Comprehensive Pressure Ulcer Prevention in Nursing Homes
Under Federal law, nursing homes are required to assess every resident for risk of pressure ulcer development using an interdisciplinary team that includes nurses, physicians, and other hands-on care givers. Why is such a comprehensive approach necessary? Holistic approaches provide better prevention and treatment plans. In this week’s episode, we welcome Dr. Aletha Tippett to talk about how simple, systematic approaches to assessments can yield great results for residents.
Schenk: Hey out there, welcome back to the podcast. As we produce this episode, we are in the middle of a pandemic, so we are not necessarily in our normal location and we are, Will and I are socially distancing ourselves from one another, and by that, I mean he is at his home and I am at my home. So we are not able to do this together at this particular time. We will remedy that in future episodes.
Today we wanted to talk about pressure ulcer prevention in nursing homes and kind of what a comprehensive approach looks like. We’re going to be talking about how an interdisciplinary team can work, how the frame of mind, how the nursing home itself from a 40,000-foot view, if they approach it in a certain why, how they can really reduce the instances of pressure ulcers, that is to say if you look at everyone in your nursing home as a risk for pressure ulcers, then it’s likely that you can put into place a simplified and standardized approach with everyone and that can go a long way to preventing pressure ulcers as opposed to having this person’s low risk over here, this person’s high risk over here, this type of thing and you’re making it a little bit more difficult. I think our guest would say to implement the appropriate interventions.
And when I say guess, I mean Dr. Aletha Tippett. Dr. Aletha Tippett will be our guest today. Dr. Tippett received her B.S. in chemical engineering from the University of Missouri in 1975 and her MD from the University of Cincinnati in 1977. Dr. Tippett has done wound care for over 20 years and has treated over 15,000 wounds. Her main areas of focus in wound care are limb salvage and pressure ulcer prevention and treatment and she brings a bioengineering approach to these, and you’ll hear a little bit more about that in the episode. She’s been honored with numerous awards in the healthcare community and is a published author and international speaker and teacher on wound care topics. Dr. Tippett is also active in hospice and is a certified hospice medical director for Brookdale Hospice in Dayton, Ohio. And she recently published a book, “Hear Our Cry,” a story about 20 years of wounds and amputations, and she’s the author – and we’ll get into this a little later when we bring her on – of a paper called “Reducing the Incidents of Pressure Ulcers in Nursing Home Residents: A prospective six-year evaluation,” which was super interesting. And with that, we’re going to bring her on – Dr. Tippett, welcome to the show.
Tippett: Thank you.
Schenk: Fantastic. Well Dr. Tippett, we wanted to have you on the show today, I guess first, by way of a background, I found a paper or a research document that you had done a few years ago about reducing the incidents of pressure ulcers in nursing homes, and that’s kind of how I found you. And there was a lot of great information in that paper through your study that you had conducted. So that’s kind of the genesis of why I wanted to have you on to just kind of talk about pressure ulcers in the nursing home setting and what we can do from a facility-wide standpoint on preventing them in the residents. But before we delve into that, if you don’t mind, can you just from a 40,000-foot view, can you explain what a pressure ulcer is?
What is a pressure ulcer?
Tippett: Well, sometimes people call them bedsores. What it really is is like your skin has had a stroke. Pressure, you know, causes – if you have pressure on something, there’s a lot of energy being exerted and if you press on your skin over a bony prominence which is going to be poking back up against that pressure, it takes about 20 minutes to create a sore. And some people call it bedsores, but it’s more commonly called pressure ulcer. The newest term is “pressure injury,” but we all know it as a pressure ulcer.
Tippett: There’s a lot of the dynamics going on, but I like to think of it as your skin had a stroke.
Schenk: I mean I think that’s a good characterization of it. So I think it goes without saying – and anybody that wants to learn a lot more about the definitions and the terms that Dr. Tippett had laid out, if you listen to
of the podcast, we talk at length about what the difference is between those terms and maybe why we have those terms and things like that, but ideally for today, for the listener, Dr. Tippett and I are going to go into a little bit in depth on obviously these are things we want to avoid, but the point…
Tippett: Oh yes.
Schenk: Right. But the point is what can the facility do to avoid them. And one of the things that attracted me to this paper that Dr. Tippett had done is the role of what’s called the interdisciplinary team in the facility in helping to prevent them. So Dr. Tippett, can you kind of walk us through what an interdisciplinary team is at a facility and what role they have in trying to prevent these injuries?
