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.