Pressure Ulcers, CMS Changes, and Patients of Size: What Are the Issues?

by Susan Gallagher Camden, RN, MSN, MA, WOCN, CBN, PhD

Introduction
An estimated 1.3 to 3 million patients in the US have pressure ulcers; incidence is higher among certain patient populations, especially when hospitalized. Immobility and comorbidities further increase risk.1 Evidence-based practice pertaining to pressure ulcers exists and has been recognized for at least several decades; however, how does this evidence apply to pressure ulcer assessment, prevention, formation, and intervention in the larger, heavier patient with a greater degree of adiposity, unusual body configuration, obesity-related comorbidities, or multiple skin folds?

Expert opinion and case studies suggest that the principles are the same; however, prospective clinical research does not exist to support specific recommendations for care. This is further complicated by recent Centers for Medicare and Medicaid Services (CMS) changes. Once thought to be a problem exclusive to nurses and reflective of nursing care, pressure ulcers are likely to receive increasing attention in the future, primarily because of CMS changes. The aim of this article is to briefly introduce clinical challenges that emerge with the recent CMS changes, describe the basics of pressure ulcer assessment, prevention, and intervention, and ask the question: “How do these issues impact the specific needs of the obese patients in acute care?”

Understanding CMS Changes
As part of the Deficit Reduction Act of 2005, CMS has introduced a plan designed to contain costs by rejecting payment of certain secondary diagnoses in acute care facilities. Therefore, today there is a renewed focus on the prevention and timely, appropriate intervention of pressure ulcers because beginning in October 2008, hospitals will no longer receive additional reimbursement to care for a patient who acquired the pressure ulcer while under the hospital’s care.

The interest in pressure ulcers as a preventable adverse event is largely because of the high volume of occurrences. For example, in 2007, CMS reported 257,412 cases of preventable pressure ulcers as a secondary diagnosis. The average cost per case in which pressure ulcers were listed as a secondary diagnosis is over $40,000 per hospital stay. The incidence of new pressure ulcers in acute-care patients is seven percent; however, the incidence rate varies greatly from facility to facility. Although this system is likely to create challenges, it may lend a new emphasis on some of the basics of nursing care, and provide a wonderful opportunity to have the problem of pressure ulcers taken to a higher level of interdisciplinary attention. To learn more about CMS changes, see the resources listed in Table 1.

What is an acceptable standard of pressure ulcer care?
The Agency for Health Care Quality and Research (AHQR), National Pressure Ulcer Advisory Panel (NPUAP), Wound Ostomy, Continence Nurses Association (WOCN), Association for Advanced Wound Care (AAWC), and others have established best practice models addressing concerns of pressure ulcers. By definition, a pressure ulcer is a direct result of pressure, friction or shear. Some factors contributing to pressure ulcers include moisture, dehydration, malnutrition, and immobility. Pressure ulcers typically occur over a bony prominence and develop because of the inability to adequately reposition the patient from that area, thus creating damage to underlying tissue.

Staging pressure ulcers is an important aspect of assessment. The pressure ulcer staging system widely used for several decades was initially described by Shea in 1975 and was based on tissue loss and depth of destruction.10 The original definitions were thought to be confusing to many clinicians and led to inaccurate staging of ulcers, especially those due to perineal dermatitis or deep tissue injury. The NPUAP has redefined the definition of a pressure ulcer and the stages of pressure ulcers, including the original four stages, and adding two stages on deep tissue injury and unstageable pressure ulcers.

Stage I pressure ulcers are described as intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; however, its color may differ from the surrounding area. Stage II is partial-thickness loss of dermis presenting as a shallow, open ulcer with a red or pink wound bed, without slough. It may also present as an intact or open/ruptured, serum-filled blister. Stage III refers to 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. It may include undermining and tunneling. Stage IV is full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed, often including undermining and tunneling. In addition to revisions to Stages I through IV, unstageable and suspected deep tissue injury were added. An ulcer is considered unstageable when it exhibits 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. By definition, suspected deep tissue injury is a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.2 To learn more about assessment parameters, consult the additional reference list provided in Table 1.
A recommended treatment program incorporates assessment of the patient and the pressure ulcer, tissue load management, local ulcer care, managing bacterial colonization and infection, operative repair, education, and quality improvement.

