CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
PREVENTING DECUBITUS ULCERS
1/
A STAFF INTERVENTION MODEL
A graduate project submitted in partial satisfaction of
the requirements for the degree of Master of Science in
Health Science,
Health Administration
by
Lila Ann Alexander
June 1980
The Graduate Project of Lila Ann Alexander is approved:
Ca 1i fom i a State University, Northridge
PREFACE
This graduate project is the outcome of a year
long search for solutions to the increasingly complex
problem of decubitus ulcers, commonly known as pressure
sores, among Los Angeles County's elderly, institutionalized population.
There had been a growing concern with-
in the Health Facilities Division of the Los Angeles
County Department of Community Health Services (LACDCHS)
over the morbidity and mortality resulting from this
largely preventable affliction of bedridden patients in
Skilled Nursing Facilities.
The Division's responsi-
bility for enforcement of Title 22 of the California
Administrative Code which specifically requires that each
.
patient in a Skilled Nursing Facility (SNF) must be given
care to prevent decubiti, led to an intensive search for
effective approaches to the problem.
The intent of Title 22, which involves a citation
system and assessment of fines, was to mandate preventive
nursing care.
Unfortunately, it has resulted in numerous
legal struggles between the State of California and
Nursing Home Operators, and there has been no visible
improvement in the plight of SNF patients who continue to
develop pressure sores.
ii i
Because of this notable lack of success of a
puniti~e
approach to what is essentially a health care
delivery issue, the Division of Planning, Evaluation, and
Development of LACDCHS, was asked to explore the issues,
identify potential solutions, and come up with a plan for
a more constructive approach.
The project was assigned to this writer while
completing a graduate student residency with the Division
of Planning.
It included an in-depth study of pertinent
issues, numerous contacts with concerned health care
providers and experts on the subject of pressure sores,
and finally resulted in the development of a demonstration
project design.
The project design has been written into
a grant proposal for implementation as a three year study/
demonstration in selected Skilled Nursing Facilities in
Los Angeles County.
The hoped-for outcome, of course, is that the
preliminary effort described in this paper will prove to
be the first step toward an improved quality of nursing
services in a rapidly expanding, and often ignored,
ment of the health care industry.
iv
seg~
Dedicated to my children
Michael and Laura
v
ACKNOWLEDGEMENTS
I would like to express my indebtedness to
'Jeanne Berthold, Ronald Dowd, and Eleanor Parsons, all
of the Los Angeles County Department of Community Health
Services, for their many hours of assistance and professional guidance in the preparation of this project.
I
would also like to thank Roberta Madison for many hours
of assistance above and beyond her role as committee
member.
vi
TABLE OF CONTENTS
Page
iii
PREFACE . .
DEDICATION
v
vi
ACKNOWLEDGEMENT
vi i i
ABSTRACT
Chapter
1.
INTRODUCTION
1
Statement of the Problem
l
2.
GOAL AND OBJECTIVES . . .
4
3.
IDENTIFICATION OF ISSUES
5
Cost . . . . .
Level of Care .
. ..
Staff Education and Motivation
Acute Hospital· Role . . . . . . .
The Need for Additional Research/
Demonstration Activities
...
Need for Grant Assistance
6
7
8
8
9
10
4.
LITERATURE REVIEW
12
5.
METHODS .
18
Pro j e c t
Phase
Phase
Phase
Phase
6.
P1 an
18
19
20
I .
II
III
IV
24
28
CONCLUSIONS
31
REFERENCES
33
vii
ABSTRACT
PREVENTING DECUBITUS ULCERS
A STAFF INTERVENTION MODEL
by
Lila Ann Alexander
Master of Science in Public Health
The incidence of decubitus ulcers, or pressure
sores, is a growing and increasingly costly problem
afflicting patients confined to skilled nursing facilities.
Current estimates· indicate that the average cost
of treating one patient is $15,000 to $30,000, and that
nationally, 3 to 4 billion dollars are spent each year
on decubitus care.
It is widely accepted that the
majority of these ulcers are preventable.
Yet, the inci-
dence continues to be high to the dismay and frustration
nursin~
personnel faced with the day to day responsibility
of providing preventive care.
This project includes a description of the contributory elements in the high incidence of pressure
viii
sores and a discussion of current issues and problems in
prevention.
Based on the identified issues, a staff
intervention model is proposed, and a plan for implementation as a demonstration project is developed.
The
principle objectives of the proposed project will be to:
1.
decr·ease the incidence of pressure sores in
participating facilities,
2.
to demonstrate reduced costs of institutional
health services as a consequence of preventing
pressure sores in long term care patients,
and,
3.
to develop and disseminate an educational
manual on nursing care techniques and nursing
staff management methods for the prevention
of pressure sores.
i
X
Chapter 1
INTRODUCTION
Statement of the Problem
Pressure sores, or decubitus ulcers, are ischemic
skin ulcers which occur as a direct result of prolonged
or extreme pressure to soft tissue.