What is an Interdisciplinary Team and how does it prevent pressure ulcers?
Tippett: Sure. The paper you’re talking about was really a great job by that nursing home and it’s a big nursing home, 150 beds, but they went six years without getting a pressure ulcer, which is pretty good.
Schenk: Wow. That’s very good.
Tippett: Yeah. That’s kind of unheard of. But in general, let me tell you, nursing homes in general do a really good job. I mean I’ve done wound care for 20 cares and have done lots of legal cases where pressure injuries happen, and hands down an injury occurred in the hospital and then the nursing home gets it from the hospital. But ulcers don’t occur that frequently in a nursing home, though some do. Sometimes they do. In fact, that nursing home that you read that report on, before I started with them, they had about 25 percent of their patients had pressure ulcers that were caused from their facility. And we formed an interdisciplinary team, which is you had nurses, you had nutritionists, you had physical therapists, you had different disciplines all working together and with the commitment to not have any injuries. And within four months, they were zero and they’ve been that way for six years that I was there with them.
Schenk: So if I understand correctly, the interdisciplinary team is kind of like what we would call the heads of the departments, so like the director of nursing, which I should say the medical director, maybe the administrator or staff, they kind of form a committee or a team?
Tippett: That would be one. This was more hands-on people. These are the people that did the work. You had aides, you had nurses, you had physical therapists, you had dietitians, people who were actually doing the work as opposed to the nursing head or the administrative head. The administrative head joined us sometimes just so she could see what was going on, but the people that did the work were the ones that were on the team.
Schenk: I see.
Tippett: Yeah, and part of it is you have to have a commitment. I mean you could have the team, but if you didn’t have the commitment, the team isn’t going to do anything. But this group, their boss, their administrative boss said, “We are going to do this,” and they said, “Okay,” and did it, you know? The team all dived in and everyone contributed their part to the program.
Schenk: And so what does the team do? Like what are some of the interventions that they can put in place that would help prevent, and as you observed at this particular nursing home, eliminate the pressure ulcers?
What does the Interdisciplinary Team do to prevent pressure ulcers
Tippett: Well we first of all decided what kind of pressure support – that’s really important. You can’t just be in a regular bed, okay? Now none of the people in this nursing home could walk. They’re all bedded down. And if you’re bedded down, how are you going to relieve that pressure? If you’re laying on a hard bed, it’s going to be really hard. You’re going to have pressure points. So we looked at what support surfaces they were on, what kind of beds they were on, what kinds of chairs they were on. And I showed them that the beds that they were on were causing injury. I had pictures. I took pictures and showed them and they said, “Whoa! Okay!” The next day, they changed and got different support surfaces and that’s what they had. They had new static air support surfaces on every bed and every chair. They even had a person that went around making sure those were inflated right and were working properly. So that’s part of what the team did was a) make sure we had the right support surfaces and b) make sure that skin was lubricated. Dry skin is a no-no. I always teach dry skin is graffiti. If you go into an area and you see graffiti, you think that this area isn’t safe, right? So if you see dried skin, think, “This is not safe,” because if your skin is dry, it’s more fragile. It can tear more easily. It can bruise more easily. It could be infected. It can get a pressure ulcer more easily. So if you lube them up, you help avoid pressure injury. And the right surface helps avoid pressure injury.
And part of the team’s job is to make sure how do people maintain that every day? How do we make sure that we’re doing this? And we appoint a wound champion, someone who knows a little bit about how wounds happen and who knows our program and then tours and looks to see, “Oh, skin is not dry. They’ve all got the right pressure support surface on board and documentation is correct. They’re writing the right things down.” That’s what the wound champion does and they’re part of that wound team.
Schenk: That makes a lot of sense. So if I understand it correctly, it sounds like some of the more comprehensive steps taken by the facility by the team is you’ve got somebody making sure that the correct support services are in place, so air mattresses, these types of things, the proper cushions on wheelchairs.
Schenk: You’ve got somebody looking out for dry skin.
How does skin moisture affect pressure ulcer development?
Schenk: And you’ve got everybody being responsible for accurately documenting wounds or the development of fishy things on the skin – fishy, fishy, fishy meaning suspect things on the skin. And then finally you have the wound or the skin champion is kind of like not necessarily the supervisor but somebody that holds the others accountable.
