Comparison of Air-Fluidized Therapy with Other Support Surfaces Used to Treat Pressure Ulcers in Nursing Home Residents—Part 1.

Rachel F. Ochs, MD, JD; Susan D. Horn, PhD; Lia van Rijswijk, RN, MSN, CWCN; Catherine Pietsch, BS, MT, CCRA; and Randall J. Smout, MS

P ressure ulcers present a serious and common problem, especially in the elderly. More than 1 million individuals develop pressure ulcers annually.1 The prevalence of pressure ulcers has been reported as 11% in skilled-care and nursing homes,2 10% in the acute care setting,3 and 6.8% in the home care setting, with a range of 0.5% to 35.7% reported between agencies.4 In 2001, the National Pressure Ulcer Advisory Panel reported an incidence rate of pressure ulcers from 2.2% to 23.9% in long-term care settings.5

Pressure ulcers impair quality of life because of pain, stress, and loss of independence leading to grief reactions,6 depression, and social isolation.7-9 Furthermore, treatment of pressure ulcers is costly. In 1994, Miller and Delozier,10 in a publication sponsored by the Agency for Health Care Policy and Research (AHCPR), estimated that the total national cost of pressure ulcer treatment exceeded $1.35 billion annually. In 1999, Berkrich11 reported an estimated yearly cost to treat 1 to 1.7 million hospital-acquired pressure ulcers, limited to an acute care setting, at $5 billion to $8.5 billion. Reports of estimates of costs to treat pressure ulcers have ranged from $4,000 to $40,000, depending on the stage of the pressure ulcer.12

Cost estimates for treatment are related to pressure ulcer severity.13 Optimal care of more severe ulcers requires increased time and resources. In 1996, Xakellis and Frantz14 reported the average cost for treatment of Stage II ulcers as $1,119, versus $10,185 for Stage III and IV ulcers, across healthcare settings. Treatment costs escalate when patients require hospitalization for complications. Pompeo15 coined the term “wound burden” to classify wounds according to their stage and size as follows: Class 1 (Stage II: <5 cm2), Class 2 (Stage II: >5 cm2), Class 3 (multiple Stage II or single Stage III: <5 cm2), Class 4 (Stage IV: <5 cm2), and Class 5 (Stage III or Stage IV: >5 cm2 or multiple Stage III or Stage IV). Using this approach, Pompeo found a statistically significantly greater cost for wound care with an increasing wound burden. For example, total average costs per patient in a long-term acute care hospital with Class 4 pressure ulcers (N = 71) were $54,954 as compared to an average cost of $38,228 for those with Class 3 pressure ulcers (N = 89).

Pompeo further contends that these analyses grossly underestimate the true cost of wound care because most studies base cost estimates on acute care settings, while the majority of costs occur in long-term care. Additionally, while prevalence rates are generally estimated using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD 9-CM) codes such as 707.0 for decubitus, many ulcers are not coded.15 In fact, in the National Health and Nutrition Survey Examination Study follow-up (NHANES1), Guralnik16 reported that only 9 out of 54 pressure ulcers were reported in discharge summaries; in the other 45 cases, patients or their representatives subsequently identified pressure ulcers.

The impact of pressure ulcers is highlighted by a four-fold increased risk of death in geriatric patients who develop a pressure ulcer; this risk is increased to six times when the pressure ulcer does not heal.17 Furthermore, as pressure ulcers increase in severity, the probability of healing decreases, while morbidity and mortality increase. A marked risk of complications from pressure ulcers occurs in nursing home or home care settings; in one study, the cumulative incidence did not plateau after a 2-year follow-up period.18

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