Preventing pressure ulcers in nursing homes
While some pressure ulcers are unavoidable, many can be stopped before they start. As the old saying goes, an ounce of prevention is worth a pound of cure. In this week’s episode, nursing home abuse lawyers Rob Schenk and Will Smith welcome guest Martha Kelso, RN from My Wound Care Plus @mywoundcareplus to talk about common interventions that can help prevent the development of pressure ulcers in nursing homes.
Schenk: Hello out there and welcome back to the Nursing Home Abuse Podcast. My name is Rob Schenk.
Smith: And I’m Will Smith.
Schenk: And you have happened to stumble across a very interesting episode today. We’re going to be talking about a medical condition that unfortunately can be common in residents of nursing homes, and that is the problem of pressure ulcers, that is to say wounds that develop due to oftentimes prolonged pressure to a certain point on the body.
Schenk: But again, we are not going to be talking about this particular subject alone. We have went out into the ether and pulled back into this show an expert in the field on this. So she’s going to be joining us. And Will, before she joins us, can you tell us a little bit about her?
Smith: Right. So we’ll be talking with Martha Kelso, and she’s the founder and chief executive officer of Wound Care Plus, WCP. She’s a visionary and an entrepreneur in the field of mobile medicine. She’s operated mobile wound care practices nationwide for years. She enjoys educating on the science of wound healing and how practical solutions apply to healthcare professionals today.
Martha Kelso enjoys being a positive change in healthcare impacting clients suffering from wounds and skin issues of all etiologies. Kelso’s desire to make healthcare a better place for consumers motivated her to form and found WCP, Wound Care Plus. In her early career, she was a wound nurse in a long-term care setting, and this past experience committed her to educate other fellow wound nurses on regulations and national standards of wound healing, thereby empowering the bedside nurse with tools and knowledge.
Kelso has educated thousands of healthcare professionals since her education efforts began, providing a solid base and foundation to excel with wound care practical application skills, wound care oversights. So we’re very honored and privileged to have her here today.
Schenk: Nurse Kelso, welcome to the show.
Martha: Well thank you so much. Good morning.
Schenk: All right. So Martha, we are really happy to have you on today. We’ve had several episodes about pressure ulcers, sometimes we call them bedsores, and we’ve maybe kind of gotten in the weeds sometimes, and we wanted to have you on to kind of give from your perspective and your experience with wound care over the many, many years you’ve been doing it, your take on pressure ulcers and pressure ulcer prevention within the skilled nursing facility setting.
But before we even get into that, what is, from your experience, your education, your standpoint, what is a pressure ulcer?
What is a pressure ulcer?
Martha: Yeah, that’s a great question. A pressure ulcer is where skin has become damaged. It’s almost always over a bony prominence, but it doesn’t have to be. Skin can become damaged from having pressure prolonged to a specific part of the body or from different forces like friction or sheering. Sheering is where we are maybe dragging the skin across the bed, for example, and so you have the bed forcing the skin to go in a different direction and can actually cause damage to the underlying tissue. And so a generic standpoint, pressure, prolonged pressure, removed circulation from the tissue and then the tissue can become damaged from lack of blood flow. So that’s kind of the treetop version of what a pressure ulcer is.
Schenk: That makes sense because I think to the extent that our audience has an understanding of what a pressure ulcer is, I think it’s a misconception that a pressure ulcer comes about only because of extended pressure, right, because that’s where it gets the name and a lot of people don’t realize that sheer can cause it or even sometimes instruments can cause it like a cast or…
Martha: Correct, a medical device.
Schenk: Exactly, medical devices, and so that’s a misconception that it’s just pressure, but that makes sense. And in the skilled nursing facility setting, why do you think that the nursing home resident is susceptible to bedsores and pressure ulcers in the first place? Like why don’t we hear incidents or pressure ulcers like in people’s houses?
Why are pressure ulcers a danger in nursing homes?
Martha: Well I think it’s also a great question. You know, wounds, generically speaking, are a barometer of health. For, generically speaking, healthy people don’t get wounds, and there’s a lot of factors that play into the predisposition for development of pressure ulcers. And so everything from being cognitively impaired, not knowing or having the wherewithal to be able to turn or reposition yourself, realizing that maybe I’ve been sitting in one place for too long so I have to get up, get moving, or even co-morbid medical conditions like diabetes, hypertension, thyroid disorder, kidney disease, all play into your skin not being healthy enough to be able to maintain itself with the higher risk for breakdown. Of course, urinary and fecal impartments plays into that, reduced meal intake, oftentimes medication predispose us to develop wounds or maybe even delay wound healing once we get a wound. And so I think there are a lot of factor that go into it.