Something that was really interesting that you talked about and I want to make sure that our listeners are on board with this and understand this is that while dry skin might be an indication of vulnerable skin, wet skin…
Tippett: Dry skin is very…
Schenk: Right. Wet skin could be a risk factor for the development of pressure ulcers on particular parts of the body as well.
Tippett: Actually wet skin – it’s not really pressure as it is as much as dermatitis types of things.
Schenk: I see.
Tippett: Not necessarily pressure. So that’s kind of a – maybe not a misnomer but kind of a wrong idea that people have had all along. And when I say lube the skin, that means it’s not the hand lotion. It’s like we use A.D. Balm, but that’s not used in all nursing homes. Some won’t use it but you can A.D ointment, something like that, antiseptic ointment, and rub that all over the body, and that protects against moisture damage also.
Schenk: Sure. See, I just wanted to reiterate that you’re not talking about the skin needs to be moist, like with perspiration or fluids, anything like that.
Tippett: No. No.
Schenk: Yeah, yeah. Okay. Wanted to make that clear, but even though you’re right, dry skin – okay, it’s really dermatitis we’re talking about that the skin can be…
Tippett: If it’s moist. If it’s got too much moisture, correct, or it can be rubbed wrong or just the moisture. But no, the lubrication I’m talking about is not something that makes your skin wet. In fact, it protects the skin against wetness.
Schenk: Wetness and dryness, yes.
Tippett: And dryness, yes.
Schenk: That makes sense. In your paper, Dr. Tippett, you talk about the concept of simplification and standardization of pressure ulcer-specific interventions. Can you kind of dive into that? What does that mean? Why is that a beneficial characteristic of a good system to prevent pressure ulcers?
How can nursing homes simplify pressure ulcer prevention?
Tippett: Well, and I’ve lectured on this recently, we know that this particular static air works. It works every time. I’ve used it for 20 years and it never doesn’t work and we used it in this nursing home that did six years, and so simplified is you don’t have to worry about, “Well gee, what’s your break score?” or “Are you high risk or low risk?” Everyone is high risk, so you treat everyone. You don’t have to worry about who needs it, who doesn’t. You treat everyone. So simplification is if they come into our facility, we slap pressure ulcer prevention on them right away, put them on support surfaces, bed and chair, and we lubricate their skin. And it doesn’t matter who they are or what the risk factors are, everyone’s got the same. So that’s simplification. And you don’t worry about stratifying your risk. You just treat everyone the same. That’s the simplified…
Schenk: Well I think we have the answer of how that nursing home went to zero pressure ulcers then, because if you treat everyone as a high risk for pressure ulcers and implement all of the interventions for someone who is at a high risk for pressure ulcers, it’s very likely that you’re going to prevent them. And even if they do occur, then it’s probable if you’re doing everything correctly, assessing everything correctly, that it was unavoidable due to the chronic illnesses of the individuals anyways. Is that – I guess that’s what I’m hearing?
Tippett: Correct. We catch it instantly and can correct it. Over the six years, they did have a couple early pressure ulcers that we jumped right on and took care of, but yeah, if you do that, if you simplify to where you don’t stratify your risk, everyone gets the treatment. You’re going to be at zero.
How does budget factor into a nursing home’s approach to pressure ulcer prevention?
Schenk: So do you, in terms of this particular nursing in my experience would be not common because it would appear to me if you’re treating everyone as a higher risk of anything, whether it be falls, pressure ulcers, UTIs, these types of things, it requires more training. It requires more interventions, which would be more money, more time. Have you seen that or is there something I’m not considering that might make it more fiscally beneficial to spend this effort?
Tippett: Well this particular system that we adopted, training was minimal. You can teach an aide in 10 minutes. And they didn’t need to know English, you could teach them. So it was very, very simple. Lubing the skin up, that takes, what, two minutes to teach someone how to do that? And putting them on – if you automatically had the right support surface on, all you had to do is make sure it was there. It didn’t take – it wasn’t an extensive training required.
Schenk: So I mean, and that was going to be my next question, is the type of training, was this something that did you develop after this study or is thing something you’ve adopted from somewhere else? Where does the training materials come from?
