Reducing Pressure Ulcer Prevalence Rates in the Long-Term Acute Care Setting

Start Page: 
50
End Page: 
59
Author(s): 
Catherine T. Milne, APRN, MSN, BC, CWOCN; Donna Trigilia, APRN, MSN, BC, CWCN; Tracy L. Houle, APRN, MSN, BC, CWOCN; Sandra DeLong, RN, BSN, CWCN; and David Rosenblum, MD

Abstract: Information about pressure ulcer prevalence, prevention, and optimal management strategies in the long-term acute care hospital (LTACH) setting is sparse. Although care processes in other patient care settings have been reported to affect pressure ulcer prevalence rates, the effect of such programs in the LTACH is unknown. To reduce perceived above-average pressure ulcer prevalence rates and improve care processes, a 108-bed LTACH used a failure mode and effects analysis to identify and address high-priority areas for improvement. Areas in need of improvement included a lack of 1) wound care professionals, 2) methods to consistently document prevention and wound data, and 3) an interdisciplinary wound care team approach, as well as a faulty electronic medical record. While prevalence data were collected, policies and procedures based on several published guidelines were developed and incorporated into the pressure ulcer plan of care by the newly established wound care team. Improved assessment and documentation methods, enhanced staff education, revised electronic records, wound care product reviews, and a facility-wide commitment to improved care resulted in a reduction of facility-acquired pressure ulcer prevalence from 41% at baseline to an average of 4.2% during the following 12 months as well as fewer missing electronic record data (<1% of charts had missing data). These study results suggest that staff education, better documentation, and a dedicated wound care team improves care practices and reduces pressure ulcer prevalence in the LTACH. Studies to increase knowledge about the LTACH patient population and their unique needs and risk profiles are needed.

     Wound prevention and management are provided across the healthcare continuum in outpatient clinics, provider offices, home health, and acute, subacute, and long-term care facilities. A long-term acute care hospital (LTACH), a vital part of the healthcare continuum, is a federally recognized healthcare setting with its own reimbursement rules and regulations.

     LTACHs provide specialized acute care for medically complex patients who no longer require the extensive diagnostic testing available at acute care hospitals but still need extended hospitalization.1 To be considered for admission to an LTACH, the individual must require 24-hour, onsite medical care by a physician along with frequent evaluation and management of multiple comorbidities with the potential need for immediate diagnostic imaging, laboratory services, ventilation management, cardiac monitoring, or complex treatment modality changes. Some patients are admitted to receive intravenous therapy services not available in other non-acute care settings. Like acute care, specialized consultation is available. LTACHs differ from chronic care settings in that they focus on comprehensive treatment of critically ill or high-acuity patients using specialized programs geared to the patient’s illness. The goal is medical recovery and return to home and family.2 Unlike rehabilitation centers, qualification for admission does not include patient ability to participate in 3 hours of rehabilitation therapies per day. LTACH reimbursement, like acute care, functions under a diagnosis-related group (DRG) reimbursement system. LTACHs participate in the Joint Commission on the Accreditation of Hospital Organizations (JCAHO) review process and must comply with federal and applicable state rules and regulations regarding patient care. Medicare is one of the predominant payors for LTACH care. Some LTACHs have a specialized rehabilitation component that may be accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF).

     Gaylord Hospital is a not-for-profit, 108-bed LTACH located in south central Connecticut.

References: 