They occur typically
in bedridden or chairfast patients confined to long-term
care facilities.
Though many factors may contribute to
the development of bedsores, the precipitating cause is
always pressure, and it is generally agreed ·that their
presence is indicative of inadequate nursing care.
Most pressure sores can be prevented.
Neverthe-
less they are a common and serious problem in our nursing
home population.
In Los Angeles County, for example,
there are 75,392 licensed beds in 173 acute hospitals,
24 psychiatric hospitals, 407 skilled nursing facilities
and 5 intermediate care facilities.
The overall rate of
occurrence of pressure sores in all types of facilities
in Los Angeles County is estimated to be 8.36%, with some
nursing homes reporting rates as high as 25%.
Based on
these figures approximately 6300 patients in Los Angeles
County are afflicted with decubitus ulcers.
1
(1)
As the
2
aging population increases, so· undoubtedly will the
proble~
of pressure sores.
Once a pressure sore develops the cost of treat-
ment is high.
Current estimates indicate that the aver-
age cost of treatment of one patient is $15,000 to
$30,000, attributable to the expense of hospitalization,
surgery and a 50% increase in nursing time.
(12) (21)
Nationally, 3 to 4 billion dollars are spent each year on
decubitus care.
(3)
Aside from monetary costs, the toll
in human suffering is incalculable.
Severe pressure
sores can and do lead to infection, bone destruction,
septicemia and other complications which can result in
permanent disability, deformity and even death.
In an effort to decrease the inordinately high
incidence of pressure sores in Los Angeles County, the
Health Facilities Qivision strictly enforces State regulations regarding pressure sores.
A pressure sore as defined by the State of California Department of Health is a lesion of the skin,
etiology of which is pressure.
th~
The pathological stages
are described as follows:
Stage I - Not a decubitus ulcer of itself, but
rather the precursor phase of a decubitus ulcer which is
characterized by redness of the skin which is not
relieved by local circulatory stimulation and/or relief
of pressure.
3
Stage II -Superficial circulatory and tissue
damage which involves excoriation, vesiculati6n or skin
break.
Stage III - Full thickness loss of skin which may
or may not include the subcutaneous tissue level and
whi.ch produces serosanguinous drainage.
Stage IV - Full thickness loss of skin with invasion of deeper tissues and/or structures such as fascia,
connective tissue, muscle or bone.
Facilities in which patients develop stage II, III or IV
pressure sores are subject to civil penalties ranging
from $50.00 to $5,000.00.
Despite the strict enforcement approach, bed
sores continue to be a serious, growing problem in this
populous County and the situation is further complicated
by the refusal by many long-term facilities to accept
patients suspected of being high risk for fear of being
cited.
Consequently there is an increasing back-up of
patients with bed-sores in acute hospitals and intermediate care facilities.
Chapter 2
GOAL AND OBJECTIVES
In order to provide a positive approach to the
resolution of this problem, it was decided in the Planning, Evaluation, and Development Division and the Preventive Health Services Bureau of the Los Angeles County
Department of Health Services to develop a study/demonstration project focused on cost-containment through
prevention.
The development of the project involved two
major objectives:
1.
To review the literature and to ascertain as
far as possible the contributory elements in the high
incidence of pressure sores, and the current state of
the art in prevention, and
2.
To develop and design a
demonstration/stud~
project on the basis of those findings.
The work was initiated in April, 1978 and on
March l, 1979 the resulting demonstration/study was
submitted to the National Center for Health Services
Research to obtain funds for implementation.
Chapter 3
IDENTIFICATION OF ISSUES
In August, 1978 the Department held a conference
organized and moderated by this writer to discuss the
problem and to solicit recommendations for solutions.
The conference included nurses, physicians, administrators, State and local Health Department representatives,
and representatives of the California Association of
Health Facilities.
The purposes of the conference were
to obtain input regarding the practical problems
tered
~n
encoun~
the day-to-day operations of the various facili-
ties and to obtain suggestions for realistic approaches
to the prevention qf pressure sores.
Although only 40 people were invited to the
planning conference, approximately 70 attended indicating
the extraordinary level of interest in this problem.
Many of the attendees were key personnel from large,
multi-unit skilled nursing facility organizations.
sure sores
ap~arently
Pres-
are a universally frustrating
problem particularly in nursing homes, but not limited
to those facilities.
Participants in this planning con-
ference had a great deal to say about a number of issues
and complicating factors which they perceived as
5
6
contributory to the high incidence of pressure sores in
this cbunty•s facilities.
Following is a discussion of those issues:
Cost:
There was almost unanimous agreement among the
participants at the conference that Medicare/Medicaid
reimbursement to long-term facilities is insufficient
to employ adequate staff to provide traditional preventive care.