How are nursing homes trained to prevent pressure ulcers?
Tippett: We train as part of our program. I mean I trained everybody on wound care. We had one session for everybody on wounds, how wounds happen and what they are and what you can do to prevent them. And then we taught all the nurses, “This is your support surface and here’s how you make sure it’s working right.” And the aides were taught, “Here’s how you lube the body up.” We just did that as part of our program.
Schenk: So I guess if I’m hearing – because in my experience, at least with how most nursing homes approach pressure ulcer prevention, you’ve got dietary, you’ve got nutrition intake, incontinent care – these are all factors that nursing homes should keep in mind with regard to preventing these pressure ulcers or at least healing them. But it seems to me you’ve really honed in these primary drivers of prevention is the support surface and literally making sure the skin has – you apply…
Tippett: You apply the proper protection.
Schenk: …the proper protection to the skin.
Tippett: Correct. Really. I have to tell you, all the other stuff, incontinence care, dietician, those are all valuable but they’re not critical. The only things that really matter to prevent pressure injuries are those two things that I mentioned.
How does CMS funding affect pressure ulcer prevention?
Schenk: I see. So can you talk a little bit – this might seem like a crazy segue but again, this was talked about in your research, but what is CMS and what does CMS funding have to do with the prevention of pressure ulcers in facilities?
Tippett: CMS is Medicare and they don’t pay you to prevent. If you get a pressure ulcer, they will not pay you to treat it. So you really don’t want to get an ulcer because they’re not going to pay you.
Schenk: You being both the facility and the actual resident – definitely neither of those entities or parties wants a pressure ulcer.
Tippett: They’re not – if you’re in a facility and you develop an injury, a pressure ulcer, and CMS is your payer, CMS will not pay for treatment of that wound.
Schenk: And why is that?
Tippett: That’s their new rule. That’s their rule and it’s supposed to penalize facilities for not performing well. If you don’t get any ulcers, they don’t dock your pay or anything. If you get one, they dock your pay.
Schenk: So I guess if I understand you correctly, it’s not the appropriate way to incentive the programs that you’re laying out.
Tippett: No. I mean, well, my facility that I wrote the paper on, they were facing closure. They had major financial penalties because of wounds that they had within their facility. So they were highly motivated to get rid of the wounds and they did great. They did great. In fact, we almost – we applied for a Comet Award, which is an award in nursing homes for special efforts and stuff. We didn’t get it but we almost got it.
Schenk: You made a good showing.
Tippett: We made a good showing, yes.
Schenk: Well Dr. Tippett, because our audience is mostly comprised of family members of nursing home residents, can you kind of talk about what the typical granddaughter, daughter, son, nephew can do if they have a loved one in a nursing home to protect that person from pressure ulcers?
What can families do to prevent pressure ulcers in loved ones?
Tippett: Well they can keep their spirits up, visit them, keep them mobile, as mobile as possible. If they can walk, they can go places, that would be great. Be generally supportive of them. Again, nursing homes typically are not dangerous places in terms of pressure ulcers compared to a hospital, all right? And if their loved one goes to the hospital, make sure that they’re really looked at when they come back because that’s when they’re likely to have an injury that shows up. But really beyond that, try to keep their loved ones as active as possible and as upbeat as possible. All those things will impact their care and impact their health.
Schenk: I see. So just making sure that the resident is mobile to get their blood flowing, get their spirits up.
Schenk: That goes a long way to preventing pressure ulcers.
Schenk: In the last couple minutes, can you kind of talk about support mattresses, air mattresses, because we’ve talked about how critical these things are – can you talk about kind of what they are and how they work on the body to prevent these things, to prevent pressure ulcers?
How do devices help prevent pressure ulcer development in nursing home residents?
