Practical methods for treating pressure ulcers in nursing homes
One recent study estimated that more than 2.5 million individuals in the US develop pressure ulcers each year. These injuries are even more acute in long-term care, causing catastrophic problems in our elderly population. In this week’s episode, nursing home abuse lawyers Rob Schenk and Will Smith welcome guest Catherine Milne, advanced practical wound nurse and co-owner of Connecticut Clinical Nursing Associates, to talk about how long-term care facilities can help prevent pressure ulcers from occurring.
Schenk: Hey out there, welcome back. Welcome back. My name is Rob Schenk.
Smith: And I’m Will Smith.
Schenk: And today we have another episode dedicated to talking about the common problem in nursing homes, and that is pressure ulcers. We’ve had a few episodes in the past month or so, weeks, dealing with pressure ulcers, whether it be preventing them or how they occur, that type of thing. Today, we’re going to talk a little about pressure ulcers, the basics, but then we’re going to get into the treatment of pressure ulcers, which we haven’t really gone into in-depth, I don’t think, on this podcast in a while.
Schenk: But we’re not going to do that alone. We are bringing in a professional, and her name is Cathy Milne. Will, can you tell us about Cathy?
Smith: Sure. Cathy Milne is a registered nurse and an advanced practice WOC nurse, which is wound and ostomy care nurse, providing care to patients across the continuum in acute care, long-term care, home health and outpatient settings. She’s employed by Connecticut Clinical Nursing Associates. She also provides consulting to organizations wishing to improve wound outcomes, conducts clinical research, lectures nationally and internationally, and is the co-editor of the text “Wound, Ostomy, Continence Secrets,” and provides clinical support to the WoundReference.com.
An active member of the Association of the Advancement of Wound Care, Cathy currently serves as a nurse board member. Additionally, she serves as an associate clinical professor at the Yale School of Nursing.
Smith: Yeah, so she…
Schenk: The Yale.
Smith: She has an enormous background and we’re very privileged to have her today.
Schenk: Cathy, welcome to the show.
Cathy: Thank you very much. Glad to be here.
Schenk: Great, great, great. Well Cathy, one of the main reasons why we have you on the show to talk about this particular subject is because oftentimes we will get questions, we’ll have people call us in situations where a loved one has developed a pressure ulcer in a nursing home, and they’re kind of at a loss because maybe this is the first time they’ve ever heard of a pressure ulcer and they’re just confused. So from a 40,000-foot view, can you just walk us through the basics of what a pressure ulcer is and how they develop before we get into the more pertinent part of the conversation with regard to how we treat them.
Cathy: Sure. So the pressure ulcer is a very complex subject. In fact, I’m currently at a conference, which is devoting two-and-a-half days to this specific issue. But simply put, a pressure ulcer is the breakdown of skin when there is an external surface pressing on the skin and compressing that skin over a bone, and the skin literally breaks down and is destroyed.
Schenk: Okay. So why is that happening? Why is that happening in a nursing home setting? Like what’s the basics?
Why do pressure ulcers occur?
Cathy: Okay, so there are a lot of reasons, and this is why the subject is very complex. So we do know that when you age, your body changes, and you actually lose fat. You also lose muscle. You have muscle wasting. And then that – so it takes less amounts of pressure to have that skin start to break down.
There are lots of other factors. If you don’t have control of your urine or your bowels, that will actually make the skin a little bit more prone to breakdown because the chemicals in both the urine and the stool. There is medical devices, so things that we think are helping patients such as splints, that actually can cause breakdown.
There is lack of nutrition. People sometimes, as they age, don’t absorb the nutrients that they need, and then we also are finding out that there may be some genetic factors that predispose older people to skin breakdowns, and there are a number of other things such as there are the types of other illnesses they may have, such as heart failure or kidney failure. We also have a subset of pressure ulcers that are associated with end of life. So it’s like an organ failing, so if your heart’s failing, your liver’s failing, your skin can fail also. So that’s part of it.
