Flap Fails to Close

A recent press release from JusticeNews Flash.com (Clinitron Bed Management For Flap Patients Is The Standard Of Care, 2013-06-19) brought back angry memories of my mother's hospitalization and death.  For exactly the reasons stated in the press release quoted below,  the hospital and the plastic surgeon refused to pay to rent the air fluidized bed that is the standard of care for flap patients.  Her surgery failed three times, and only one night in all that time was she allowed to have the Clinitron bed.

"Patients, providers, and families expend great effort in attempting closure of Grade 3 and Grade 4 decubitus ulcers. Patients die, become progressively debilitated, suffer a loss independence, and become progressively depressed directly because of decubitus ulcers. All necessary and appropriate care must be utilized for these patients, and that would include the use of clinitron beds after flap closure. Cost cutting and the rationing of state of the art medical care should not compromise this unfortunate population and all attempts must be made to obtain a successful flap outcome. The prospect of using less expensive beds that have inferior pressure relieving capabilities is a repulsive idea that is the result of unjustified rationing of medical services brought on by aggressive hospital administers trying to save cost and the expense of patients who suffer from chronically disabling conditions."

Take Action on AHRQ Findings

AHRQ Findings Match NDF

Issues Major Report Confirming NDF Protocol

 

Now that we have the support of the AHRQ, the NDF must take steps to make those results known.  We will write each of the pressure ulcer experts named in the AHRQ report as having contributed to the effort, urging each of them to work at their state level to require that hospitals make the necessary investment in advanced support surfaces. 

 

The Agency for Healthcare Research and Quality (AHRQ) of the Dept of Health and Human Services is charged with providing evidence-based information so that providers and consumers can make the best possible clinical decisions.  The AHRQ has just released a comprehensive 358 page report (Comparative Effectiveness Review Number 87) reviewing and summarizing all known information bearing on pressure ulcer prevention. The report is entitled "Pressure Ulcer Risk Assessment and Prevention: Comparative Effectiveness".

This report comes to precisely the same conclusion that the NDF did back in its July 2008 study, "Reducing Pressure Ulcer Incidence through Braden Scale Risk Assessment and Support Surface Use", Advances in Skin & Wound Care, p 330-334. This study forms the basis for the NDF Prevention Protocol, a procedure adopted by many hospitals to effectively drive their pressure ulcer incidence to zero. The protocol consists simply of two elements:

 

1. Assess the pressure ulcer risk for every patient at admission using the Braden Scale.

2. Immediately place each at-risk patient on a pressure-relieving surface proven to have been effective in pressure ulcer prevention.

 

As the following excerpts from the conclusions of the AHRQ study illustrate, the AHRQ has also come to the conclusion that only risk assessment followed by support surface use have been demonstrated to be effective pressure ulcer prevention tools:

 

"Studies of diagnostic accuracy found that commonly used risk-assessment instruments (such as the Braden, Norton, and Waterlow scales) can identify patients at increased risk for ulcers, with no clear difference among instruments in diagnostic accuracy"

 

"In higher risk populations, good- and fair-quality randomized trials consistently found that more advanced static mattresses and overlays were associated with lower risk of pressure ulcers compared with standard mattresses (RR range, 0.20 to 0.60), with no clear differences between different advanced static support surfaces."

 

The AHRQ was unable to find any other factor that could be shown to be effective in pressure ulcer prevention:

 

"Evidence on other preventive interventions (nutritional supplementation; repositioning; pads and dressings; lotions, creams, and cleansers; and intraoperative warming therapy for patients ES-18 undergoing surgery) was sparse and insufficient to reach reliable conclusions.....".  

AHRQ Finds NDF Was Right

Back on October 12, 2013, we wrote the Agency for Healthcare Research and Quality (AHRQ) of the US Dept of Health and Human Services to comment on their publication,  Preventing Pressure Ulcers in Hospitals - A Toolkit for Improving Quality of Care.  The AHRQ Toolkit included a wide variety of activities, including turning, repositioning, nutrituional aupplements, pads and dressings, lotions and cleansers, etc.

We wrote that their toolkit was unnecessarily complicated and detailed, and urged the adoption instead of the NDF Prevention Protocol:

               1. Assess the pressure ulcer risk for every patient at admission using the Braden Scale.

               2. Immediately place each at-risk patient on a pressure-relieving surface proven to have   been effective in pressure ulcer production.
                            
In reply the AHRQ wrote that "The hospital is given the option to customize its prevention strategy based on the tools provided".  (This has been the case forever with no discernable improvement - ed.)

But this month (May 2013) the AHRQ has published its 400+ page comprehensive Comparative Effectiveness Review number 87, Pressure Ulcer Risk Assessment and Prevention: Comparitive Effectiveness.  In this exhaustive report the AHRQ was able to make only three definitive statements:

1." ...commonly used risk assessment instruments (such as the Braden, Norton, and Waterlow Scales) can help identify patients at increased risk for ulcers.."

2." ....randomized trials consistently found that more advanced static support surfaces were associated with lower risk of pressure ulcers compared with standard mattresses in higher risk patients with no clear differences among different advanced static support surfaces."

