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n terms of human suffering and treatment costs, the costs associated with advanced wound care are enormous. Coupled with increasing litigation expenses, the importance of a good skin health management program cannot be over estimated. In our previous article, we reviewed the impact of pressure ulcers in the long-term care (LTC) setting and further examined existing pressure ulcer risk assessment tools and their shortcomings. We then introduced a new method of pressure ulcer risk assessment.¹ This article will overview the success rates of many prevention and reporting strategies, then address the importance of incorporating a routine, standardized method of pressure ulcer documentation.

Pressure Ulcers: Prevention and Reporting

       A brief literature review highlights numerous publications, including those from the Agency for Healthcare Research and Quality (AHRQ, formerly the Agency for Health Care Policy and Research or AHCPR), supporting incorporation of evidence-based protocols to prevent and treat pressure ulcers.^2–7
In one recent study,⁷ it was demonstrated that the implementation of a new skin care protocol comprised of a cleanser, barrier cream, and barrier film, along with a staff education program, led to a significant reduction in ulcer development and incontinence dermatitis. The study concluded that the introduction of this relatively limited prevention protocol, “maintained or improved patient’s skin condition and significantly reduced the resources used in delivering nursing care.”⁷ Another series of randomized trials examined the clinical utility of risk-directed specialty surface assignment in the intensive care unit of a large hospital. It was demonstrated that significant reduction in nosocomial pressure ulcers could be achieved and that the risk assessment process could be incorporated into routine ward policy with relative ease (see Figure 1). However, a recently published study suggests that success stories, such as the ones mentioned above, may be far less common than could be hoped.⁸ Using pressure ulcer quality indicator (QI) scores along with a survey of pressure ulcer prevention and treatment practices, the study examined 362 LTC facilities, 321 of which had pressure ulcer QI scores available between April 1 and September 30, 1999.
       Overall, the pressure ulcer QI score in the facilities was 10.9 ± 6.2 percent and 15.7 ± 8.9 percent for high-risk residents and 3.1 ± 3.6 percent for low-risk residents, respectively. Among other findings, it was reported that:
1. More than 40 percent of facilities used a pressure ulcer risk assessment tool that was not evidence based
2. Fewer than 13 percent of the facilities surveyed used any form of the pressure ulcer prevention or treatment guidelines from the AHRQ
3. There was no relationship between the number of prevention strategies or the number of treatment strategies and pressure ulcer QI scores.
       Pressure ulcer incidence reports from an acute care hospital showed similar results. Despite having a monitored reporting system in place since 1991, “a significant number of patients at risk of, or with, pressure ulcers were not reported as such by ward staff.”⁹ Furthermore, 12 patients who were not reported had pressure ulcers severe enough that they were on a specialty surface.
       Clearly, these results indicate a substantial gap between published guidelines and actual practice. It is findings like these that have led some to conclude that we simply do not take the prevention and treatment of pressure ulcers seriously enough.⁹
       It has been shown that having pressure ulcers leads to increased mortality and substantially increases LTC liability.^10,11 A study that examined 118 nursing home lawsuits showed that the plaintiff was successful in the majority of cases. In cases where the defense prevailed, it was concluded that the most successful defense was to present and support the facts through accurate documentation.

Figure 1. Risk assessment trial results. Three trials using risk-directed assessment and preventive measures for over 1,500 patients were conducted at a large teaching hospital. Each successive trial showed a further reduction in the incidences of pressure ulcers as well as a reduction in the use of specialty surfaces. Resident Manager’s Wound Module was developed using such risk-directed assessment tools.

Figure 2. Wound location, type, and size

Figure 3. Wound bed evaluation

Pressure Ulcer Documentation Tools

       It has long been recognized that the reverse staging of a pressure ulcer as it heals is a poor method of assessing the healing process. As a result, numerous tools have been developed to assess pressure ulcer (and other wound) status and/or appearance. These include Pressure Sore Status Tool (PSST),¹² Pressure Ulcer Scale for Healing (PUSH),¹³ the Wound Healing Scale (WHS),¹⁴ the Sessing Scale,¹⁵ and the Sussman Wound Healing Tool (SWHT).¹⁶ A critical appraisal of these tools published by Woodbury, et al.,¹⁷ assessed:
1. The purpose and methods for the development of each instrument
2. The extent to which the instruments have been validated
3. The practicality of their use
4. The work remaining to establish their suitability for clinical and/or research purposes.
       In brief, the appraisal concluded that for successful implementation of any of these systems, a caregiver must be familiar with wound treatment methods and be properly trained to use the tool to achieve reliable results.
       Outside of the research arena, use of the PUSH tool to monitor individual patients’ wounds is not widespread.¹⁸ After modifying the PUSH to capture facility-wide data, a study examined 374 patients with 989 wounds, representing over 13,500 patient-days of care in a long-term acute care hospital. The modified tool was used to document the overall progress of healing and examine pressure ulcer healing as a function of time. The resulting information now serves as a benchmark for the facilities to judge the effectiveness of ulcer care.

Figure 4. Wound appearance and periwound condition

Figure 5. Necrotic tissue and drainage report

Figure 6. Wound undermining

Figure 7. Overall wound progression

Review and Assessment of Ulcer Documentation

       Recognizing the need to easily capture standardized wound information on a routine basis, Censeo Inc. (London, Ontario, Canada) developed risk assessment and pressure ulcer documentation software that operates on a handheld PC. Figures 2 through 6 highlight the standardized approach of the Wound Manager program. The assessment begins with wound measurements, which are then used to calculate wound area and volume. (These measurements are plotted over time to show the wound’s progression.) The assessment then proceeds through the evaluation of the wound bed, periwound skin conditions, the presence and type of drainage or necrotic tissue, and the presence of wound tunneling or undermining. Standardization of the terminology used in the assessment process means that all wounds are documented in an identical manner and leaves very little room for interpretation. By making the assessment both computerized and routine, changes in wound status are more easily identified and acted upon. This efficient documentation approach enables the wound outcomes data to be utilized in three critical ways: clinically, administratively, and corporately. First, bedside caregivers can easily and objectively monitor the progress of individual patients and their specific wounds over time (Figure 7). This gives immediate feedback on the successes and/or failures of the wound treatment care plan. Not only does the system display the clinical outcomes, it allows caregivers to immediately review the resources (e.g., specialty surfaces, dressings, topical agents) and care planning that went into achieving the observed results.
       Second, an aggregate of all wound data allows for real-time review by clinical managers and administrators. This information provides the platform for quickly identifying facilities or areas within facilities in need of quality improvement initiatives. (Conversely, it also identifies areas or facilities with exceptional practice patterns, enabling administrators to ascertain factors that lead to successful outcomes.) Lastly, by incorporating an evidence-based, routine, standardized pressure ulcer risk assessment, prevention, and wound documentation process, the LTC facility substantially mitigates the risk of pressure ulcer litigation. Properly documenting implementation of preventative and treatment strategies remains the key to successfully defending against frivolous claims.
       The consistent use of evidence-based wound risk assessment techniques coupled with standardized wound documentation will invariably lead to improved intervention. These improved practices will result in fewer incidents of wounds and will contribute to improved wound care. The third and final article in this series will address implementing an evidence-based pressure ulcer risk assessment and wound documentation program.