Published in the August 2009 issue of Today’s Hospitalist
A new rule on reimbursement for inpatient pressure ulcers is putting pressure on physicians to aggressively assess and manage their patients’ risk of skin breakdowns.
Related article: Vanquishing pressure ulcers – one hospital’s success
Late last year, the Centers for Medicare and Medicaid Services (CMS) moved to stop paying to treat pressure ulcers except for those documented as being present on admission. That puts hospitalists in the difficult situation of trying to manage a condition that may not always be avoidable.
That was the message that geriatrician Elizabeth Foy White-Chu, MD, delivered during a session on wound care at this year’s Society of Hospital Medicine meeting in Chicago. Dr. White-Chu directs the wound healing center of Boston’s Hebrew SeniorLife, which is affiliated with Harvard Medical School.
“We’re coming around to the concept that skin, just like any other organ, can fail, particularly at the end of life or in frail, older adults or very sick patients,” Dr. White-Chu said. But even if you can’t prevent all pressure ulcers, she added, there’s still a great deal you can do to mitigate both patient injury “and the financial downside for your hospital.
“Documentation and quality care are of the utmost importance,” Dr. White-Chu stressed. “As long as you document what you’re doing for these patients “as far as nutrition, incontinence and moisture, positioning and mattress selection “if a pressure ulcer still forms, at least you’ve tried everything you can to prevent it.”
Risk factors and red flags
According to a recent Today’s Hospitalist poll, 92% of respondents said that their hospital now screens for pressure ulcers on admission. Widespread screening is good news, Dr. White-Chu noted, because the Medicare payment guidelines state that physicians must document pressure ulcers that are present on admission. Otherwise, Medicare will not pay the treatment costs of any pressure ulcers that progress to stage III or IV during hospitalization.
“Nurses may stage pressure ulcers, but the CMS wants a doctor to say, ‘Yes, there is a pressure ulcer on admission,’ ” she said. Expect to find pressure ulcers in as many as 15% to 25% of patients, particularly those transferred from nursing homes or long-term care facilities. And count on patients with underlying skin issues to deteriorate further once they’re in acute care.
“They have underlying causes, they’re getting sicker, and they’re being restrained either because of delirium or lack of mobility,” Dr. White-Chu said. “Those all lead to even higher prevalence.”
One critical factor: How long does it take the patient to get to the wards? Studies have shown, for instance, that patients who spend as few as three hours on a stretcher waiting in the emergency department may already have tissue injury or even a pressure ulcer. “You need to be aggressive and get those patients mobilized,” she said.
Patients who are wheelchair-bound are another concern, she added. While these patients are supposed to have their wheelchairs assessed for pressure points every two years, Dr. White-Chu said that many wheelchair users go without such assessments. That puts them at greater risk for coccyx or ischial ulcers.
And even when you don’t find a pressure ulcer on admission, a history of the condition is a major red flag.
Studies have found that it takes as long as 300 days for these wounds to completely heal. Even then, “that area has scar tissue, not nice fat and muscle being rebuilt, and the skin has only 40% of its tensile strength for the rest of the patient’s life,” Dr. White-Chu said. “When patients say they’ve had a pressure ulcer before, you need to pick that up.”
How often should you assess patients for pressure ulcers while hospitalized? In addition to on admission, Dr. White-Chu said that many hospitals call for assessment every 24 hours. Assessments should be made at least every 48 hours, she pointed out, and when a patient’s condition changes. (Assessment intervals vary by institution, so check your hospital’s policy.)
The most commonly used predictive tool is the Braden Scale, which has six risk components: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The lower the score, the higher the risk.
Keep in mind, Dr. White-Chu said, that the scale is just a tool and shouldn’t replace looking at the entire clinical picture. A history of pressure ulcers, for instance, or a low value on one of the subscores, even if the overall score is OK, should cause concern. Hospitals should have protocols in place so that patients at higher risk get switched to specialized mattresses, are put on a turning schedule or receive some kind of prevention intervention.
Treat the underlying cause
When a pressure ulcer develops, Dr. White-Chu said, treating the underlying cause is just as important as impeccable wound care. “The majority of pressure ulcers form over bony prominences,” she reminded audience members, “so when I see ischial tuberosity or coccyx ulcers, I think of sitting wounds.”
She associates lying-down wounds with sacral and ear ulcers, she added, and heel ulcers with delirium. “These are the patients pushing up against the bed all the time,” she said. In addition to bony prominences, she’s also seen “nasty ulcers” develop around tubes that are hard to reposition, including Foley catheters and wound-vac tubing.
To aid prevention, many facilities are moving to non-powered specialized mattresses, which are filled with air, water, gel or foam, or some combination. For patients with stage III or IV pressure ulcers, guidelines recommend that they be moved to powered mattresses, which mechanically vary pressure.
If you use a specialized mattress, Dr. White-Chu warned, make sure it doesn’t replace a turning schedule and excellent wound care. While no head-to-head studies have established the superiority of one type of mattress over another, she said that foam mattress overlays have also proven effective in pressure-ulcer prevention and management.