And the other piece, which I would think would be neglectful not to talk about, is that I think people would like to always point fingers at the staff caring for the patient, and I’m not saying that everybody is at fault and there’s certainly nobody at fault also is in that continuum – there may be a time where somebody did not get the right type of chair cushion or the bed cushion or something like that, and that could be a contributing factor. So it’s very complex to kind of piece all these factors together. A lot of times quality of life – Mom wants to sit up all day and she doesn’t like to go back to bed, so you have to weigh that stuff in too.
Schenk: That makes sense.
Smith: Yeah, and I think it’s helpful when you remember that the skin is an organ and organs can fail because of diseases, because of age. So yeah, it’s a multi-factored phenomenon.
Schenk: You’re absolutely right. And so Cathy, we have a handle on what a pressure ulcer is, kind of how they develop and what are some of the risk factors. So can you walk us through – probably the audience is familiar in the basics of staging. Can you talk about the progression of a pressure ulcer, stages and actually your opinion on whether or not staging is an adequate way to measure a wound like this?
How does a pressure ulcer develop? What are the stages of development?
Cathy: So the staging categories currently are really being debated. Originally there was no such thing as staging. We called these wounds either partial thickness, meaning they took the two top layers of the skin, the epidermis and the dermis, or full thickness, meaning it involved muscles or subcutaneous tissue or fat tissue. And it wasn’t until the National Pressure Ulcer Advisory Panel was formed that they actually staged things by level.
So we do know that the European Pressure Ulcer Advisory Panel is strongly considering going back to partial thickness and full thickness because it is very difficult to stage pressure ulcers.
So the question about progression is a very interesting one in that the thought is that partial thickness pressure ulcers are really superficial and they don’t get any deeper because it’s really friction has occurred on the top levels of the skin whereas the full thickness pressure ulcers are really starting from the bottom and going out. So you really don’t see those occurring at the time they occur, over a period of either several hours or several days, then you can actually see them. So they don’t really progress because it’s the event that happens, it’s what you see looks like a progression, like it is getting worse, but the tissue damage has already occurred.
Schenk: That makes sense. And I guess I never thought about it that way. It’s not as if you’re watching it grow bigger and bigger. Can you kind of elaborate on that?
Cathy: Yeah, so as a healthcare provider or a loved one, you’re watching a wound get larger and larger, but really what you’re seeing is the tissue takes time to die. It doesn’t all die at once. So while you think it’s getting larger, the issue is that the tissue has already died and is progressing to its area of total death. So clearly where you have the most pressure, that tissue would die first, and areas where you would have less pressure would die a little bit later. So that’s why you see things get worse or appear to be worse when really it was probably that one event that did this.
Schenk: And that’s why staging this one through four is problematic.
Why is pressure ulcer staging problematic?
Cathy: Yes, and in fact, about 64 percent of nurses and over 50 percent of general physicians cannot stage properly.
Schenk: Did you say 64 percent?
Cathy: A lot of research – yeah, 64 percent.
Cathy: Yeah, and it’s a problem because we try to base our care on data, and if the data is wrong to start with, then you don’t get the right results.
Smith: Yeah, we had another guest on here a couple weeks ago that was talking about, complaining about the lack of a clear standard across the board.
Schenk: Not complaining in the sense of complaining, but like critiquing.
Smith: Yeah, critiquing.
Smith: Critiquing that the staging method, that the way that they do it in the hospital, in the nursing home, acute care, it can change. It’s different.
Smith: The first method that you mentioned just makes sense to me. I mean it sounds like it’s either going through these layers or it’s not. So we’ll see what happens.
Cathy: Well it’ll be interesting to see what the Europeans do because they’ll be meeting in the next couple weeks, might need to start looking at their process and their guidelines over there.
Schenk: Yeah. So I guess that brings us then to the crux of the show, which is treatment. And I guess, I’ll let you explain it, but let’s start with full thickness ulcers. What are some common – because I was going to say stage four or stage one, you know what I mean? But I don’t want to put out misinformation. So walk us through what are common means of treating full thickness ulcers.
How are pressure ulcers treated?