Present reimbursement rates are approximately
$27.00 per day for patients in skilled nursing facilities.
Furthermore, Medi-Cal will not reimburse for pressure
relieving devices such as egg crate mattresses.
bursement is the same for
as it ·Js for
11
11
Reim-
high-risk 11 bed-ridden patients
low-risk 11 ambulatory patients.
At $27.00 per 24 hour day, the hourly rate is
less than $1.13.
This st:Jm, then, is far less than that
needed in these inflated times to provide the care
required by bed-ridden patients ... particularly in consideration that the most commonly accepted method of prevention of bedsores is the turning or repositioning of
patient at least every two hours, 24 hours per day.
Although it is true that not every patient requires
repositioning every two hours, it is also true that some
11
h i g h - r i s k 11 pa t i e n t s mus t b e t u r n e d e ven mo r e f r e q ue n t l y
if pressure sores are to be prevented.
7
The survey indicated that between 8.36% and 25%
of .!l_l·patients
in~
have pressure sores.
75,392 beds in Los Angeles County
The conference group agreed that
prevention of bed sores is far less expensive to the
patient, to the facility, to the County, State, and to
the Federal Government - than treatment.
But the cost
of such prevention, in terms of staff, is beyond the
financial ability of the average facility to handle using
traditional preventative approaches.
Level of Care:
Level of care is tied closely to cost.
Frequently
patients are transferred directly from an acute care
facility (where reimbursement is $300/day) to a skilled
nurse facility (reimbursement $27/day).
Some patients,
because of multiple predisposing factors cannot be ade-
.
quately cared for in a chronic care setting but do not
require acute services.
Patients with severe systemic
disorders and/or terminal disease need to be treated in
a sub-acute care facility rather than a nursing home.
This is significant in that the number of such facilities
is extremely small in this and most other urban communities ..
8
Staff Education and Motivation:
Education of all nursing personnel regarding
principles and techniques of prevention is critical.
The
importance of staff education was stressed frequently at
the planning conference and will be an essential component
of the proposed demonstration project.
Although skin care
is a basic element of all nursing education programs, its
importance as a preventive measure is frequently forgotten
or overlooked by nursing staff occupied with more immediate or apparently more urgent patient care priorities.
Motivation is an additional problem in many
nursing homes.
Since preventive care, by its very nature,
tends to be invisible until it fails, employees do not
ordinarily receive personal recognition or rewards for
their pre.ventive efforts.
And, because of unstable con-
ditions, low pay, and the generally poor image of the
nursing home industry it is difficult to attract andretain competent and motivated employees.
~~te
Hospital Role:
· Although pressure sores often occur in acute
hospitals, there is a tendency to think of them only in
connection with long-term care facilities.
Many nurses
at the planning conference indicated that pressure sores
frequently start in acute hospitals and are inherited by
long-term facilities, which are then held responsible for
9
neglecting patients.
It was suggested that the role of
the acute care hospital in the high incidence of pressure
sores be recognized, and that a plan for coordination
between acute and long-term facilities be developed.
The high incidence of pressure sores, then, is
apparently a result of staffing and budgetary problems,
particularly in skilled nursing faclities.
If these and
related problems can be resolved or new methodologies
found, the occurrence of pressure sores in SNF's should
be reduced drastically, leading to a major reduction in
health care dollars now being expended on their care and
treatment.
The Need for Additional Research/
---Demonstration Activ1ities:
The bulk of research on the subject of pressure
sores indicates that many principles of prevention are
known.
Failure to prevent decubitus ulcers is largely
due to inadequacies in nursing care delivery.
Nearly everybody agrees that the best
treatment is prevention, which leans heavily
on relentless nursing care and meticulous
skin hygiene. (2:210)
This statement reflects the conclusions found in nearly
all articles reviewed on the issue of preventing pressure
sores.
It is also known that to provide effective preventive
nu~sing
care a ''key factor remains the early
10
detection of patients at risk ... 11
(16)
A tool for risk
assessment devised by Norton et.al., in 1962 provides a
reliable method for nurses to evaluate and detect
patients at risk.
(17)
Once a patient has been identi-
fied as at risk, nursing staff can provide preventive
care at a time when those measures are most effective.
Need for Grant Assistance:
There is a significant and growing need to improve
the methods or to develop
new~
more cost-effective ways
of preventing pressure sores.
This need cannot be met by the health facility
industry alone nor can it be met by the offical local or
State health departments for a variety of reasons.
Among
these reasons:
-Lack of financial resources to enable improvement of preventive measures using traditional
methodologies.
-Legal inability of the County to engage in
research or study/demonstration activities which
might lead to new or improved preventive measures
using 1 oca·t taxpayer-derived resources. The
County provides services to those of the popula-·
tion who are unable to provide such services for
themselves.
in-patients
However, even services to long-term
(thos~
susce~tible
to pressure sores)
l l
are necessarily extremely limited.