Martha: And then additionally, if we’re not doing what we should be doing, you add all those factors together, and then maybe we’re not turning them like we need to be or getting them up and moving off their derriere when we need to be. That of course elevates our risk as well.
Smith: And there are a couple of conditions that are often confused, at least initially, with bedsores or pressure ulcers. Can you talk about the differences between diabetic ulcers or venous ulcers and bedsores?
How are pressure ulcers different from diabetic ulcers?
Martha: Yeah, there are a lot of conditions out there that mimic pressure wounds and that’s part of the challenge. I would think that even with my company that 90 percent of our wounds are misdiagnosed when they get to us.
Smith: Oh wow.
Martha: So a lot of wounds that have been called pressure that aren’t pressure – sometimes moisture associated skin damage lesions are misdiagnosed as pressure wounds when they’re not. We have had cases of Morgellons ulcers, which is actually a form of cancer, and in the elderly, if you’re going to have a Morgellons ulcer, it’s usually where there’s been repetitive sources of inflammation, and so it’s where they would have urine and fecal incontinence. But because people don’t realize that Morgellons ulcers exist, we’re not getting them biopsied and checked for cancers, and they do mimic pressure wounds. They look identical.
Smith: Got you.
Martha: And so from a global perspective, if you think about how many pressure ulcers exist within the United States, it’s about 25 percent of all wound types. About one in four wounds are actual pressure. Additionally about 60 percent of wounds have mixed etiology. You can actually have a wound that’s diabetic, has venous, has arterial and pressure components, and so you actually have to address all four issues at the same time in order to get a wound to heal.
Schenk: That’s really – that’s a really interesting point. And to go back to what you said previously, I think it’s a big misconception when we get potential clients and family members of loved ones that have what they consider pressure ulcers, they’re kind of shocked to realize, well, I’ve got a list of questions for you to determine whether or not there’s any problems with the care they received because they don’t realize that diabetes, vascular disorders…
Schenk: …cancer, all kinds of things play into whether or not that wound could have been prevented regardless – you could be in space and that wound would have happened. You mentioned a minute ago about the incontinence. You listed a few things, the reasons why that would heighten the likelihood of a pressure ulcer in the skilled nursing facility setting. Why is that?
Why does incontinence increase the risk of pressure ulcers?
Schenk: With regards to incontinence, why is that kind of like a danger zone in itself?
Martha: Sure. Any time you have a wet, wet skin, right, you think about even people, even your children actually, when you hang out in your bathtub too long, you get kind of that bathtub effect where your skin wrinkles? So it reduces your skin’s ability to handle friction or sheering forces. So somebody that perspires a lot, maybe a more obese person that perspires a lot of maybe even developed a fungal infection from being too moist for too long, all of those reduces the skin’s ability to stay intact. And then especially when you’re having to turn somebody or move them, it increases the – it actually decreases the skin’s resistance against those sheering forces.
And then you think about feces, for example, have acidity in it. It’s coming from our stomach or from our colon. It alters the skin’s pH, the bacteria in our stool can also decrease the skin’s resistance to not break down.
And so it’s interesting because it’s 2019, which is super fun. We’re living in a fun age in the medical arena, because there are so many great products on the market now. For example, there’s a company that developed a barrier wipe, essentially. It’s synthetic. It goes on the skin, stays in place for up to seven days, but it allows sweat and moisture to come through it. It doesn’t allow urine or feces to get to the skin. And that’s groundbreaking. Additionally, there are some overlay mattresses, a device that you put on top of a mattress that’s powered, there’s a fan, and it evaporates the moisture on our skin, even if we’re a heavy wetter. It evaporates in a matter of minutes so that urine or liquid feces is not staying next to our skin. The challenge is some of these products are new and they’re not well recognized yet in the medical industry, but they do exist.
Smith: Yeah, I think that on our podcast, we talked about one time this new fabric technology. There are new sheets that they have that cut down on sheering. It’s amazing, but not widespread at all.
What does the term ‘microclimate’ mean?