Cathy: Okay. So regardless of whether it’s partial thickness or full thickness, you need to get off that area. It needs to have no contact with any surface. That sounds great in terms of a standard, but very difficult in many cases when in real life. For example, how do you get out of bed and not put any weight on your heel if you’re transferring? So it can be very difficult. But that’s really a standard for everything. You try to do as much what we call pressure redistribution, so because we know that we cannot float people and levitate them, it just doesn’t exist. So that’s number one. That’s for every pressure ulcer. We need to look at nutrition. You need energy and that is in the form of food to help heal any damaged tissue. So that doesn’t matter what stage that is.
So when you’re getting down to those full thickness things, there’s a variety of wound care products and treatments out there and it really should be assessed, this wound should be assessed by a certified wound person. There are a couple of wound care certifications out there, all of which are rigorously tested, so it wouldn’t matter if you had a nurse practitioner, a nurse, a physician, a physical therapist, but you really want somebody who has certification in the area.
Like not everyone drives a Ford of drives a Chevy, all humans in terms of their wounds are different too, so it has to be an individualized care. But the general principle besides the pressure redistribution and the nutrition is the moisture management, so we’ve got to keep any urine and stool out of the wound. There are – the wound should be cleaned and packed with some kind of medicine or dressing, depending on the characteristics of the wound. And clearly anything we can do to help the entire patient, so is it their diabetes that is out of control? We need to manage their blood sugar. We need to look at some of their medicines, because there are certain medicines that will slow wound healing. So we really need – we always say don’t look at the hole in the patient, look at the whole patient.
Schenk: That makes sense. Cathy – I’m sorry, go ahead.
Cathy: No, because the only way to heal these horrible things are really to really treat the entire patient and not just the wound.
Schenk: Yeah, that’s like a holistic approach. I get it. So Cathy, you mentioned earlier that nutrition is important and then you talked about blood sugar, but let’s go to nutrition first. I want to address both. What about nutrition, like what do they need? More carbs? More protein? More fats? Walk us through what we’re looking at in terms of treating a pressure ulcer through proper nutrition and hydration.
How does nutrition and hydration factor into pressure ulcer healing?
Cathy: So essentially for people in long-term care, I find that eating anything, really has enough protein and enough fats – they need calories. Clearly you don’t want to give everybody a bag of chocolates and say, “Here’s 3,000 calories.” So you want a healthy, well-balanced meal that gives you a lot of food that you can convert into energy, and that’s really fat and protein. Again, people who are older, their kidneys don’t function as well, so they can’t have the protein that we really want them to have to heal, so it does take longer for someone to heal because of that.
Schenk: So protein is important, in other words.
Cathy: Protein’s very important. And there are a lot of other ways – I really would suggest families work with the dietician in the facility to identify comfort foods that the patient really likes and that they will eat. And it also helps – the family can help by identifying certain foods and perhaps can work something out with the facility that they can actually bring in healthy things that might be beneficial to the patient.
Schenk: And then if you could, touch on how is blood sugar important to the healing of a pressure ulcer?
How does blood sugar factor into pressure ulcer healing?
Cathy: So people with diabetes and elevated blood sugar actually will have impaired wound healing for a number of reasons. One of the reasons is that you need white blood cells to help you heal the wound. They do a number of chemical and molecular signaling so the right things come to the wound to help things heal, and those white blood cells, they can get coated, essentially, in sugar, if your blood sugar is high, and then they don’t work. So that’s one thing.
The other thing – you need blood vessels to grow into the wound to help that heal, and if you have diabetes or high blood sugar, then those blood vessels either don’t form or they form poorly so you don’t get good blood flow into the wound to help it heal.
Schenk: That makes sense. And so, Cathy, let’s do the hypothetical. Let’s say we’re monitoring, we’re managing moisture, we’re making sure the individual gets the appropriate amount of nutrition, the appropriate macronutrients, that the wound is being cleaned and packed with the appropriate medications, blood sugar levels are checked. Take us through the scope from the worst pressure ulcers to the least worrisome and talk about how long on average it usually takes to heal the wound.
