Introduction
Pressure ulcers (PUs) are a problem in all health care settings including home health care. Persons who develop PUs experience significant pain, are often socially isolated, and may develop complications such as cellulitis, osteomyelitis, or bacteremia that require hospitalization.1-5 Costs for PU treatment is approximately $11 billion per year.6 Because PUs are a major and costly health care problem and are considered to be generally preventable, health care providers have focused on reducing their incidence.
Clinical practice guidelines for PU prevention provide recommendations for practice, but they are based on evidence from acute and long-term care settings. Despite a 0.84% to 17% incidence of PU among home health care patients,7-10 research to determine how clinical guidelines for prevention can be adapted for use in home health care is missing. The purpose of this study was to delineate interventions and activities used to prevent PU in home health care.
Background
Several clinical practice guidelines for PU prevention have been published by various professional and regulatory groups.11-13 The focus on PU prevention intensified with the release of the Institute of Medicine14 report "To Err Is Human" in 1999. This report identified PU as a commonly occurring medical error and an indicator of poor-quality health care. Long concerned about the quality of care among nursing home residents, the Centers for Medicare & Medicaid Services released new regulations for nursing home surveyors in 2004 that specified the Centers for Medicare & Medicaid Services expectations regarding PU prevention for Medicare and Medicaid patients.15 These regulations stressed evidence-based PU prevention practice, underscored the need for use of a validated tool or known risk factors to identify patients at risk for PU development, identified protein and kilocalorie requirements for patients at risk, and emphasized the importance of providing adequate pressure redistribution through use of appropriate surfaces and routine repositioning. In 2006, the Joint Commission16 followed Centers for Medicare & Medicaid Services' lead and added National Patient Safety Goal 14, Prevent Health Care-Associated Pressure Ulcers, to improve nursing home resident care.
A campaign to prevent PU in hospitalized patients was introduced by the Institute for Healthcare Improvement (IHI) in December 2006.17 The ultimate goal of the 5 Million Lives Campaign was zero PU incidence through reliable implementation of preventive interventions. The IHI proposed that all patients undergo admission skin and PU risk assessment, followed by daily reassessments for PU risk. For patients identified as being at risk for PU, the IHI recommended daily skin inspection, measures to minimize exposure to moisture, measures to improve nutrition and hydration, and use of routine repositioning and pressure redistribution surfaces to minimize interface pressures. The IHI initiative promoted a bundled approach to PU prevention that stated if a patient is at risk for PU development, all prevention interventions appropriate for the patient must be provided. If even 1 intervention was not provided, then prevention was not performed.
Evidence-based guidelines for PU prevention and treatment were released by the National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel in 2009.12 Their recommended interventions are more extensive than those proposed by the IHI and include a complete skin assessment and PU risk assessment on admission to all health care settings, and periodic PU risk reassessments. For patients found to be at risk, PU prevention should include regular skin assessment; nutritional support when indicated; measures to protect the skin from excessive moisture or dryness; regular turning and repositioning and use of bed and chair pressure redistribution surfaces to minimize pressure, shear, and friction; and education about PU prevention for all persons involved in care. Accurate documentation of prevention care is stressed. Although these guidelines include updated recommendations for PU prevention that can be used by health care professionals across health care settings, specific directions for their implementation in each setting, such as home health care, are not provided.
The 2010 WOCN Guideline for Prevention and Management of Pressure Ulcers13 supports the recommendation for PU risk assessment on admission, followed by regular reassessment. A schedule for reassessing risk in each health care setting is provided. These evidence-based guidelines also propose a head-to-toe skin inspection be performed on admission to the care setting and at least daily thereafter or per specific setting regulation. Recommended interventions to prevent PU for patients determined to be at risk include minimizing friction and shear; reducing pressure through regular repositioning, turning of the bed- and chair-bound individual and appropriate support surface use; nutrition; and patient/caregiver education. Added measures to manage skin moisture from incontinence not mentioned in the international guidelines include establishing a bowel and bladder management and retraining program, use of incontinence briefs, and use of urinary and bowel containment systems in selected cases.
Studies on the impact of comprehensive PU prevention programs in hospitals commonly report a 40% to 50% decrease in hospital-acquired PUs; in some cases, a 70% to 80% reduction in hospital-acquired PUs was achieved.18-21 Lyder and colleagues22 found that a bundled approach to PU prevention in 2 nursing homes not only decreased the incidence of PUs by 76% to 87%; it also provided a reduction in the cost of preventive care.