1. Gage B, Pilkauskas N, Dalton K, et al. Long Term Care (LTACH) Payment System Monitoring and Evaluation PHASE II REPORT. Available at: www.cms.hhs.gov/LongTermCareHospitalPPS/Downloads/RTI_LTCHPPS_Final_Rpt. pdf. Accessed September 13, 2008.
2. Dematte D’Amico JE, Donnelly H, Mutlu G, Feinglass J, Jovanovic B, Ndukwu I. Risk assessment for inpatient survival in the long-term acute care setting after prolonged critical illness. Chest. 2003;124(3):1039–1045.
3. National Pressure Ulcer Advisory Panel Board of Directors. Cuddigan J, Berlowitz DR, Ayello, EA (eds). Pressure ulcers in America: prevalence, incidence, and implications for the future. An executive summary of the National Pressure Ulcer Advisory Panel Monograph. Adv Skin Wound Care. 2001;4(4):208–215.
4. Schwien T, Gilbert J, Lang C. Pressure ulcer prevalence and the role of negative pressure wound therapy in home health quality outcomes. Ostomy Wound Manage. 2005;51(9):47–60.
5. Bostick J. Relationship of nursing personnel and nursing home care quality. J Nurs Care Qual. 2004;19(2):130–136.
6. European Pressure Ulcer Advisory Panel. DeFloor T, Bours G, Schoonhoven L, Clark M. Draft EPUAP Statement on Prevalence and Incidence Monitoring. Available at: www.epuap.org/review4_1/ page6html. Accessed November 30, 2007.
7. Van Gilder C, Macfarlane GD, Meyer S. Results of Nine International Pressure Ulcer Prevalence Surveys: 1989 to 2005. Ostomy Wound Manage. 2008;54(2):40–54.
8. Eskildsen MA. Long-term acute care: a review of the literature. J Am Geriatr Soc. 2007;55(5):775–759.
9. Whittington K, Briones R. National prevalence and incidence study: 6-year sequential acute care data. Adv Skin Wound Care. 2004;17(9):490–494.
10. Vollman K. Ventilator-associated pneumonia and pressure ulcer prevention as targets for quality improvement in the ICU. Crit Care Nurs Clin North Am. 2006;18(4):453–467.
11. Holmes AM, Ayello EA, Zulkowski K, Edelstein T. A Collaborative Statewide Multi-Facility Initiative Reduces Pressure Ulcers. Poster Presented at the WOCN Society 39th Annual Conference. Salt Lake City, Utah. June 9–13, 2007.
12. Holmes A, Edelstein T. Envisioning a world without pressure ulcers. Extended Care Product News. 2007;122(8):24–29.
13. Minnesota Hospital Association. Safe skin call to action. Available at: www.mnhospitals.org/index/tools-app/tool.353?view=detail. Accessed November 15, 2007.
14. Long MA, Reed L. Practice Innovation: Development of a Wound Care Team in a Long Term Acute Care (LTAC) Facility. Poster Presented at the WOCN Society 39th Annual Conference. Salt Lake City, Utah. June 9–13, 2007.
15. American Society for Quality. Failure modes and effects analysis. Available at: www.asq.org/learn-about-quality/process-analy.sis-tools/overview/fmea.html. Accessed October 27, 2007.
16. Alexander T, Hiduke R, Stevens K. Rehabilitation Nursing Procedures Manual, 2nd ed. Columbus, Ohio: McGraw-Hill;1999.
17. Wound, Ostomy, and Continence Nurses Society (WOCN). Guideline for prevention and management of pressure ulcers. Glenview (IL): Wound, Ostomy, and Continence Nurses Society (WOCN); 2003.Available through www.wocn.org.
18. Paralyzed Veterans of America. Pressure ulcer prevention and treatment following spinal cord injury: a clinical practice guideline for health care professionals. Washington (DC): Paralyzed Veterans of America; 2000. Available through www.pva.org.
19. American Medical Directors Association (AMDA). Pressure ulcers in the long-term care setting. Columbia (MD): American Medical Directors Association (AMDA); 1996. Available through www.amda.com.
20. Agency for Health Care Policy and Research (AHCPR). Pressure ulcers in adults prediction and prevention. Rockville, Md: U.S. Department of Health and Human Services, Public Health Service, AHCPR; May 1992.
21. National Pressure Ulcer Advisory Panel. Management of tissue load: an excerpt from the third NPUAP slide set. National Pressure Ulcer Advisory Panel. Adv Wound Skin Care. 1997;10(6):35–38.
22. Thomas DR, Rodeheaver GT, Bartolucci AA. Pressure ulcer scale for healing: derivation and validation of the PUSH Tool. Adv Wound Care. 1997;10(5):96–101.
23. Hiser B, Rochette J, Philbin S, Lowerhouse N, TerBurgh C, Pietsch C. Implementing a pressure ulcer prevention program and enhancing the role of the CWOCN: impact on outcomes. Ostomy Wound Manage. 2006;52(2):48–59.
24. Granick M, Ladin D. The multidisciplinary in-hospital wound care team: two models. Adv Wound Care. 1998;11(21):80–83.
25. Gottrup F, Holstein P, Jorgensen B, Lohmann M, Karlsmar, T. A new concept of a multidisciplinary wound healing center and a national expert function of wound healing. Arch Surg. 2001;136(7):765–772.

























Anonymoussays: June 4.2009 at 15:00 pm

Excellent article. This study supports the notion that pressure ulcers are less about patient risk factors and more about the quality of care given. Study after study show that the incidence of pressure ulcers is directly related to the quality of care given and not to patient risk factors. Once we all get that message,stop blaming our high risk patients and begin paying attention to quality prevention measures,the incidence of pressure ulcers will fall. Kenneth Olshansky,M.D.

Reply to this comment »

Post new comment

  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
  • Use to create page breaks.

More information about formatting options

Image CAPTCHA
Enter the characters shown in the image.