How long does it take a pressure ulcer to heal?
Cathy: So that’s very interesting because when you look at the data, they basically say a stage one and stage two should be healed between 16 to 21 days, and that a full thickness wound, which is a stage three or a stage four, really should be healed within 12 weeks. Now the data actually is from a very select population that actually goes to wound centers and really, at least in my experience, does not reflect patients that usually stay in the long-term care setting. And obviously, there are a lot of factors that can either make what I’m going to say extended or shorter, so the average – if you have everything in place, the average stage two, usually it’s about 30 days in long-term care. And the threes and fours, I usually tell my patients it’s usually 26 weeks, and that’s a long time. However, when you say 26 weeks, you have to be really clear about things have to all be in place and everybody has to be a team, including the patient and the family has to be a part of that.
Schenk: I was going to say, because it’s very important. That’s with everything going very well.
Schenk: It’s six months. So when you throw a monkey wrench in there, perhaps they’re not eating what they’re supposed to, perhaps maybe they’re not being repositioned or the appropriate devices aren’t in place, that’s going to elongate the healing process or stop the healing process completely.
What factors prevent a pressure ulcer from healing?
Cathy: Correct. And actually acute illness, if they happen to catch the flu or pneumonia or a urinary tract infection, that wound will go backwards, because the metabolic needs that that patient is using to heal the wound actually kind of goes to that acute issue. So the wound kind of gets ignored for a little bit. When people get sick, they actually go backwards.
Schenk: That’s right. And that’s the thing is we’ll have people call us and want representation for pressure ulcer wounds, but there are so many comorbidities that they have and so many things that their bodies are already fighting that it’s…
Smith: It’s an organ. The skin’s an organ.
Schenk: It is an organ.
Smith: It shuts down.
Smith: I’ve actually got a family member who’s got a pressure ulcer right now and we can’t get him to stop smoking, and it’s like that’s contributing to it terribly.
Cathy: Right. And so for every cigarette you smoke, there’s a three-hour delay in wound healing.
Cathy: Wound healing stops for three hours.
Schenk: That’s interesting, Cathy. Where is that data coming from?
Cathy: So if you Google it, you can find it, and I believe there is a study that actually looked at that in terms, like a doppler laser study.
Smith: That’s insane.
Schenk: Yeah, I can definitely see that. Smoking is awful.
Cathy: And also just exposing the wound to cool air, the coolness, even though it’s 68 degrees or 72 degrees, that too can actually make the cells move slower, so it can slow wound healing.
Schenk: I see. So smoking, cool air, what else? Let’s say you’re doing everything you’re supposed to from a nutrition, cleaning the wound, something like that, if there anything else? You mentioned diseases, illness the body’s fighting – what else hinders the healing process?
Does depression affect pressure ulcer healing?
Cathy: I think depression is a big piece and I don’t think it’s really addressed – which has come first? Do you get depressed, don’t move and then get a pressure ulcer? Or do you get a pressure ulcer, and because you have to deal with something you can see which looks unpleasant, your routine is altered because somebody has to come in and care for it, you’re being repositioned, you’re doing something that you’re not usually doing, do you then get depressed? So we do know there is an association between depression and slower wound healing.
Schenk: Interesting. That makes sense. Your psychological has an effect on the physiological, I guess if that’s using the right nomenclature. If you don’t feel good, you’re not going to heal. That makes sense.
Schenk: But that is a chicken and the egg because now that I’ve got this wound, am I unhappy or was I unhappy and got the wound?
Schenk: So Cathy, can you walk us through – you mentioned the National Pressure Ulcer Advisory Panel. Can you tell us a little about that organization? I’m not saying that you’re a representative of it, but maybe some of our audience wants to look at some more background on it.
What is the National Pressure Ulcer Advisory Panel?
Cathy: So the National – NPUAP, the National Pressure Ulcer Advisory Panel, was a group of multi-disciplinary clinicians that really found that pressure ulcers were really its own entity and needed to be address. We did clinical practice guidelines and science so the rest of healthcare providers could care or help prevent and then care for these people.