3. "Evidence on effectivenes of other preventive interventions (nutritional supplementation; repositioning; pads and dressings; lotions, creams, and clensers; ...) compared with stand care was sparse and insufficient to reach reliable conclusions."

Evidently the AHRQ has convinced itself that the NDF Prevention Protocol is the only thing that makes sense.

How Widespread is this Despicable Practice?

The March 2013 issue of Advances in Skin & Wound Care contains an article, "Construct Validity of the Moisture Subscale of the Braden Scale for Predicting Pressure Sore Risk"   by Omolayo, T et al.  One of the factors contributing to moisture in the Braden Scale is incontinence.

"The authors were surprised to find incontinence briefs in use among participants who are reported to be continent.  It appears briefs are used when residents cannot reach the commode in a timely manner or when nursing assistants are unable to respond promptly to resident calls. Briefs become a toileting alternative. This economy of effort is not consistent with the goals of mobilizing residents to prevent muscle weakness, decrease incontinence, and prevent PrU's.  Toileting deserves more attention.  If residents receiving rehabilitation services are encouraged to use briefs instead of walking or being assisted to the commode, it is possible that mobilization and bladder training controls are not being met. This may delay rehabilitation or result in longer nursing facility care.  There is evidence that bladder training and mobilization can be improved with regular toileting, and this should be a goal of care.  One study of culture of care in two nursing facilities demonstrated that, even in a setting with a strong culture of care, a commitment to continence care and incontinence prevention was not fully embraced."

Evidently many facilities are using diapers to replace nursing assistants, thereby saving money and increasing profits.  This is exactly what happened to our mother in the hospital, leading to her pressure ulcers and her death. This despicable practice must stop.  An investigation is needed  to see how widespread this practice is.

NY State Bill Would Require NDF Protocol in Hospitals

The NDF has been contacted by a representative of the NY State Legislature to inform us that a bill modeled after the New Jersey Law is making its way through the State Senate.  The New York bill covers hospitals as well as nursing homes, whereas the New Jersey law includes nursing homes only.  Hospitals   would be required to have on hand sufficient pressure-relieving mattresses to be provided to every pressure ulcer at-risk patient upon admission to the hospital.

It was explained that this is something some members of the legislature have wanted to do for some time, but the results of the last election had only now made possible.  We were also told that when New York passes such a law, other states are likely to follow.  The law will be known as "Nellie's Law".   This is an extremely hopeful development as we continue to strive for eradication of hospital-caused bedsores.

Amazing Wonderful News

The most hopeful news we have seen has just been announced by the Collaborative Alliance for Nursing Outcomes.  The current issue (Jan 2013) of Advances in Skin & Wound Care contains a research paper, "Eliminating Hospital-Acquired Pressure Ulcers: Within Our Reach".  The  authors used records from 78 hospitals, mostly in California, over the period 2003-2010, and found that, on average, the rate of hospital-acquired pressure ulcers (HAPU) had decreased steadily from 11% to 2%. Pressure ulcers of Stage III and above had decreased from 2% to .4%.

All of the hospitals included in the study were non-profit or government facilities.  This is extremely promising data and we can only hope that for-profit facilities may be shown to have done as well.

How did these hospitals achieve these very promising results? The authors state:

"The most commonly reported interventions were protocol development, staff education, new use of a risk assessment tool, performance monitoring, development of a team approach, use of new beds/support surfaces, implementation of guidelines, providing feedback to staff, and linking staff with resources."

Clearly, the only substantive changes in this list are the use of a risk assessment tool and the purchase of new beds/support surfaces. All of the other items mentioned are just staff guidelines for implementation of the new protocol. That new protocol is the NDF Prevention Protocol as described in our  report, "Reducing Pressure Ulcer Incidence through Braden Scale Risk Assessment and Support Surface Use", submitted July 5, 2006 and published July 2008 in Advances in Skin & Wound Care.  We are extremely gratified to have this confirmation of the efficacy of the NDF Prevention Protocol, whether the hospitals involved realize they were using the NDF protocol or not.

Promising Developments in Early 2013

The State of Connecticut has strong requirements for hospital reporting of adverse events.  This year, hospitals reported a rate of serious pressure ulcer development at only half of that reported last year.  Dr. Mary Reich Cooper, vice president and chief quality officer for the Connecticut Hospital Association, said the state’s hospitals are making extensive efforts to identify patients at risk of ... pressure sores upon admission. 

The Greater New York Hospital Association, a trade association comprising hospitals in New York, New Jersey, Connecticut and Rhode Island, just announced their free organizational assessment of a pressure ulcer prevention and management program.  The program requires that "all consumers receive a comprehansive skin inspection and risk assessment by a registered nurse at time of initiation of services by your organization".  Interventions to be considered for all at-risk patients include "pressure reduction, off-loading, pressure redistribution, the need for special mattress....devices."

Little by little, we believe the essentials of the NDF Prevention Protocol (Advances in Skin & Wound Care, July 2008) are being acted upon by hospital officials.