-The County of Los Angeles operates a long-term
rehabilitative facility, the Rancho Los Amigos
Hospital, which has an excellent in-service education program including pressure sore prevention
education.
However, it is beyond the capacity
of the training staff - as well as illegal - to
provide pressure sore prevention training to the
staffs of the hundreds of private health care
facilities of the Los Angeles community.
The variety of issues touched upon in this planning conference indicate that prevention of bed sores is
a complicated and difficult task primarily because of
staffing and budgetary problems.
needs to be done is available.
pull together the
~arious
The knowledge of what
What is necessary is to
known principles of prevention,
develop them into a staff intervention model and implement
this in a
clinic~l
setting.
Chapter 4
LITERATURE REVIEW
The problem of pressure sores has been extensively
discussed in nursing, medical and hospital literature.
Many articles describe the various stages of ulcer formation and the numerous treatment techniques available for
use once an ulcer has formed.
The majority of articles,
however, reiterate the time honored concept of prevention
as the most effective and rational approach to the problem.
There is widespread agreement in the literature
with the author who observes:
The majority of serious pressure sores can be
prevented, and therefore, they represent negligence
on the part of the patient or medical team. Their
occurrence, nevertheless, is frequent. (20:155)
There is also widespread agreement that once established
a pressure sore is difficult to cure and can progress to
involvement to deep tissue structure and bone.
(19).
(7) (15)
Here, perhaps more than in any other clinical dilem-
rna, the adage
11
an ounce of prevention is worth a pound of
cure 11 holds especia1ly true.
The essential elements of
prevention include frequent turning to relieve
pr~ssure,
meticulous skin care and maintaining good nutrition.
12
(1)
13
("IO) (11)
The principles are clear. That the best
method of treatment is prevention is undisputed.
This involves keeping the patient consistently
in a dry bed, turning him every two hours and
maintaining him in a high state of nutrition.
{14:290)
Frequent turning and good skin care are nursing
responsibilities which must be provided 24 hours a day,
seven (7) days a week.
All the efforts of a day shift
can be to no avail if evening and night staff do not
provide the same level of care.
A good risk assessment system is also considered
by some authors to be an essential component of any
preventive effort.
By weighing the patient•s risk of decubiti at
the point of admission to hospital or nursing homeor at the point of discharge if he faces considerable
immobilization at home--you've gone a long way
toward ensuring that he won't actually get one.
(2:213)
Unfortunately, there is little discussion in the
literature of the problem of identifying patients at risk.
Only one substantial study of risk assessment was found
in this review.
The study was done in Great Britain in·
1962 and involved 250 elderly patients admitted to a
hospital with no evidence of pressure sores.
There-
searchers evaluated 5 components of each patient•s condition:
general condition, mental state, activity,.mobil-
ity and incontinence.
(8:293)
14
In this scoring system the patient is assigned
a numerical score of one to four in each category.
In
the activity category, for example, an ambulatory patient
would receive four points; a patient who walks with help,
three points; a chairbound patient, two points; a bedfast patient, one point.
Based on the totals of all five
categories, each patient in the study was assigned an
overall score between five and twenty, with five indicating a patient hypothesized to be at highest risk of
developing pressure sores, and 20 indicating lowest risk.
Of the 250 patients 24% developed decubitus ulcers during
hospitalization~
and 70% of these occurred
during the first two weeks after admission.
The inci-
dence of pressure sores in patients with scores under
twelve was nearly 50% and only 5% for patients with
scores of eighteen to twenty.
On the basis of their
findings the researchers decided on a score of fourteen
as the onset of risk.
It was demonstrated in the same study that provision of intensive nursing care to high-risk patients
resulted in a decreased incidence of pressure sores from
24% to 9%.
Intensive nursing care consisted of reposi-
tioning the patient every two hours, twenty four hours a
day, and general hygiene to the skin.
Although this rating scale is considered by its
developers to be a reliable tool for assessment of
15
patients at risk, and although it appears in many nursing
textbooks, it is apparently still not in widespread use.
A more recent article in the American Journal of
~ursing
discusses the significance of the patient's
health-illness status as an inclination of risk because
of increased metabolic requirements for protein, fluids
and vitamin C.
(9)
It is also known that specific
disorders predispose to the development of pressure
sores.
(19)
Implementation of a risk assessment system can
help nursing personnel to function more efficiently and
to focus efforts on those patients found to be especially
susceptible to decubitus formation.
Staff motivati'on isa persistent and exceedingly
difficult problem to deal with in the prevention of
pressut·e sores.
Nursing~
One head nurse, however, reports in
on her highly successful efforts to eliminate
bedsores on a 43 bed orthopedic ward by her use of staff
motivation.
