For as long as people have been immobilized by illness, there have been pressure ulcers. In 1961, British physician and Egyptologist J. Thompson Rowling described pressure sores in unearthed Egyptian mummies, and there are references to them in scientific literature as early as the 1800s. Pressure ulcers continue to plague the infirm today. The prevalence of pressure ulcers in long-term care facilities has been estimated to be around 23%, according to information from the National Institutes of Health, and as high as 60% in quadriplegics.
There are those who see pressure ulcers as the almost inevitable result of immobility. The Center for Medicare and Medicaid Services disagrees, and has put into place new limits on payment for treatment involved in hospital-acquired pressure ulcers, beginning in October of this year.
At the North Shore-LIJ Health System’s Stern Family Center for Extended Care and Rehabilitation, Manhasset, N.Y., the staff is way ahead of the curve. “We have not had a hospital-acquired pressure ulcer on our 2SW Rehabilitation Unit since June 2006,” says Joanne Newcombe, RN, MA, BC-NE, chief nursing officer.
To what does she attribute this remarkable accomplishment? “Incredible leadership on the unit, teamwork, esprit de corps, and the fact that everyone is involved in the effort,” she replies.
Setting a GoalPictured left to right: Anna-Marie Amoroso-Scorsese, RN; Roberta White, RN, MSMA, GNP-BC, CWOCN, CRRN; Carole Clement, RN; Marie Leroy, CNA; Curtisann Gairy, CNA; and Jill Cox-Watford, LPN.
In the latter part of 2006, staff of the 2SW Rehabilitation Unit was challenged by the nurse manager, Carole Clement, RN, BSN, to prevent all pressure ulcers during the next year. They had already started working toward the goal during 2006, and the beginnings of the program were in place. “Everyone got involved,” says Clement.
Newcombe points out that excellent care begets excellence. “Once we started moving toward this goal, Carole and her staff were able to put together a plan that included everyone. Everybody ‘owns’ the vision.”
The bedrock that the plan is built upon is a partnership between the professional nurses and the certified nursing assistants, or CNA. This “from-the-ground-up” approach begins when the patient is admitted. The initial admission skin assessment is done with a CNA present and involved in the assessment and discussion. The nurse capitalizes on this opportunity to instruct the CNA and the patient about a personalized plan to prevent skin breakdown. Risk factors are discussed and special needs are addressed so that the CNA can begin doing basic interventions on his or her own.
Teaching the CNAs to do skin observation and to understand the factors involved in skin care and pressure ulcer formation empowers them to be the eyes and ears of the nurse, says Roberta White, RN, MS, WOCN, Wound Care nurse practitioner at the Stern Family Center. Because CNAs are usually not limited to their own assignment, they see most of the patients during a given time period. Clement notes that they often stop White to discuss special problems they observe and may request an intervention based on their observations. It is not unusual for a CNA to request heel protectors for a patient or to suggest a toileting schedule for a patient who may have problems with incontinence.
The CNA is expected to check each patient’s skin every day on every shift and understand what the baseline is. Newcombe notes that there is a lot of peer-to-peer education on the part of the CNA staff, and staff members expect each other to follow through from shift-to-shift on the interventions implemented. New staff members quickly learn that the unit culture is prevention-focused and are shown how to become part of the team.
“Best practice” guides the approach to prevention, says Newcombe. The monthly meeting of Pressure Ulcer Champions is a popular committee membership. The group helps to design signage for the patient room to teach patient and family members as well as staff. These signs are used by the CNAs to reinforce the education done by the rest of the nursing staff.
“We have a monthly meeting and do a lot of teaching based on what is identified by the group,” says White. “We wanted to focus on assessing the skin on patients’ feet, so we started a ‘Don’t be beat; check those feet!’ program. The CNAs on the committee pointed out that good lighting is crucial to being able to make that assessment, so we purchased pocket flashlights with our slogan on them. It’s gratifying for them to have the equipment to be able to do the job.”
Expanding the protocols and commitment to the rest of the facility has yielded remarkable results, says Newcombe. The overall incidence of hospital-acquired pressure ulcers in the facility dropped by 29% during 2007, and another 29% so far this year.
“CNAs are an integral part of the pressure ulcer prevention team,” says Newcombe, and the leadership fosters a climate of mutual respect. “Our mission is based on a ‘Patient First’ philosophy,” she says. She notes that it is gratifying to see the staff embrace this philosophy and implement it in the way they conduct all the care offered to patients.
“Respect starts with the nurse manager,” says White. “The staff feels safe because Clement promotes a blame-free environment. Everyone is able to be comfortable and focus on the patients.”
The leadership of the facility sets the tone for the staff, says Clement. Having a caring attitude toward the staff promotes the same attitude on their part to the patients. Staff members know they are valued, recognized, and rewarded. There is a friendly competition among the staff to keep enthusiasm for pressure ulcer prevention alive.
The cost of pressure ulcers in dollars in the United States is in the millions. The compassion and caring that patients experience when the staff is focused on the prevention of pressure ulcers are priceless.