And that point when they were formed, most hospitals were running a 42 to 50 percent pressure ulcer rate, meaning you came into a hospital setting, you didn’t have anything on your skin, and half of those people left with a pressure ulcer. So it was a huge – I really look at it as the first patient safety initiative.
So they formed back in the ‘80s, I believe, and they have been at the forefront, taking the research that’s out there and helping coming up with clinical practice guidelines and methods for us as healthcare providers, best practices so we can a) help prevent, and then b) what to do should they occur.
Actually, I think there was a study by a nurse practitioner named Lisa Corbett who actually found that 30 percent of all hospital admissions had pressure ulcers, and most of those people never had seen a healthcare provider before coming to the hospital. So the family members – so we really need to do a better job educating people who are trying to care for their loved ones at home.
Schenk: That’s a good segue. What are a couple things that families of loved ones who have somebody in a nursing home or even an elderly person at their house, what are some tips that you can give them for the treatment or prevention of pressure ulcers?
How can families get involved in pressure ulcer prevention?
Cathy: So trying to get the right equipment in the home or at the long-term care facility is really key. And sometimes you need to get an outside expert to come in, otherwise you try to see what you have in the facility that you’re in to come up with what are you doing and what can I do to help? And a lot of times, Mom may not want to turn because it hurts her because of her arthritis, and so a lot of times, we want to engage the family to help us to help them.
Smith: Right. That makes sense.
Cathy: So really trying to be part of that team can go a long way.
Schenk: Yeah. That makes sense. Well Cathy, this has been extremely, extremely informative. Thank you so much for coming on the show and talking about this. You’ve actually mentioned several things that I don’t think we’ve touched on this podcast before. We’ve had a few episodes on pressure ulcers, but you managed to shed some new light on this for our listeners so we really appreciate that.
Cathy: Great, and I’d be more than happy to come back.
Schenk: Oh, fantastic. We’ll take you up on that. Thank you very much.
Cathy: Okay. Great. Great, thank you so much.
Smith: All righty.
Schenk: Yep. A lot of great information. And she didn’t mention this – or she might have mentioned this, right now she’s at a conference, a wound care conference, that’s taking place in Atlanta.
Smith: Yeah. And one of the most interesting – well it’s all interesting, and I’ve been looking this up now, this idea of it’s always interesting to me when you can put time scales on poor activity, like every cigarette you smoke takes a day off your life or whatever those statistics are. It’s interesting, this idea, which I’ve looked this up – it’s crazy that every time you smoke a cigarette, you’re delaying the body’s healing process by up to three hours. And a lot of it has to do with the fact that nicotine is a vasoconstrictor, so you’re not getting blood flow there, you’re not getting nutrients, so that’s a big, big deal. If you’ve got a loved one that has a wound, man, smoking or whatever they’re using, any kind of nicotine is going to really, really impair their ability to heal.
Schenk: That’s right. And as Cathy mentioned, nutrition is very important.
Schenk: So you have to eat all of your veggies.
Schenk: All of your veggies.
Smith: I knew that was going to be the segue.
Schenk: You did?
Smith: Yep. It is – I don’t know who comes up with these holidays or whatever they’re called, but it’s Eat Your Veggies Day.
Schenk: Today, Monday the 17th of June.
Smith: Although in reality, protein is far more important than what you’re getting from the veggies, I think. Protein is extremely important.
Schenk: That’s right.
Schenk: But anyways…
Smith: As far as wound – I’m talking about healing of wounds because…
Schenk: Not just general health.
Smith: Yeah, because your body needs the protein to – it’s a whole in the body. You need to close it up. You need to create more skin, connect the tissues, and you need protein to do that.
Schenk: And happy Eat Your Veggies Day everybody. With that, that’s going to conclude this episode of the Nursing Home Abuse Podcast. Thanks to Cathy for coming on. New episodes every week Monday mornings coming at you on our website, which is NursingHomeAbusePodcast.com or on our YouTube channel, or you can check us out wherever you get your podcasts from. And with that, we will see you next time.
Smith: See you next time.