(6)
She met individually with every staff
member to identify problems and obtain input.
She
t~en
held staff meetings and provided inservice instruction
for all three shifts.
Staff members developed, as a
group, a plan of action.
no pressure sores on
Within four months there were
the ward and no new ones deyeloped
in the two years following the implementation of the
preventive plan.
16
Another report in the American
Association Journal
(4)
He~lth
Care.
describes a similar approach in
reducing an unacceptable level of pressure sores in a
long-term care facility.
The nurse consultant in this
situation was requested by the hospital's administration
to work with existing staff to improve preventive care.
Although staff members had insisted that a higher nurse/
patient ratio was the solution, the problem was ultimately
solved with no increase in staff size.
In this case, key
strategies included obtaining staff involvement by developing agreed upon standards of care, and implementation of a plan for monitoring and documenting skin care
given.
Within nine months there were no pressure sores.
which had originated in the facility.
Both of these situations illustrate the impact
of staff commitment and involvement.
lems of staff
morale~
Attention to prob-
and use of motivation techniques,
are essential components of a preventive care program.
Finally, there are a number of helpful adjuncts
to the turning/skin care routine.
dietary regimens,
devices,
(5)
These include special
pressure relieving and flotation
(14) (18), and a variety of special beds which
turn patients automatically.
(13)
These, however, can-
not replace the basic elements of frequent turnin9 and
continuous attention to skin hygiene.
17
In summary, the literature review indicates that
the
tr~ditional
and current methods of prevention of
pressure sores depends on consistent, conscientious
nursing care which involves turning patients at least
every two hours, maintaining adequate circulation to
susceptible areas of the body, and keeping skin clean and
dry.
A pressure sore prevention project would ideally
decrease the incidence af pressure sores in a given
facility by improving nursing care delivery through staff
education, motivation, and a formal prevention care plan.
Chapter 5
METHODS
Based upon considerations and issues discussed
at the August, 1978 conference described earlier, and
upon the findings obtained in the literature review it
was decided to propose a three-year demonstration project
focusing on prevention through the implementation of a
staff intervention program in selected skilled nursing
facilities in Los Angeles County.·
Project Plan
The principal objectives of the proposed project
are:
l.
to demonstrate reduced costs of institutional
health services as a consequence of preventing pressure
sores in long-term care populations,
2.
to decrease the incidence of pressure sores
in selected long-term facilities by developing and implementing a staff intervention program and model, and
3.
to draft, use, and test-in conjunction with
above-an easily understood, up-dated manual on all aspects
of pressure sore prevention, and upon approval and finalization of the manual, to publish it and make it available
18
19
to health facilities and providers in both the public
and private sectors.
It is proposed to divide the study/demonstration
project into four phases:
Phase I - Estimated time: 8 months
This phase will consist of data collection and
evaluation of data for facility selection.
Data will be
collected from a representative sample of approximately
400 nursing homes in Los Angeles County.
be excluded from the sample if they:
Facilities will
1) specialize in
developmentally disabled, or long-term psychiatric
patients since they are not typically bedfast or
fast, or
chair~
2) have equal to or less than 10% ·incidence of
decubitus ulcers in the prior year.
Since the county
average incidence is 8.3% an incidence above 10% will be
considered high.
A demographic study of the patient population
will include the following characteristics:
1.
Age
2.
Sex
3.
Race
4.
Risk Category
a.
Mobility
b.
Incontinence
c.
State of
conscio~sness
20
d.
General condition
e.
Menta 1 state
f.
Type of illness
g•
Nutritional state
h.
Previous history of bedsores
Based on the analysis of facility characteristics
and patient population, all current Los Angeles County
Skilled Nursing Care Facilities will be stratified
according to:
over,
1) size,
2) staffing patterns and turn-
3) average length of
pati~nt
stay and any other
variables identified as potentially significant resulting
from data analysis.
Subsequently, two stratified random
samples will be chosen of 10 or more facilities for both
the experimental and control groups.
During this phase a manual of pressure sore prevention techniques will be developed for use in the staff
education phase of the project.
The manual will cover
but not be limited to the following subjects:
assessment,
2) turning and positioning,
4) methods of monitoring skin care, and
1) risk
3) nutrition,
5) use of pres-
sure relieving program and devices.
Phase II - Estimated time:
10 months
This phase will consist of the development of the
staff intervention program including design of an education curriculum and a staff motivation plan.
21
Staff education and motivation have been consistently cited as the most urgent need for improving
nursing pet·formance in the prevention of pressure sores.
Staff memlwrs of the Brotman
r~lemorial
Hospital Decubitus
Laser Services in Culver City, California, for example,
conduct on-site educational visits in
long~term
facili-
ties where they have placed their post-operative decubitus
patients.
Nursing personnel in those facilities indi-
cated that these visits have a significant positive impact on staff performance.
