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reventing pressure ulcers and other skin breakdown among residents in extended care facilities is a constant challenge for healthcare providers. Incidence rates (new cases) of pressure ulcers have been reported to range from 2.2 percent to 23.9 percent in the long-term care setting.1
       There are clearly identifiable and inevitable physical changes associated with aging that can increase the skin’s risk for breakdown. Two examples include the reduced number of densely packed cells at the skin’s surface and changes in the skin’s natural oily lipid layer. These two changes increase the potential for fluid loss (resulting in dry skin) and reduce the skin’s barrier function from outside contaminants.2
       The costs associated with pressure ulcers can be enormous. Conservative estimates for cost of treatment range from $500 to $50,000.3 Litigation is prevalent with awards reaching into millions of dollars. Facilities may be faced with fines and rising insurance premiums. While there are costs associated with preventing skin breakdown, the cost of treating wounds, litigation and fines, and a facility’s reputation may far outweigh the cost of prevention.
       A well designed prevention plan may help to decrease the incidence of new wounds and may reduce or eliminate the high costs associated with wound occurrence. Additionally, reducing the incidence of pressure ulcers may result in improved morale among staff and improved satisfaction among residents and their families/caregivers. Therefore, reducing the incidence of wounds may result in improved clinical, financial, and emotional outcomes.
       The Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research)4 has identified four areas of significance to consider when developing a prevention initiative: 1) risk assessment—identifying individuals who are at risk for skin breakdown and implementing interventions based upon those risks; 2) skin care and early treatment—maintaining and improving tissue tolerance to pressure; 3) mechanical loading and support surfaces—turning/positioning residents and using support surfaces to reduce the time and intensity of pressure; and 4) education—educating staff, residents, and families regarding the causes of skin breakdown, measures to reduce those risks, skin care, and prompt interventions for identified skin lesions.
       Facility leaders should consider the benefits of a comprehensive plan of care for pressure ulcer prevention. A comprehensive plan should include the use of quality products, user-friendly protocols (sometimes called guidelines or algorithms), staff education, and consistent documentation of preventive care.

Quality Products
       When selecting skin care products, especially for aging individuals, one should understand the characteristics of such products and their effects on the skin. Often, persons with less clinical expertise in skin care are making the decisions about skin care products that are used by healthcare facilities.5 Sometimes these decisions are made simply on the cost of the products rather than the cost benefit for the resident and facility. All products are not the same. By understanding aging skin and product ingredients, savvy healthcare providers will be able to choose products with ingredients that are most appropriate.
       Skin cleansers, for example, can impact the integrity of the skin, and an antimicrobial, pH-balanced, no-rinse skin cleanser can be the first step in skin protection. This may be especially true for patients with skin exposed to urine and feces and patients who are cleansed several times each day. Surfactants are chemical substances commonly used in cleansers to remove dirt from the skin that is not removed with water alone. There are four categories of surfactants, characterized by their electrical charge: anionic (negative charge), cationic (positive charge), amphoteric (both positive and negative charges), and nonionic (no electrical charge).5
       Sodium lauryl sulfate is an example of an anionic surfactant that is found in soaps and some commercial skin cleansers. Sodium lauryl sulfate is recognized as a skin irritant. Additionally, because of its alkalinity (high pH), soap is poorly rinsed and, therefore, leaves a residue on the skin. Soap can reduce the skin’s natural lubricants, which help hold moisture in the skin, and interferes with the skin’s normally acidic mantle (low pH). The acid mantle helps to deter the proliferation of bacteria on the skin. Most people would not consider cleansing their own face with soap several times each day; however, soap is commonly used for cleansing residents’ skin after multiple episodes of incontinence each day.
       Cleansers with nonionic surfactants, like polysorbate 20 or 60, may be the most desirable. Nonionic surfactants have a low potential for toxicity and are often used in cosmetics and food products.5
       Nonionic surfactants are also used in some bath products. In a four-month retrospective study, protocols that included a no-rinse cleanser as part of an overall preventive care plan resulted in a decline in the prevalence of skin tears from 23.5 percent to 3.5 percent when compared with the previously used protocols utilizing soap and water regimens. Reductions in caregiver time and overall costs were also documented. Additionally, no new skin tears occurred during the four months of the study.6 In a separate controlled study, among 64 residents at a different facility, the staff observed a 90-percent reduction in skin tears in the group using the nonionic, no-rinse cleanser.7

