Power to Heal: Best Practices in Pressure Injury Prevention and Wound Care

Complications from pressure injuries and venous wounds can seriously threaten the health of patients in all care settings. Whether the injuries develop during acute hospitalizations or short-term or long-term post-acute care, the risks are many.

The evidence shows that it pays for clinicians and caregivers across the healthcare continuum to prevent pressure injuries. Knowing the risk factors and early indications can help all staff work together to prevent pressure wounds and identify contributory problems and appropriate treatments as early as possible.

Recent research asserts that preventing pressure injuries in all hospitalized patients provides the highest value in comparison with standard care or prevention only for patients with high risk scores. Prevention efforts include assessing risk factors, examining skin and tissue, proactively providing protective skin care, and assessing nutrition status.

Awareness of Risks

Hospital-acquired pressure injuries affect about 2.5 million patients each year, and about 60,000 of those patients die.

Risk factors include:

• Diabetes
• Incontinence and insufficient skin hygiene
• Limited ability to change positions
• Nutritional deficiencies
• Smoking
• Depressed immune system
• Vascular disease

To encourage prevention, the Centers for Medicaid and Medicare Services (CMS) tracks pressure injuries in skilled nursing facilities (SNFs) under its Quality Reporting Program because they are “high-cost adverse events across the spectrum of healthcare settings, from acute hospitals to home health.” Proactive steps are needed because a high incidence of pressure injuries can reduce Medicare reimbursements for a full year and hurt the organization’s reputation for much longer.

CMS notes that pressure injuries have a strong association with longer hospitalizations, longer inpatient rehabilitation facility stays, and patient mortality. These types of injuries also can affect post-acute care residents’ pain, activities of daily living, and rehabilitation gains, as well as predisposing patients to infection, sepsis, osteomyelitis, and cellulitis. To complicate matters, patients with pressure injuries often have comorbidities that can make diagnosis and treatment more difficult.

An analysis of Medicare data found that patients with hospital-acquired pressure injuries had longer lengths of stay (11.2 days) than those who did not develop pressure injuries in the hospital (4.8 days). The study concluded that patients who developed pressure injuries in the hospital “were more likely to die during the hospital stay, have generally longer hospital lengths of stay, and be readmitted within 30 days after discharge.”

Training on Best Practices

With the immense impact of pressure injuries, education on prevention is important, as is proper training on skin and wound management, to help mitigate risk to the patient and the organization. Comprehensive wound care training is rarely a focal point in basic healthcare education for the range of disciplines involved in skin and wound care, notes Bill Richlen, PT, WCC, DWC, a clinical instructor for the Wound Care Education Institute, powered by Relias. The more wound care education that clinicians and caregivers obtain, the more likely they are to treat patients using evidence-based care rather than personal opinion, Richlen observes.

Wound care education can help the entire care team recognize the risks and work together diligently to avoid these types of problems. By familiarizing themselves with best practices ahead of time, clinicians and caregivers can promote healing and discourage complications when wounds develop.

Besides a focus on pressure injuries, wound care training can help team members take a multidisciplinary approach to prevention and treatment. Focused education can help clinicians identify different wound etiologies and the best interventions to optimize healing for specific types of wounds, such as arterial, neuropathic, and venous wounds.  Understanding the causative factors can inform evidence-based approaches to minimize disease progression and avoid recurrence of wounds.

Venous wounds usually develop because of vein deterioration and poor blood circulation. Researchers estimate that 6 million to 7 million people in the US have advanced venous disease and meet criteria for chronic venous insufficiency diagnoses. The researchers estimate that 150,000 new patients a year receive a diagnosis of chronic venous insufficiency, with overall treatment costs for those patients reaching about $500 million.

Proper treatment is important to the patient’s health and to the facility’s financial health. Having a certified wound care specialist on the team can have a positive ripple effect. When nurses or other staff members gain wound care knowledge, they can share best practices with others.

Certification Linked to Progress

Research has shown that having certified team members can pay off in improved patient outcomes. Results from an Ohio Health Care Association (OHCA) study show that wound care certification also can be linked to better performance on quality measures. Striving to improve pressure injury treatment, OHCA used grants to fund wound care certification training from the Wound Care Education Institute (WCEI) for nurses in Ohio SNFs. Of 199 nurses who took the training and the certification exam, 70% passed and became certified.

OHCA then analyzed pressure ulcer quality measures (QMs) in the facilities with wound care certified specialists. The quantity of pressure injuries decreased significantly in SNFs performing in the bottom 25% on the Ohio pressure ulcer QM between 2016 and 2017. Even facilities performing in the top 75% on the pressure ulcer QM still showed noticeable reductions in quantity from 2016 to 2017 with certified wound care specialists on board.

Certification training can help physicians, nurse practitioners, physical therapists, occupational therapists, licensed practical nurses or licensed vocational nurses, and nutritionists recognize causative and contributing factors and use evidence-based approaches for prevention, care, and treatment.

Costs of Prevention vs. Treatment

Better training makes sense beyond improved patient outcomes. Understanding the legal risks to healthcare organizations, clinicians, and other caregivers is vital as well. More than 17,000 pressure injury related lawsuits are filed each year, according to the National Pressure Ulcer Advisory Panel (NPUAP). As noted, the rate of facility-acquired pressure injuries also can hurt QM performance and Medicare reimbursements.

The costs associated with pressures injuries are considerable. Several studies have found that prevention of hospital-acquired pressure injuries is more cost effective than standard care. A simulation model tracked patients for one year after their admission to an acute-care hospital. The study estimated the cost as $10,054 for standard care vs. $7,276 for care with preventive measures per hospitalization.

CMS notes that the average cost for a hospital stay related to pressure injuries was estimated at $40,381. NPUAP estimates costs could range from $43,000 to $127,000 per hospital stay. Pressure injury prevention, on the other hand, costs less than $100 a day per patient, according to one study.

Another study examined the cost-effectiveness of evidence-based strategies with the potential to improve prevention of pressure injuries. The authors examined the following prevention methods in long-term care:

• Using pressure redistribution mattresses for all residents
• Giving oral nutritional supplements to patients with recent weight loss and high-risk status
• Using skin emollients with residents who have dry skin
• Using foam cleanser that included emollient and water repellent with patients needing incontinence care

The researchers concluded that the data clearly supported using pressure redistribution mattresses for clinical and economic reasons. The costs of using foam cleansers for incontinence and emollients for dry skin appeared to be supported by the financial and clinical data as well. They noted, however, that nutritional supplements had a high cost in relation to the quality improvement.

Clearly, nutrition is important to wound care, as nutritionist Julie Stefanski, MEd, RDN, CSSD, LDN, CDE, FAND, emphasizes. Vitamin deficiencies can hinder wound healing. Because an effective immune response relies on adequate protein, a high-calorie, high-protein supplement may be needed if diet alone is not working, notes Stefanski, who is a Relias writer and a spokesperson for the Academy of Nutrition & Dietetics.

Strengthening Team Expertise

With so many factors having the potential to complicate wound care, gaining targeted expertise on clinical and care teams can make a notable difference.

The hard facts are that pressure injuries and venous wounds are linked to many different types of pain points—patient physical discomfort, mental declines, increased risks of other illnesses, financial penalties for the organization, increased caregiving demands, and staff morale when treatment is not successful.

With proper education in pressure injury prevention and wound care, your team can be armed with powerful knowledge to avoid these pain points and safeguard the health of your patients and the reputation of your organization.

If you are interested in learning more about pressure injuries and wound care, view our webinar, “Insider Secrets to Wound Care.”