At Rancho Los Amigos Hospital, where many patients
have spinal cord injuries and are at extremely high risk,
nursing personnel and patients are carefully educated
regarding the :prevention of pressure sores.
Unfortu-
nately, becuuse of a Los Angeles County ordinance prohibiting County employees from training non-County employees based on lack of resources, this educational
program is not available to the hundreds of facilities
in the comn1unity.
The curriculum of the proposed program will be
developed with consulting assistance from the Coordinator
of Contintdng Nursing Education at Rancho Los Amigos
Hospital, lind from medical and nursing personnel at both
Rancho and
~rotman.
The manual of prevention techniques
compiled du1·ing Phase I will be used as an adjunct in the
curriculum ,!evelopment.
The State of California has
22
evinced interest in participating (non-financially) in
the development of the manual and its possible use
~tate­
wide.
Because patients at highest risk of developing
bedsores are generally bedridden, incontinent, unconscious
or incoherent and unable to respond or assist with their
own care, they are usually considered very difficult to
manage.
The physical care of such patients is often
viewed by nursing staff as particularly tedious and unpleasant.
Such lack of staff motivation has been impli-
cated as a serious barrier to effective implementation
of preventive care, and we will therefore develop a plan
for motivating and organizing nursing personnel for use
in conjunction with the in-service curriculum.
This plan
will include techniques of staff development, as well as
monitoring methods suggested by experienced nurses and
administrators.
Near the completion of the staff intervention
model design, a training team of two Registered Nurses
will· be prepared to conduct the in-service education and
staff motivation program in the selected skill nursing
facilities.
Also 5 part-time Student Professional Workers
will be employed to act as on-site representatives.
During the second half of Phase II a pre-test of
the curriculum and training program to the nursing staff
of a selected skilled nursing facility will be developed
23
and administered.
This will require a facility with highly
cooperative supervisorial and administrative staff, and
one which will not be participating in the actual study.
The pre-test will measure the effect of staff
education on participant's understanding and application
of preventive techniques.
It will consist of a knowledge
test which wi11 cover items in the educational curriculum,
and an observational schedule which will be used to evaluate changes in nursing behavior to reflect application of
knowledge of the techniques of maintaining skin integrity.
Two hypotheses will be measured in this phase of the project.
Hypothesis 1:
There will be a significant increase
in nursing personnel's knowledge regarding maintenance of
skin integrity from pre-test to post-test.
Pre-test and
post-test data will be compared using a t-test (repeated
measurement formula).
Hypothesis 2:
Nursing personnel will score sig-
nificantly higher on the skin integrity maintenance observational schedule after the educational program than before the educational program.
Observational schedule
scores before the educational program will be compared to
observational schedule scores after the educational program using a
t~test
(repeated measurement formula).
During the last three months of Phase II 10 or
more skilled nursing facilities will be selected to
24
participate in the implementation of the staff intervention
model based on the selection criteria developed in Phase I.
Phase III - Estimated time:
12 months
This will consist of implementation of the staff
intervention program in the selected facilities, and
measurement of outcomes.
During this phase the R.N. team will conduct onsite in-service education in each of the 10 selected
SNF's.
This will require approximately one week in each
facility.
During this time they will also provide training
to supervisorial staff in techniques of staff motivation,
and will be available for consultation throughout the
remainder of the project.
When the training of nursing staff is completed
staff performance, occurrence of skin problems, and changes
in the patient population and the environment which might
affect the outcome of the study will be observed and documented.
A trained Student Professional Worker will be
placed in each facility for 20 hours per week to make
those observations and keep detailed field diaries.
Time
spent on staff training and the provision of preventive
nursing care will be documented and patient data will be
collected by use of admission questionnaires and follow-up
cha r·t reviews.
25
The results of this stage of the project will be
measured in terms of change in staff behavior, and changes
in the incidence of pressure sores.
The research design will consist of a four cell
model - an experimental and a control group with pre- and
post-test measurements.
From a pool of randomly selected
skilled nursing facilities with a history of decubitus
ulcer incidence, ten will be randomly assigned to each
group.
The experimental facilities will have staff tested
for knowledge of decubitus ulcer prevention care and
observed for patient care techniques.
given an educational program.
They will then be
At the end of the training
period, observation of all newly admitted patients will
begin at both experimental and control facilities.
Twenty five new patients who have been examined
and are free of decubitus ulcers at the time of admission
will be rated With respect to their risk factor.
The risk
assessment scores will be determined using the system
described by Green (8:293), and compared to assure the
comparability of the two groups .. T-tests will be used to
assess whether the two groups are significantly different.
Then a statistical program to partial out the impact of
the difference could be used, or
subseq~ent
analyses could
be modified, if size permits, to analyze the data separately for high, moderate and low risk groups.
26
Patients will then be followed for six weeks and
evaluated for evidence of pressure sores.