What is an acceptable standard of skin care for the obese patient?
Although all aspects of a skin care plan apply, by virtue of the special nature of larger patients, a few of the aspects of care are especially critical. Risk assessment, recognizing atypical pressure ulcers, repositioning, nutrition, and the plan of care may need to be adapted to meet the patient’s needs. If a pressure ulcer is present on admission, it becomes essential that the physician document the characteristics of the ulcer. The same is true of hospital staff members based on their level of training and responsibility. Ongoing assessment and intervention is critical and should only deviate from recognized hospital procedure and protocol if the patient’s unique needs warrant this, and then documentation should reflect this according to suggestions made by the hospital risk manager or clinical expert.

Risk assessment for the obese patient
Although not supported in the literature, larger patients may be at greater risk for development for pressure ulcers for at least two reasons: difficulty in assessment and comorbidities. Assessment can be more difficult because turning and repositioning, moving tissue, and examining folds is challenging, posing a practical challenge. The second reason for greater risk may lie in the fact that patients with obesity often have corresponding comorbidities, such as diabetes, peripheral vascular disease, hypertension, and lymphedema, that likely correlate to certain types of skin breakdown, including pressure ulcers.

Several risk assessment tools exist; however, the Braden Scale for Assessment of Pressure Sore Risk (Braden Scale) is the most commonly used tool in the US. The tool can be viewed online at http://www.bradenscale.com/braden.PDF. Six parameters are assessed and assigned a numeric value that collectively reflects the patient’s risk for developing a pressure ulcer. A prevention-based plan of care is employed based on the patient’s assessed level of risk. Developed in 1984 by Braden and Bergstrom, the Braden Scale consists of six subscales that evaluate a patient’s sensory perception, activity level, mobility, nutritional status, and the skin’s exposure to moisture, friction, and shearing forces. A numeric score is assigned for each subscale. Adding the six subscale scores yields a total Braden Scale score, which can range from 6 to 23. Lower total scores are associated with higher risk of developing pressure ulcers.3

Although the Braden Scale is likely to capture risk regardless of weight, the challenge to clinicians is designing a meaningful prevention-based plan of care that accommodates the special needs of larger patients. For example, consider the following special questions: Are resources available to assist the patient in ambulating safely? Are pressure redistribution surfaces designed to function properly with added weight and width? Are caregivers provided with extra-long gloves in order to provide adequate incontinent care? Is the dietitian familiar with the nuances of obesity? The challenge to clinicians is to adapt care practices to the unique needs of this special patient population.

Recognize atypical, pressure-related skin injury
In addition to typically occurring pressure ulcers, larger, heavier patients can be at risk for atypical or unusual pressure ulcers, which occur due to pressure within skin folds, as a result of tubes or catheters, or from an ill-fitting chair or wheelchair.
For instance, pressure within skin folds can be sufficient to cause skin breakdown. Many obese patients have a large panniculus, some weighing as much as 50 pounds or more. Tubes and catheters burrow into skin folds, especially if the tissue is edematous, fragile, damaged or cellulitic. This causes erosion of the skin surface. Pressure from side rails and armrests not designed to accommodate a larger person can cause skin or deep tissue injury on the patient’s hips and trunk/torso.4

Repositioning the larger, heavier patient
Atypical skin breakdown can be minimized by using properly sized equipment. Additionally, the patient needs to be repositioned at least every two hours, as do tubes and catheters. Tubes should be placed so that the patient does not rest on them. Tube/catheter holders may be helpful in this step. The abdominal panniculus must be repositioned in order to prevent pressure injury. Alert patients are usually able to lift the pannus off of the suprapubic area or describe to clinicians the manner in which the patient prevented injury at home. If clinically appropriate, the dependent, weak, or unconscious patient can be placed in the sidelying position and the nurse can lift the pannus away from the underlying skin surface, allowing air to flow to the regions while relieving pressure. Rotation therapy is available to ensure sufficient repositioning for a very large patient who otherwise may pose a realistic challenge to frequent turning. Despite the value of rotation therapy in the prevention and treatment of skin injury among obese patients, it is necessary to take precautions to prevent friction and shear. Correct pressure settings, fitting the patient to the appropriate-sized surface, and assessment for skin changes can provide these precautions.5 Keep in mind that full-body lateral rotation therapy serves as an adjunct to turning and repositioning for purposes of promoting skin and preventing caregiver injury.6

The inability to adequately reposition patients is a significant concern, especially among obese patients.7 The challenge of repositioning the patient is at the heart of external factors that contribute to pressure ulcer formation. Additionally, caregivers who fear injuring themselves during repositioning procedures are likely to hesitate to provide adequate care. Consider the numerous resources available to help in lifting, transferring, and repositioning patients who are unable to do so for themselves. Specialized training, resources (clinical experts) and tools (equipment) are the essence of repositioning.