Martha: And I will tell you in October of 2019 in long-term care, CMS is requiring buildings to answer how are you addressing the microclimate? The microclimate is that word for how are you addressing the moisture problem between skin and surfaces, and it’s going to be an expectation now.
Smith: Yeah, well we’ll see what happens. Most of the places we deal with don’t address that at all.
Schenk: And that’s actually a good point. Martha, in your opinion, what are some of the – not stuff that’s cutting edge or a couple years old, what are some of the tried-and-true things that family members, when they walk in to visit their loved ones, where in their instance their care plan has indicated that they’re a moderate or high risk of developing pressure ulcers, what are some of the tried and true mechanisms to prevent those wounds that are just basic?
What are some common ways to prevent pressure ulcers?
Martha: Yeah, so somebody you know that can’t get up and moving easily, it’s important to identify what kinds of surfaces they’re sitting on, or if there are other things we can do to help them get off their pressure areas for a few minutes every few hours without necessarily having to transfer them. And so there’s Tilt-N-Space wheelchairs, for example, and they’re designed to recline by 30, 40, 50 degrees. It can recline a resident or client and let them sit reclined for 10 or 15 minutes, and that’s more than enough time to get the blood restored and moving in the areas they’re sitting on without having to transfer them to a recliner or transfer them and have them lay down in bed. When I become a resident in long-term care, I’m not going to want to lay down much. I’m going to want to see what’s going on. I’m not going to want to take a nap if I don’t want to take a nap.
Additionally there are pressure relieving mattresses that can go in, wheelchair cushions. There are dressings on the market now that have a pressure release indicator, so even if you don’t have a wound, you can put the dressing in place and it helps redistribute the pressure. Broda’s been around a long time, but Broda wheelchairs are designed to have a pressure relief surface, again, so that people don’t have to get up and don’t have to move if they don’t want to. It allows them to be mobile as they desire to be mobile.
In 1940, there was a study that was done about turning people every two hours. At the same time, it was done in 1940, and the entire United States didn’t have electricity in 1940, let alone the same mattresses or the same beds, right? At the same time, it’s still the standard of care.
Smith: Oh, absolutely. And so are you suggesting that it’s outdated at this point or there are better things to do.
Martha: Yes. Yeah, in my opinion, the turn every two hours is very outdated. At the same time, we haven’t come up with a better standard of care yet. So it doesn’t mean you throw the baby out with the bathwater.
Schenk: Yeah, yeah. Got you. That makes sense. So Martha, let’s say – let’s fast forward a little bit. Let’s say unfortunately a pressure ulcer has developed. What are some of the most common techniques to treat and heal a pressure ulcer, and I guess a basic question is if a pressure ulcer, depending on how advanced it is, can it be healed?
What are common methods to heal a pressure ulcer?
Martha: You know what? We see a lot of wounds, and it honestly depends on the rest of the resident’s body, the rest of the client’s body. Do they have enough tissue stored to heal? How’s their protein? How’s they intake? How’s the rest of their body. And then how bad is the wound? Is the bone infected? You know osteomyelitis, the surgical bone debridement with six to eight weeks of antibiotics and a possible course of hyperbaric. If they’re not a candidate for surgical debridement, it may not be a wound that can heal.
And they do take time to heal. We’re dealing with a sick person, a non-healthy person to begin with, or they wouldn’t have a wound. I was just on average thinking about our company, about 80 percent of pressure wounds can be healed within a reasonable amount of time. The other 20 percent takes longer. Again, it’s 2019, so we have access to things like platelet-rich plasma. We’ve developed a skin graft that’s 100 percent painless and doesn’t leave a scar. I always say there’s really no such thing as a cookie-cutter wound, but the more tools you have in your toolbox, the easier they are to heal.
Smith: So talk about debridement for a second because we have that in all of our worst cases.
What is a debridement of a pressure ulcer?
Martha: So I’m guessing you mean sharp debridement. There’s numerous kinds of debridement – biological debridement, like maggot therapy, there’s enzymatic debridement like SANTYL or like collagenase ointment, mechanical debridement, autolytic debridement. Advanced wound specialists will use sharp debridement, and long-term care, the current federal regulation is that you can only do a subcutaneous debridement, which is the level just below the skin. You cannot do muscle or bone debridement in long-term care. That was a standard set by CMS a handful of years ago. And so if it’s a provider coming out to the nursing home, they can only debride down to the level just below the skin, otherwise the resident has to be transported to the hospital. Sharp debridement is currently the gold standard to remove necrotic, nonviable tissue quickly and get the wound from a stalled-out phase into a healing phase.
