An estimated 50,000 to 60,000 patients die each year from conditions related to pressure ulcers. Recognizing the impact pressure ulcers have on mortality rates, patient quality of life, and hospital costs, Forsyth Medical Center of Winston-Salem, N.C. launched an initiative in July 2008 to reduce its already lower-than-average incident rate.
For an acute-care facility the size of Forsyth – with 961 beds – the medical literature suggests that incident rates range from seven percent to 11 percent as a national average. Since 2003, Forsyth Medical Center’s rate has typically averaged 3.6 percent or less, and with the new emphasis put in place a year ago, that number has dropped to less than 0.5 percent, according to recent quarterly audits.
Although it is commonly believed that skin breakdown and pressure ulcers are preventable, other factors put many patients at risk, including: poor nutrition; diabetes; incontinence; immobility; peripheral vascular disease; and renal failure, among others.
“We as health care providers and nurses can play a big part in preventing pressure ulcers and skin impairments, but when you look at the overall picture of many patients, some problems are unavoidable,” said Shirley D. Matthews, R.N., Regional Wound, Ostomy and Continence Nurse (WOCN) coordinator for the Triad Market of Novant Health, Forsyth’s parent company. The Piedmont Triad region of North Carolina includes Greensboro, Winston-Salem and High Point. Matthews coordinates care at several facilities, including Forsyth Medical Center and the 22-bed Medical Park Hospital in Winston-Salem.
All of the mattresses or beds in the hospitals have foam, foam/air, or air surfaces to evenly distribute pressure and prevent ulcers, but the initiative launched last year focuses on early detection and aggressive treatment, as well as prevention.
“One of the major changes we made is ensuring that our nurses perform a thorough skin assessment on every admission to detect any problems that might be going on from the time the patient comes through our doors. Because there are multiple entry points into the system, we rely on staff nurses, operating room nurses and emergency room nurses to provide these assessments, and we’re finding many impairments when patients are entering our facility,” said Matthews, who has 20 years of wound-care experience and has worked for the organization for 29 years.
To help the nursing staff identify at-risk patients and take appropriate actions for prevention or intervention, every patient is assessed using the Braden Scale on admission and on every shift thereafter. If a skin impairment is detected at any time, Wound/Ostomy Services is contacted. A set of routine orders is in place to allow the staff nurse to provide immediate treatment if needed.
Staging of pressure ulcers was defined in 1975. The National Pressure Ulcer Advisory Panel redefined staging of pressure ulcers in 2007, adding a definition of “deep tissue injury,” which may be difficult to detect, especially in individuals with dark skin tones. These wounds may rapidly evolve, affecting layers of tissue, even with optimal treatment.
Staging is subjective and even experts sometimes disagree. “Because staging is complex and incorrect staging can lead to inappropriate care or the possibility that a wound could be incorrectly staged as a Stage I pressure ulcer when, in fact, there are deeper issues down at the bone interface, we’re asking the nursing staff not to stage the impairment, but to call Wound/Ostomy Services if they see any skin issue that may be related to pressure,” Matthews said. “One of our Wound/Ostomy nurses with special training in wound care further evaluates the impairment, makes recommendations for care, and works with the patient’s physician to develop and implement an appropriate treatment plan.”
Matthews and a team of four other Wound/Ostomy nurses usually see 30 to 50 patients a day at Forsyth Medical Center and Medical Park Hospital to provide initial assessments or follow-up visits related to skin care or ostomy issues.
Largely because of the misperception that pressure ulcers are preventable, hospitals often contend with costly lawsuits, and the Center for Medicare & Medicaid Services (CMS) has announced that it will stop reimbursing hospitals for care related to pressure ulcers that are hospital-acquired.
“Forsyth and Novant have always taken skin care very seriously and made it a very high priority in our nursing care,” Matthews said. “As a result, for years our incident rate has been below the national average, and our recent emphasis on early detection and aggressive treatment has brought those numbers down even more. For me, the rewards of this work revolve around patient outcomes and the relationships that develop with long-term patients. When we see wounds heal and patients do well, we can see that what we do makes a difference.”
About Forsyth Medical Center
Forsyth Medical Center is part of Novant Health, a not-for-profit integrated group of hospitals and physician clinics, ranked as one of our nation’s 10 best healthcare systems. Novant staff cares for patients and communities in North and South Carolina. Hospital affiliates include Presbyterian Hospital, Presbyterian Orthopaedic Hospital, Presbyterian Hospital Matthews and Presbyterian Hospital Huntersville in the Charlotte, NC area; Forsyth Medical Center and Medical Park Hospital in Winston-Salem, NC; Thomasville Medical Center in Thomasville, NC; and Brunswick Community Hospital in Supply, NC. The Novant Medical Group consists of more than 1,000 providers in 232 clinic locations. Other Novant facilities and programs include two nursing homes, outpatient surgery and diagnostic centers, rehabilitation programs and community health outreach programs.
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Media Contact: Freda Springs
Tel. (336) 287-4203 (Cell)
E-mail: fssprings@novanthealth.org
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