In addition, one randomized, controlled trial found that foam overlays for operating room tables can play a definite role in prevention. But steer clear of donut cushions, which may relieve pressure on the coccyx but put pressure everywhere else. Air-filled boots designed to prevent heel ulcers, on the other hand, can be helpful but “can sometimes cause problems in other locations. Just work with patients and with what your facility can provide.”
For positioning solutions, Dr. White-Chu said that occupational and physical therapists “can be your best friends.” And for patients who don’t have severe vascular disease, “elevating the legs won’t hurt them. Just put a pillow under their heels, and it’s totally offloading.”
Will this ulcer heal?
To treat pressure ulcers, Dr. White-Chu said there isn’t much evidence to support the use of hyperbaric oxygen therapy. Likewise, a systematic review published in the Dec. 10, 2008, issue of the Journal of the American Medical Association found no clear winners among support-surface or wound dressing alternatives, or among nutritional supplementation approaches, other than protein supplementation. The same was true for electric current, light or vacuum therapy, and ultrasound therapies, all of which need to be tested further in larger randomized trials.
How you treat pressure ulcers does depend, however, on whether or not you think the ulcer can heal. That decision comes down to determining if patients have enough blood flow. The best non-invasive method for assessing limb vascular infrastructure in many patients, Dr. White-Chu added, is toe photo-plethysmography (PPG).
When she’s treating younger patients and those without diabetes, Dr. White-Chu said she’ll try to find a palpable pulse or order a Doppler ankle-brachial index (ABI). But older patients and those who are diabetics, she pointed out, may be prone to medial calcinosis in their arteries, which can produce a falsely elevated ABI.
PPGs, on the other hand, much more accurately reflect toe pressures. Make friends with your vascular surgeons, she said, and discuss what PPGs “including segmental pressures “they would be able to measure.
A palpable pulse typically indicates 80 mmHg of pressure. You’re looking for a reading of 50 mmHg or more from a toe PPG or an ABI reading of more than 0.5 to indicate adequate blood flow.
A transcutaneous oxygen tension (tcO2) value of more than 30 mmHg would likewise indicate sufficient blood flow. But Dr. White-Chu advised against tcO2 readings because they are prone to operator error and are more expensive than toe pressures. For patients without adequate blood flow, microscopic distal surgery may be an option with either bypass or stenting, although not all vascular surgeons are comfortable performing these procedures.
How to promote healing
To promote healing, Dr. White-Chu said she focuses on three components. The first is moisture balance. “You don’t want the wound too wet, which will bring in bacteria,” she said, “but you also don’t want it so dry that cells won’t migrate.”
The second component is bacteria balance, keeping in mind that “a little bit of bacteria is good for wounds, signaling cells to come in and clean up the area.” The third component is debridement to remove yellowish, necrotic tissue.
While there are many products on the market, she counsels physicians to not “get hung up on the latest and greatest.” Instead, think of how you need those products to function.
Products that provide a good combination of all three components, Dr. White-Chu said, are cadexomer iodine and silver dressings.
“If wounds are sopping wet, think about foams and alginates,” she said. “For bacterial balance, go for silver products.”
For debridement, you can choose among a host of products, including gels and enzymatic agents such as collagenase. As for sharp debridement, Dr. White- Chu said that the textbook approach is that it has no place in treating pressure ulcers. But the reality sometimes is reflected in the slogan, “Nothing heals like cold hard steel.”
“If you feel comfortable in your debridement skills and can be gentle, that’s one way to go.” On the other hand, she advised against using whirlpools for debridement. “They are huge baths of bacteria,” she said.
Maggot therapy, which is now offered in some hospitals, can be quite helpful. And when choosing products, steer clear of lanolins and fragrant lotions that can cause skin sensitization and allergies down the road.
For maintenance or nonhealing wounds, on the other hand, concentrate on bacteria balance, not moisture balance or debridement. And be sure to document whether a wound is healing or nonhealing, how you’ve discussed that distinction with the family, and what you’re doing to keep a nonhealing wound as clean as possible to prevent further deterioration.
Pressure ulcer infections come in two varieties: superficial or deep tissue. Suspect a superficial infection if, despite good treatment, nutrition and continence care, the wound continues to not heal and you see a lot of granulation or drainage.
Symptoms of deep tissue infections are warmth, tenderness and pain, particularly in patients with nephropathy. In patients who have diabetic ulcers that you can probe to the bone, think osteomyelitis. Treat superficial infections with topical or oral antibiotics, and use oral or IV antibiotics for deep tissue infections.
For deep pressure ulcers, wound-vac treatment or surgical debridement may be an option, as may flap procedures “but only for younger patients who aren’t frail and who have stellar nutritional status, said Dr. White-Chu.
“They have to be prone almost a week after surgery and they then have a slow sitting-up schedule, which can be excruciating,” she said. “Flap procedures fail between 30% and 60% of the time for all comers, so it’s better if you and your plastic surgeon are very selective with your patients.”
As for care post-discharge, keep in mind that many wound-care products are expensive. “Find out what patients can afford,” Dr. White-Chu advised, “and work within their needs.”
Deborah Gesensway covers U.S. health care from Toronto.