It may be neces-
sary to lengthen the observation of patients, however, if
the study done in Phase I indicates that a substantial
proportion of ulcers developed in patients beyond six weeks
in Los Angeles County.
At the same time a records search
of their files will be done to check on the possibility of
the occurrence of pressure sores which were treated and
cured within the six-week period.
An equal number of
patients who had been admitted prior to the training of
staff and had a stay equal to or more than six weeks will
be studied at both the experimental and control facilities.
Patients with a length of stay longer than six weeks will
only be studied for six weeks to make them comparable to
the patients in the experimental group.
These latter co-
horts will represent the pre-study patients for purposes
of computations of decubitus ulcers incidence.
Their six-
week experience will all have occurred prior to the introduction of the educational program.
Hypothesis 3:
Incidence of decubitus ulcers will
be significantly less for the experimental group than for
the control group.
Hypothesis 4:
Incidence of decubitus ulcers will
be significantly less for the experimenta1 group than for
the pre-study group (an equal number of previously cared
for patients from the same experimental institutions).
27
Prior to testing of Hypotheses 3 and 4 the following analyses will be conducted to assure that the.
specified uncontrolled variables will not be significantly
influencing the outcomes.
A comparison of the incidence of decubitus ulcers
developed will be analyzed in relation to whether the
patients were transferred to the skilled nursing facility
from an acute facility3 intermediate care facility or were
admitted from home.
The length of time ill prior to
admission to the skilled nursing facility based on four
categories (equal to or less than 1 month, more than l-6
months, more than 6 months - year, more than 1 year) will
be analyzed.
Both of the above analyses will utilize a
one-way analysis of variance.
If no significant dif-
ferences are found subsequent analyses will combine all
categories.
If significant differences occur then subse-
quent analyses will be conducted utilizing the significant
categories.
Data will be analyzed using a two-way analysis of
variance:
two (experimental and control treamtent groups)
by two (equal number of pre-study patients from the experimental and control facilities) using a one-tailed test of
significance set at the .05 level of probability.
28
Phase IV - Estimated time:
6 months
This will consist of organization and writing of
results and a cost benefit analysis which will include
calculation of the costs of educating nursing personnel,
costs of additional nursing time spent on preventive care,
and an update of estimated average expenditures for the
care and treatment of pressure sores.
This information
will be analyzed to develop a comparison of the costs of
prevention versus the costs of treatment.
A framework for cost/benefit analysis will be
established which incorporates;
a) a set of design cri-
teria based on anticipated impacts of the proposed intervention,
b) the intervention character-istics required to
solve the problem and achieve the ultimate objective, and
c) the constraints anticipated from limitations of resources ( both human . and techno 1 o g i c a 1 ) , be h a vi or a 1 , f i nancial and traditional health care practices.
Based on this framework, a classical cost/benefit
ratio will be developed which details major costs and
benefits expected as a result of intervention.
Cost and.
benefits will be forecast over a time period consistent
with the average life expectancy of patients afflicted,
(approximately 10-15 years).
This approach will produce
a cohort for purposes of extrapolation to the universe
of patients.
Both costs and benefits will be appropriately
discounted to reflect current value.
A liberal discount
29
rate will be applied to costs
{15%)~
and a conservative
discount rate will be applied to benefits (5%) to counter
the inherent tendency to inflate the overall ratio.
In general, a cost means that some highly placed
value has to suffer, and a benefit means that the value is
satisfied.
Costs and benefits are not always measured in
monetary terms.
For purposes of this project, the fol-
lowing definitions will be employed.
A.
Benefits - A tangible expression of what is intended
to be achieved.
In this project we intend to reduce costs associated with treatment of pressure sores, reduce the incidence of a major health problem, and add knowledge to the
field of health.
1.
Direct Benefits - Will include the saved costs
of caring for the problem·at issue in terms of reduced
expenditures of funds and reduced incidence of pressure
sores.
2.
Indirect Benefits - Will include the preven-
tion of acute hospital days avoided, reduction of hospital
b~ds
which result in the above, and days of institu-
tionali~ation
B.
avoided.
Costs - A tangible expression of value incurred as a
result of the problem.
30
In this project the costs associated with the
problem.include current expenditures of funds, existing
levels of incidence of
pressure sores and foregone oppor-
tunities as a result of the problem.
l.
Direct Costs -Will include those incurred in
treatment, educational costs, staffing changes, and regulatory costs.
2.
Indirect Costs -Will include costs associated
with inability to provide treatment for the primary cause
of institutionalization, added costs of unnecessary acute
hospitalization, and so on.
Chapter 6
CONCLUSIONS
At the t i 111 ~=' o f t h i s wr i t i n g t h e p r o p o s e d d em o n stration project is being considered for funding by the
National Center fc11' Health Services Research.