Protocols
       Evidence-based, easy-to-follow protocols or algorithms for preventive care are extremely valuable. The first step for preventing wounds is to identify at-risk residents; therefore, a protocol may direct the user to complete a risk-assessment screening tool, like the Braden scale.4 The Braden scale is an evidence-based tool that scores individuals in the following categories: moisture, mobility, activity, nutrition, sensory perceptions, friction, and shear. The individual is assigned a total score, indicating his or her level of risk for pressure ulcer development. Although the Braden scale uses a total score, interventions for those at risk should be based upon scores of individual categories of the tool. For example, interventions for residents with a low score for mobility may include a turning and positioning schedule, the use of specific support surfaces, and consultation with a physical therapist.
       Protocols may also specify frequency of skin inspections as well as interventions for skin care. Supplemental tools may be useful to keep the protocol simple and easy to follow. The Skin Care Products Algorithm (see Figure 1) is an example of such a tool. Although this algorithm is written in generic terms, it may be customized to include the specific products of the facility.

Figure 1. The Skin Care Products Algorithm is an example of a supplemental tool that may be useful in keeping protocols simple and easy to follow.

       All staff, residents, and family or caregivers play a role in wound prevention. Therefore, structured, organized, and comprehensive education should be offered at levels appropriate for all participants. Education for staff should include: 1) risk-assessment tools; 2) etiology of skin breakdown; 3) skin assessment; 4) the use of support surfaces, positioning, and turning; 5) interventions for skin care; and 6) documentation of significant data (AHRQ).4 Residents, family members, and/or caregivers should be taught about the causes of skin breakdown and their role in helping to reduce the risks.
       Accurate documentation regarding prevention interventions serves to communicate the interventions with others, to help when tracking results, and may help minimize liability risks. Documentation may be narrative or captured on a flow sheet. Some clinicians like flow-sheet style documentation because it provides cues for documentation and helps to promote consistency.
       The use of a comprehensive initiative that includes quality products, protocols, and education can impact pressure ulcer incidence rates. Regan, et al.,8 implemented a prevention initiative in a 125-bed extended care facility that included:
• Risk assessment on admission
• Implementation of a protocol for skin care products
• Prevention protocols according to the AHRQ guidelines
• Pressure reduction surfaces
• Patient/caregiver education
• Clinical supervision.
       As a result, pressure ulcer incidence rates were dramatically reduced from 24.2 percent to 0.9 percent over an eight-month period. In a follow up, 19 months after the initiation of the program, the authors found that incidence rates remained at 0.9 percent.
       Nissen9 implemented a similar comprehensive prevention program within two extended care facilities: one with 166 beds and the other with 195 beds. The pressure ulcer incidence rate at Site 1 was 11.98 percent before program implementation. At 8 and 16 months after program implementation, incidence rates were 4.3 percent and 3.2 percent, respectively. The incidence of pressure ulcers at Site 2 was 20.58 percent before program implementation. As with Site 1, incidence rates at Site 2 were reduced with the prevention initiative. At eight months after program implementation, pressure ulcer incidence was 3.06 percent and 2.38 percent at 16 months.
       Although preventing wounds is a daily challenge for healthcare providers, identifying and implementing an easy-to-follow plan can make the challenge less daunting. By identifying products with desirable ingredients, working with experts to develop a protocol or algorithm, and providing preventive care education that stimulates changes in behavior, healthcare facilities should recognize the clinical, financial, and emotional benefits.