Nutritional Considerations
Upon admission, the patient should have a consultation with a dietitian to determine the best nutritional plan to prevent risk and support healing. A malnourished person does not have the ability to synthesize enough protein to repair tissue. The dietitian should conduct a nutritional assessment that includes a thorough history and a physical examination. If malnourishment is suspected, lab tests should be run to check serum albumin and lymphocyte counts. If the patient is found to be at risk for malnutrition, it is imperative to begin nutritional intervention with proteins, dietary supplements, and nutrients. Meeting concerns of malnutrition and obesity is best addressed using an interdisciplinary approach, including specially trained staff members.

Moisture Control
Moisture is problematic on many levels. Excess moisture on the skin surface, which collects in skin folds, threatens the general health of the skin. Bacterial, fungal, or viral overgrowth can occur in a warm, moist environment. Patients often complain of itching and burning, which leads to pruritis; scratching already compromised skin can lead to superficial trauma.8 Microorganisms can enter these breaks in the skin barrier, leading to cellulitis. Special considerations for hygiene are necessary to reduce overgrowth of microorganisms and to control odor. Consider some of the recent developments in skin fold management, including the silver-impregnated textiles.

Creating a plan of action
As caregivers begin to address pressure ulcers, obesity, and CMS mandates, we need to consider the evidence available to us when creating an action plan. Evidence-based practice includes research, expert knowing, and patient/family preference.

Hospitals should use evidence-informed practice strategies to develop a process (map, recipe, diagram, flowchart) showing the prevention, assessment, and timely intervention. The plan should be comprehensive, flexible, and able to adjust to individual patient situations.9 The flowchart should be tied to more detailed tools and resources such as forms, protocols, training material, patient education materials, documentation, checklists, products, and equipment.

Instruction provided by a specially trained or certified expert should include pressure ulcer definitions, formation, prevention, progression, and treatment among non-obese and obese patients, including challenges in hydration, nutrition, mobility, assessment, documentation, and special needs. Most hospitals have pressure ulcer prevention and treatment protocols as well as a certified wound ostomy continence nurse (WOCN). A collaborative relationship between the bariatric team and the wound care team best serves the training needs of clinicians and the clinical care needs of bariatric patients.

Conclusion
Keep in mind that change is never easy. However, CMS has delivered to American health care providers a rather substantial mandate to transform acute care pressure ulcer prevention and timely appropriate intervention. The stakes are high in that this mandate affects the top two concerns facing hospitals today: patient outcomes and reimbursement.

The bariatric, wound, and risk management teams are in key positions to make significant contributions to outcomes pertaining to care of the obese patient at risk for pressure ulcers in the acute care setting. The lack of evidence makes it difficult to affirm even what we think about wound care in general, much less consider the numerous complexities of the person of size. Many factors influence the development and healing of pressure ulcers. Clinicians of every discipline play a pivotal role in this challenging and complex process, using a comprehensive approach involving skin care, attention to pressure, nutritional support, and patient and family education. An interdisciplinary approach that addresses the unique needs of the obese patient is the essence of preventing development of pressure ulcers in this evolving environment.

References
1. Pressure ulcers. Accessed August 1, 2008 at: http://www.merck.com/mmpe/sec10/ch126/ch126a.html
2. Pressure ulcer staging. Accessed August 1, 2008 at: http://www.npuap.org/pr2.htm
3. Braden Scale for Prediction of Pressure Ulcer Score. Accessed August 1, 2008 at: www.bradenscale.com/bradescale.htm
4. Camden S. Nursing care of the bariatric patient. Bariatric Nursing and Surgical Patient Care. 2006;1(1):21–30.
5. Gallagher SM. Obesity and the skin care in the critical care area. Critical Care Nursing Quarterly. 2002;25(1):69–75.
6. Camden SG & Shaver J. Promoting dignity and preventing caregiver injury while caring for a morbidly obese woman with skin care challenges. Bariatric Nursing and Surgical Patient Care. 2007;2(1):77–82.
7. Kramer K, Gallagher S. WOC nurses as advocates for patients who are morbidly obese: A case study promoting use of bariatric beds. JWOCN. 2004;31(1):276–281.
8. Gallagher S. The challenges of obesity and skin integrity. Nurs Clin N Am. 2005;40(2):325–335.
9. Gallagher S, Langlois C, Spacht D, et al. Preplanning protocols for skin and wound care in obese patients. Advances in Skin and Wound Care: J Prevention and Healing. 2004;17(8):436–443.
10. Shea JD. Pressure ulcers. Clin Orthopedic Related Research. 1975;112:89–110.

Category: Past Articles, Review