Schenk: Right. And is that considered a first resort or last resort? Where does that fall within the range of treatments that are options?
When is debridement appropriate for a pressure ulcer?
Martha: Any time you have nonviable tissue in the wound, the chance – I mean it’s not healthy tissue. There’s no adequate blood flow going to that part of the tissue, and so it harbors bacteria. And so the goal would be to get that tissue, nonviable tissue out of the wound as quickly as possible. But bedside nurses cannot sharp debride. It has to fall to a practitioner, a physician’s assistant or a doctor, but it would be one of the first considerations of getting the wound to start healing. Additionally though, you have to know what wounds to debride and what wounds not to debride. So if a wound is on the heel of the foot and there’s not good blood flow, you would not want to sharp debride that wound because it’s just going to destruct. It’s not going to heal. There’s not enough blood flow there, oxygenation and nutrients to start filling it back in. You need to check blood flow and make sure you are debriding the right type of the wound. A pyoderma type wound is contraindicated to sharp debride to cut into it. Malignant lesion – contraindicated. And so it kind of goes back to how do you know that a wound is a pressure wound?
Smith: That’s a good question.
Martha: Did you walk in and find it and go, “Look, it’s over a bone so it must be pressure?” Arterial wounds occur over bone.
Smith: So how do you know?
How to determine if a wound is caused by pressure?
Martha: Well you would assess somebody and see if the wound is directly laying on a pressure point. You have to observe the patient as a resident when they’re in their wheelchair, when they’re laying in the bed, when they’re laying on their side. If pressure is not there, you don’t call it pressure. And that’s the CMS standard today. It actually says for the purposes of coding, determine that the wound is not related to pressure and that other conditions have been ruled out. There is no diagnostic study in the world today that can prove that a wound is pressure. For arterial wounds, we can order an API, an arterial gram, an arterial doppler, we have studies out there we can order that prove that a wound is arterial.
Schenk: I see.
Martha: There are studies out there that can prove a wound is venous or prove it’s cancer or prove it’s pyoderma or scabies or whatever it is.
Schenk: Martha, so what are the ramifications of a pressure ulcer other than the fact that it’s an open wound on the body? What happens? What are the complications? What are the dangers of the pressure ulcers?
What are the dangers of a pressure ulcer?
Martha: Well I think with all wounds, any time you have a break of the skin, it’s at risk of infection. You have a risk of it not healing. There can be increased pain, right? It can deteriorate and go down the bone. It can deteriorate and develop gangrene. You may have to put someone on palliative care or hospice if it’s not curable. And so I think any time that the largest organ in our body, which is skin, any time there’s a break in the skin, any reason, where risks for having complications – of course if it gets infected, we have to put him on antibiotics. We know antibiotics cause other complications like C.-diff or multi-drug resistant organisms, so the ripple effect is bad. We don’t want wounds. We want to heal them. We want to prevent them.
Schenk: That’s really important what you said and that when I first got into this area of the law, that’s one of the first conversations I had with my first experts in one of these cases, and I never thought about it that way, and that’s exactly what they said is the skin is an organ, and I guess I hadn’t thought about that since fourth grade of health class, but it’s an organ just like your brain, your heart, everything else, and if that organ is unhealthy, you’re susceptible to these wounds and it’s dangerous.
So Martha, in the few minutes that we have left in the episode, can you just give some advice to our audience, the family members of residents in nursing homes, on pressure ulcer prevention? What would you advise them do to make sure that this doesn’t happen to the loved one, and if it does happen to the loved one, what should they do next?
What should families do for loved ones that have a pressure ulcer?
Martha: You know what’s interesting? I do a lot of training and educating both for nurses, physicians groups, nursing home industries and, of course, family members who come to the presentation, but the medical industry, I think, it’s 2019. It’s like gone are the days where doctors wore a badge that said “Trust me, I’m a doctor.” We don’t follow blindly anymore. We shouldn’t. I believe that patients and family members are in the driver’s seat. You’re in charge. It’s your leg. You’re attached to it.
So I teach people, there are really four questions, and you can plug it into any medical condition, not just wounds. But there are four questions that everybody should ask, right? Family members, administrators, DONs, wound nurses. We should all be holding each other accountable.