Tippett: Okay. Well in my book, the very best is static air. It’s just an air-filled cushion. It doesn’t have power, so it’s not dependent on power cords, which some of them are. So if you have a bed that has to be plugged in, if your power goes out, your bed’s not going to work. And so I like the one that doesn’t depend on the power. And it causes the body to kind of float, and if you’re floating, you’re not going to have any pressure anywhere. Now there are low air loss beds and they blow air into the beds. They’re considered pretty high level pressure support, but a) they’re powered, you have to have them plugged in, b) you have to have them set right and oftentimes they’re not set right, c) they’re blowing air. A lot of people have infections like C. difficile, stuff like that. If you’re blowing air, you’re just blowing that into the air and I really don’t like that. So I’m not a fan of the low air loss mattresses though you’ll find those used very commonly, especially if someone has an ulcer, they need the low air loss mattress, but I would advise try to avoid that if possible. The gel pad does not provide any pressure support so don’t be misled thinking the gel pad is going to help because it isn’t. And foam is pretty standard, and it’s not bad but you’re still going to have pressure. It’s foam so it’s not the highest level as opposed to like a static air is going to totally relieve the pressure, and that’s what you want on the chair and on the bed. You need them on both.
Schenk: I see. So that makes perfect sense. And with regard to the – I’m not using the right word, the moisturizer for the skin, what – yeah, can you talk about that a little bit more? What is it and how often do you apply it?
Tippett: You apply it every day. My favorite is Bag Balm. You can buy that over the counter. It was invented over 100 years ago for cow udders. Well lo and behold, farmers who used it noticed that their hands were in really good shape. So every farm family always had Bag Balm on their kitchen counter. And now it’s common. Shania Twain uses it on her lips. People everywhere are using it because it’s a lanolin-based, really good moisturizer and inexpensive, eight bucks for a can, which lasts a long time.
Schenk: Well if Shania Twain is using it, it must be good because she looks like she’s defying all aging at all.
Tippett: There you go! There you go. But a lot of facilities won’t use this because they’ll say, well it’s not FDA-approved. Well yeah, it’s a cosmetic. It’s not a medicine per se. But A.D. ointment is approved and it’s similar to Bag Balm. So A.D. ointment is a good one. Plain oil is okay, like olive oil or something like that is fine. You know, how families could help, they could bring a moisturizer like that in and they could come in and put it all over their mom or dad or whoever.
Schenk: Okay. And I mean, like I guess it would be important for the family not necessarily to get permission but at least notify the nursing home so at least they can be placed into the care plan that this is being done and not just willy-nilly start. Because if there’s already a pressure ulcer, you might be interfering with the healing of the wound if you’re slapping olive oil on something, but my understanding…
Tippett: You probably wouldn’t be, but yeah, you might.
Schenk: Well possibly if you’re not washing your hands, these types of things.
Tippett: Yeah, right.
Schenk: Well Dr. Tippett, this has been very educational. We really appreciate you coming onto the show to talk to us about these things. Some of these concepts are a little bit different from what we normally on the show on these things.
Tippett: Thank you. Thank you.
Schenk: You’re very welcome. So thank you so much.
Tippett: I’m glad you asked about it.
Schenk: Yeah, of course. Of course. We have a lot of shows dedicated to pressure ulcers and there’s a lot of different points of views on their preventions and their treatments. So I want to have as much information on this show as possible and not necessarily have it from one perspective.
Tippett: Well good. Good, good, good. Well you all stay healthy in this pandemic, okay?
Schenk: We certainly will. Thank you so much.
Schenk: Bye-bye. So Dr. Tippett has a lot of really interesting perspectives on these things, and like I was mentioning to her, some of these things might be a little bit different from how other wound care doctors handle their residents or their patients, but a lot of interesting things. The main thing that I would like to stress is family involvement even though we didn’t get to that until the end. I think family involvement is very important and I agree with Dr. Tippett that you want to get, to the best of your ability, get your loved one moving, get them up and going if possible, even if they’re immobile, like if they have paralysis on one side, work the other side. Do what you can with that from a physical standpoint. From a psychological standpoint, it’s always good to get the spirits up. I feel if you’re right in your soul, if you’re right in your mind, your body will follow. So that’s really great advice and the great advice is support services are extremely important with regard to preventing pressure ulcers. Making sure if your loved one is at high risk or if they happen to be a resident, if your loved one is at one of these places where everyone is treated as high risk, then having the proper support surfaces can go a long way to protecting your loved one.
So on behalf of Dr. Tippett, we really appreciate you coming on the show. We really appreciate you watching the show, I mean, on behalf of Dr. Tippett. Anyway, we will – let’s see, I think we have another pressure ulcer episode coming up. That might be the next one – I’m not quite sure, but we really appreciate you sticking around. Again, like and subscribe wherever you get your podcast from, subscribe on our YouTube channel and we appreciate you. And with that, we will see you next time.