Pressure Ulcers are on the rise. CMS states they remain one of the top reasons for hospital admissions. Home Health agencies want to deliver good care. The costs for care are rising. And home health agencies are being scrutinized when trying to sit at the ACO table.
How viable is your agency pressure ulcer care program? Do your clinicians know how to answer related OASIS questions regarding pressure sores? You need to look at having a solid wound care/pressure ulcer reduction program as the ACOs have started to focus on those programs. Recently, an agency was asked about frequency as to Braden Scale utilization. They could not answer quickly. Do you know your standard protocol? These answers aren’t just for the wound care specialist any more.
Let’s talk Pressure Ulcers. What is a Pressure Ulcer?
The Agency for Health Care Policy and research defines a pressure ulcer as “any lesion caused by unrelieved pressure resulting in damage to underlying tissue.” CMS define the pressure ulcer as “a loss of epidermis and variable levels of dermis and subcutaneous tissue.”
An increase in number of pressure ulcers while under the care of a home health agency is considered a Potentially Avoidable Event- Risk Adjusted. The OASIS seeks information with two questions: M1306 Unhealed Pressure Ulcer at Stage II or Higher and M1308 Current Number of Unhealed Pressure Ulcers at Each Stage.
Pressure Ulcers are frequently painful, impair physical and psychological well-being, and the patient is at an increased risk of death. 45% of wound care patients will be hospitalized due to complications at some point during the home health care experience. In 2000, the average cost of a pressure ulcer admission was $20,241. In 2005 it was $36,652, and in 2010, it was over $48,000.
OASIS C Home Health Process Measures include Pressure Ulcer Prevention in Plan of Care: M2250 Interventions to Prevent Pressure Ulcers Plan of Care as well as Pressure Ulcer Treatment Based on Principles of Moist Wound Healing in POC: M2250 Pressure Ulcer Treatment Plan of Care.
Facts for the Non Clinicians
The skin is the largest body organ covering on average 3000 square inches, weighing 6 pounds, and receiving about 33% of the body’s circulating blood volume. It is divided into three layers: the epidermis, the dermis, and the subcutaneous tissue. The skin is one of our greatest protectors against infection. It also assists to regulate temperature, sensations, and metabolism.
The skin requires adequate hydration externally, as well as internally. If the skin is damaged, it demands more protein and Vitamin C. If exposed too long to heat or the sun, it will burn or be otherwise damaged. As we age the cell production declines forcing the skin to become thinner and weaker.
Harsh soaps and chemicals can reduce the number of cell layers in the outer most portion of the epidermis (top layer of skin). Certain medications, such as prednisone can interfere with cell regeneration of the epidermis as well as negatively impact collagen synthesis.
Sitting or lying in one place too long can cause increased pressure, vascular occlusion and tissue hypoxia (decreased oxygen and blood to the tissue site). If the pressure continues an accumulation of metabolic waste occurs because of diminished circulation and tissue necrosis or death of the tissue occurs.
Common sites include:
Home health clinicians know they must assess the back of the head, the cervical spine, the scapula, and the ankles as well, as, they too, are common pressure points.
Tissue damage is classified by Stages 1-4 or unstageable. The National Pressure Ulcer Advisory Panel (NPUAP) defines the stages as follows:
Stage 1: “Intact skin with non blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.”
Stage II: “Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.”
Stage III: “Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present, but does not obscure the depth of tissue loss. May include undermining and tunneling
Stage IV: “ Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining or tunneling.”
Unstageable: “Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.” This may also be unstageable due to nonremoveable dressing or device.
The Braden Scale
The Braden Scale is a pressure sore risk predicting tool. It looks at the following subscales: sensory perception/cognitive function, activity, mobility, skin moisture, nutritional intake, and friction and shear. The first five items are assigned a risk value of 1-4 with the latter item assigned a 1-3. The risk of pressure ulcer is determined by the lower the score, the higher the risk.
The risk values on the subscales are tallied:
At Risk = 15-18 points
Moderate Risk = 13-14 points
High Risk = 12 or less points
In home health, a patient who has limited mobility, is wheelchair or bed bound, has exposure to moisture due to incontinence, does not eat or drink adequately, and/or has poor skin turger should have a Braden Scale assessment completed on each visit. Home health aides should be well trained in pressure ulcer prevention. They should understand how specific tasks are linked to specific risks.
Activities, such as repositioning patients every two hours should be linked to the sensory subscale. Keeping skin clean and dry, while using moisture barriers, should be linked to the specific moisture subscale.
Critics believe that because there is no formal/standardized training available in the public domain delineating how to use the Braden Scale that inaccuracies exist. They also believe that there is insufficient time to use the scale as frequently as necessary. Clinical judgment is used to score each subscale and as a standard practice, most clinicians have been found to err on the side of “when in doubt or if patient is on the borderline, assign a lower score.”
Many studies have shown, that when a formal risk assessment, such as the Braden Scale has been used and the levels of risk were linked to preventive protocols with each caregiver seeing the reasons for each task, the incidence of pressure ulcers dropped by 60%. That is a huge statistic that reflects a savings in human suffering and financial cost.