies have shown associations between low serum albumin level and the presence (19, 20), severity (17, 18), and healing (21, 22) of pressure ulcers. Other measures of nutritional status, such as body weight, have been shown to correlate with presence (19, 20) and severity (17) of pressure ulcers. Although no direct evidence shows that adequate nutrition will prevent ulcers, these studies provide indirect evidence that prevention of malnutrition will reduce risk for pressure ulcer formation. Quality Indicator 4 Pressure Ulcer Evaluation IF a vulnerable elder presents with a pressure ulcer, THEN the pressure ulcer should be assessed for location, depth and stage, size, and presence of necrotic tissue BECAUSE baseline assessment guides interventions, provides data for later comparison to evaluate healing, and can help predict time to healing. Supporting Evidence. No controlled trials of assessment of pressure ulcers have been done, and some experts believe that such studies may be impractical or irrelevant [23]. Several sets of guidelines support formal assessment of pressure ulcers, with documentation of findings, and focus on wound characteristics as a useful method for evaluating and documenting healing. The NPUAP suggested that 1) assessment should include multiple characteristics; 2) pressure ulcer staging is useful for diagnostic purposes only; and 3) size and stage are insufficient measures of healing and, although important, should be used in conjunction with assessment of other wound characteristics (24). Others have also acknowledged the role of assessment in planning and evaluating therapy (3, 25, 26). Observational data support these consensus statements and suggest that many wound characteristics are important predictors of healing or determinants of interventions. Wound Depth and Stage Pressure ulcers are commonly classified according to staging systems based on the depth of tissue destruction. Stage 1 lesions are least severe, and stage 4 are most severe. Staging systems are best used to diagnose wound severity and show a relationship to healing outcomes, but they do not facilitate monitoring of healing over time (2, 24, 26, 27). Full-thickness wounds (stage 3 and stage 4) generally take longer to heal than partial-thickness wounds (stage 2) (28). A prospective study showed that stage 2 pressure ulcers were 5.2 times more likely to heal than stage 4 pressure ulcers (29). Several other prospective studies also found that wound depth was a predictor of healing and time to healing (21, 30). Two retrospective studies demonstrated that wound depth was related to healing characteristics (31) and that change in depth was related to healing time (8), yet both studies found that initial wound depth did not correlate with healing. Size Several studies have demonstrated a relationship between wound surface area and time to complete healing. In a prospective study to determine progress of healing within specific time frames, van Rijswijk (32) examined the characteristics of full-thickness pressure ulcers in 119 patients (48 of whom had full-thickness ulcers) who were seen in diverse settings. Healing was measured by using surface area tracings, with follow-up of 15 months. Mean reduction in wound surface area for ulcers that healed versus those that did not was significant at 2 weeks (45% vs. 3%) and at 4 weeks (77% vs. 18%). In a secondary analysis of full-thickness pressure ulcers, only 25% healed completely within 50 days, but three quarters had 50% reduction in surface area within 39 days (33). Ulcers with a surface area decrease of at least 39% after 2 weeks healed more quickly than those with a lesser decrease in surface area (median time to healing, 53 vs. 70 days). Retrospective studies also support the relationship between early reduction in surface area and shorter time to healing (8, 31). Presence of Necrotic Tissue Wound bed characteristics determine treatment options (8, 34). Several studies have shown that replacement of necrotic tissue with granulation and epithelial tissue is indicative of healing (32), and the presence of necrotic tissue at baseline is associated with slower healing