So the four questions are: Why is the wound there? Question two: How do you know? Are you guessing? Did we do studies? Did you see pressure? If you didn’t, are we assuming? How do you know – so we’re treating the right condition, right? Question three is what’s keeping it from healing? Oh, they have an occlusion. All right. Number four is what are we doing about it? They have an occlusion so we’re taking them to a vascular surgeon. Vascular wants to do surgery. They’re not a surgical candidate. Okay, what are we doing about it? So they have a wound. Okay, great. It’s pressure. How do we know? We saw pressure in her. Okay, what’s keeping it from healing? Well we need to get their foot off the bed. We’re going to float it with pillows. Great, now what’s keeping it from healing? Okay, well it’s infected. Okay. What are we doing about it? We’ve done a tissue culture. We’re sending it off for results. We’re waiting on those results. We’re going to get them on the antibiotic. Great.
And so just those four simple questions I think help hold us accountable, and if the answer is ever “I don’t know,” you know there’s a breakdown in process.
Schenk: Yeah, that makes sense. Well Martha, this has been extremely informative and we are very glad that you are able to come on this show. Is there a way that people can maybe reach out to you if they – we also have ombudsmen, we have nurses that listen, if anybody out there wants to get in contact with you, is there a good way for them to shoot you an email or hit you up on Twitter?
Martha: Sure. Thank you for asking. We have an email that’s monitored by numerous people, other nurses in our company as well, and it’s firstname.lastname@example.org. You can go to our website at www.mywoundcareplus.com or they can call our office at 888-256-3814. We’re very responsive. We take wounds seriously and we know somebody’s loved one out there that needs answers. Additionally nurses need education. Doctors need education. We all need education. I feel like knowledge is power.
Schenk: Very good, Martha. Well thank you so much.
Martha: Yes, thank you guys for the opportunity. Talk to you soon.
Schenk: And just to reiterate, she was a little humble on the website, her website, which is mywoundcareplus.com. There are so many resources just perusing them.
Schenk: There are so many resources for you out there with regards to pressure ulcer prevention, pressure ulcer treatment. She was mentioning earlier before we were recording about how families can go on that website and download pamphlets to take to the nursing home that have questions listed out for you with regard to pressure ulcer prevention, which I think are very important on top of what she mentioned about the four questions you need to ask.
Smith: Because a lot of – another thing we were talking about off air is that a lot of the perspective and treatment and understanding of pressure ulcers is outdated, and we just don’t – even the measurement of staging is different from home health care to hospitals to nursing homes. So this is on the cutting edge of something that’s extremely prevalent and important, so I highly suggest people to check out mywoundcareplus.com.
Schenk: And just to reiterate that this month is Older Americans Month.
Schenk: So celebrating all month, older Americans. I guess that’s 65 or older. I didn’t deep dive into the research on this.
Smith: Yeah, I feel like it is. It’s senior citizen’s discount.
Schenk: Yeah. My mom was always like, she was – when she reached that age, she would tell me that it was strange that like she would see 15 percent off without being told, like off her coffee, and she’s like, “Why’d I get 15 percent off?” Well, we don’t want to tell you.
Schenk: We assume you have now earned this discount.
Schenk: But at any rate, and then on top of that, on Saturday, it’s Visit Your Relatives Day. So all of you out there that have a family member in a nursing home, assisted living facility, knock out two birds with one stone in celebrating Older Americans Month and Visit Your Relatives Day on Saturday.
Smith: And speaking of visiting relatives and older Americans, it’s also somebody’s birthday this month.
Schenk: Yeah, my sister’s birthday.
Smith: I’m sure she’ll appreciate that.
Schenk: On Friday. I don’t know how old she is. She was born in 1971.
Smith: Okay, she’s seven years older than us. She’s 48.
Schenk: Yeah. So happy birthday, KB. So this episode, this podcast in general is available, new episodes every Monday morning. You can catch us on our YouTube channel, our website, which is NursingHomeAbusePodcast.com, or you can download the audio and listen on your way to work, while you exercise, while you cook dinner, on Stitcher, Google Play, I think, I don’t know what they call that now – it’s not iTunes anymore, it’s like Apple Cast? We have to update ourselves – Pod Puppies. Anywhere where you get your podcasts from, we are available there and ready to rock. And with that, thank you to our guest Martha Kelso, RN, and with that, we will see you next time.
Smith: See you next time.