If imple-
mented it is anticipated that the project will result in
a significant decr·pase in the incidence of pressure sores
in participating r~cilities, and \'lill
provide a staff
intervention model which could be implemented in other
long term care faCilities.
It will also result in a more
comprehE~nsive unciP.I'standing of
the costs associated with
prevention, and a tomparative analysis of costs of prevention and treat111nnt.
The development of accurate infor-
mation regarding the costs of providing preventive care
will be a major co11tribution at a time when nursing home
operators claim th>1t it is impossible to provide adequate
preventive care at current State and Federal reimbursement
rates.
If the exrrcted results do not uccur, and there
is no significant ,,eduction in the incidence of pressure
sores, this project still will have provided considerable
information concerning the relationship between nursing
care and preventi(\q, the effectiveness or risk assessment,
31
32
the impact of staff education and motivation on staff behavior, and pertinent cost factors.
There has been a notable dearth of clinical studies
of the prevention of pressure sores (as evidenced in the
literature review), despite the growing numbers of chronically ill, high-risk persons confined to long term care
institutions.
Whatever the outcomes the project will
undoubtedly yield considerable data and information to
serve as a basis for further exploration of issues in the
prevention of decubiti, and will perhaps reveal more effective approaches to preventive care.
And finally, a con-
centrated effort to solve a problem currently plaguing
Skilled Nursing Facilities, may incidentally lead to the
idenification of, and/or solutions to, other problems of
nursing care for the aged and chronically ill.
REFERENCES
1.
Bamberg, J. Estimate of prevalence of decubitus
ulcers in health facilities. Unpublished l~eport of
survey conducted by Health Facilities Division,
Los Angeles County Department of Health Services,
August 10, 1978.
2.
Bradner, J. Putting pressure on decubitus prevention.
fatient fare, August l, 1974, 8:210-227.
3.
Center for Decubitus Ulcer Research Information, and
Education. Unpublished data. Jenson Beach, Florida,
August, 1978.
4.
Eusanio, P.L. Monitoring skin care eliminates
decubitus ulcers. American Health Care Association
Journal, November, 1976, 2:50-l.
5.
Everette, M. Decubitus ulcers: nutrition.
Inter·disci pl i nary Approach .!Q_ the _Problem of
Dec ub i t us Qlc e_ J an u a r y 6 , 1 9 7 8 , Pp . 3 - 7 .
_r_::_ , .
6.
Fleming, A. Motivating a staff plagued by failure.
l'Jursing 'J.2, March, 1975, 5:86-8.
7.
For decubitus: a new protocol and a warning.
Emergency ·Medicine, April, 1977, 247-254.
8.
Green, M.F. The team approach.
February 26, 1976, 72:292-4.
9.
Gruis, M., and B. Innes. Assessment: essential to
prevent pressure sores. American Journ~ Qi Nursj_!}_g_,
Vol. 76 No. 11, November, 1976, Pp. 1762-1764.
10.
Guthrie, R., and D. Goulian, Jr. Decubitus ulcers:
prevention and treatment. Geriatrics, August, 1973,
28:67-77.
11.
Nursing
Time~,
Jellis, A.J. Pressure sores: way of prevention.
limes, February 26, 1976, 72:291-2.
~J:!_rs'i___!!g_
33.
34
12.
Korn, A., and Gerald Glantz. Laser decubitus service:
a new concept. Unpublished paper presented to the
Second International Symposium of Laser Surgery~
October 24, "1977.
13.
Lilla, .J., R. Friedrichs, and L. Vistnes. Flotation
mattresses for preventing and treating tissue breakdown. Geriatrics, September, 1975, 30:71-5.
14.
Lowthion, P.
Nursi~ Tim~,
15.
t~oolten,
S.
Pressure sores: practical prophyliaxis.
February 26, 1976, 72:290+.
Bedsores.
Hospital Medicine, May, 1977,
13:53-5+.
16.
Norton, D. Research and the problem of pressure
sores. NL!rsing Mirror, February 13, 1975, 140(7):
65-7.
17.
Norton, D., R. Mclaren, and A. Exton-Smith. An
investigation of geriatric problems in hospital.
National Corporation for the Care of Old People.
London, 1962.
18.
Paradis, R. Flotation pad therapy for decubitus
ulcers. Archives of Physical Medicine and
Rehabilitation, January, 1975, 56(1):40:-·3~
19.
P·inel, C. Pressul~e sores. Nursing
February 5, 1976, 72:172-4.
20.
Sather, M., C.E. Weber, Jr., and J. George.
Pressure ~ores and the spinal cord injury patient.
Qru_g Intelligence and Clinical Pharmacy, Vol. II,
March, 1977, Pp. 154-169.
21.
Spira, M., l1. Moore, S. Hardy, and F. Gerow. Care
of the decubitus ulcer patient. GP, April, 1969,
39:78-89.
I_ime~,