Surprisingly, few studies have examined PU prevention in home health care. Most of those reported to date describe the implementation of a PU prevention program but provide little evidence concerning the effectiveness of these programs. Reported outcomes have been limited to an increase in specific components of a prevention program, such as Braden Scale use, number of dietary consultations, nurses' knowledge of preventive care, or number of certified WOC nurse consultations postimplementation.23-25 Hanson and colleagues26 found a decrease in PU prevalence after implementation of a prevention program in one home health care agency. However, incidence data were not reported; thus, changes might have reflected differences in the sample surveyed as opposed to any impact on the development of new ulcers. Werkman and colleagues10 described a statewide collaborative effort coordinated by the New Jersey Hospital Association Quality Institute to prevent PUs in patients across the care continuum. After implementation of a prevention program that included an admission skin and risk assessment, nutritional support, appropriate use of redistribution surfaces, and repositioning, PU incidence among home health care patients was reduced 78% over 2 years (from 0.84% to 0.2%).
The lack of evidence-based guidelines specific to the home health care setting is a major obstacle to designing and implementing effective prevention programs in this care setting. Published studies have tended to extrapolate general guidelines for PU prevention in home health care but few studies have described how home health care staff accomplish PU prevention in this setting. Therefore, our knowledge of the most effective prevention interventions, or unique aspects of their implementation in the home health setting, is limited. Delineating interventions and activities important to PU prevention in the home health care setting is needed.
Methods
A focus group design was used for this study. A focus group is a type of group discussion designed to produce high-quality, reliable, valid data that address the needs of key stakeholders and contribute to high-quality decision making.27 The purpose of a focus group is to generate consensus on a given topic in an open atmosphere. The group follows a semistructured format in which 1 or more moderators ask a series of predetermined questions and encourage group discussion. The semistructured format enables participants to elaborate on ideas and bring up new topics of importance which researchers may or may not have included.28,29
A convenience sample of certified wound care nurses who practiced in home care at least 50% of the time were recruited for the one 75-minute focus group discussion. Announcement of the opportunity to participate in the focus group discussion was made at a WOCN Society conference. After initial participants were identified, snowball sampling was used to identify additional participants. Specifically, nurses who self-reported they were certified in wound care were asked to identify other certified wound care nurses who practiced in home health care. All of the female participants provided written consent for participation in the study followed by verbal assent prior to the focus group. The institutional review board at the University of Kansas Medical Center approved study procedures. Each participant agreed in the signed written consent that she was a certified wound care nurse who practiced in home health care at least 50% of the time. Because the sample of certified wound care nurses was geographically dispersed, the focus group was convened by teleconference. Use of teleconference to conduct focus groups has been found effective in previous studies30-32 and has been employed by the primary author in past research activities.
A semistructured moderator's guide was developed by the authors to lead the focus group discussion. The guide contained a scripted introduction to the project, open-ended questions, and suggested probes to stimulate group discussion and obtain specific information. Open-ended questions were organized by PU prevention intervention. Examples of these questions are included in Table 1. Participants were also asked to describe other interventions they have used to prevent PU not mentioned in clinical practice guidelines and to describe their years of home health and wound care experience.
The focus group was comoderated by the authors, who have extensive experience in PU prevention, focus group methodology, and qualitative analysis techniques, including text analysis, which was used for this study. The session was monitored to ensure that the discussion remained relevant to the study, that all group members had opportunities to contribute, and that responses were not inhibited or shaped by dominant members. The focus group discussion was audiotaped and transcribed verbatim.
Data Analysis
Transcribed data were independently analyzed by the coauthors using standard text analysis techniques.28 Participant comments were read and reread to obtain a sense of the whole and then inductively coded to designate data that contained similar material. We independently identified thematic statements organized by PU prevention strategy and interventions unique to home health care and then met to reach a consensus. Few to no differences were noted. Thematic statements were translated into action statements that could be used in development of a PU prevention program for home health care use. Preliminary results were distributed to focus group participants for review, clarification, or comment. Results were refined as needed based on this feedback.
Results
The 9 focus group participants were from New Jersey, Pennsylvania, New York, Missouri, and Iowa. Two participants had more than 10 years of wound care experience, 3 had 5 to 10 years, 3 had 3 to 5 years experience, and 1 participant had less than 1 year of wound care experience. Seven had 10 or more years of home health care experience, 1 had 5 to 10 years of home health care experience, and 1 participant had less than 5 years of home health care experience.
Assessment of Skin and PU Risk
Interventions and activities used to prevent PU in the home health care setting are summarized in Table 2. Participants affirmed the importance of admission skin assessment to identify the presence of PUs and other skin integrity problems. Skin assessments also are performed when home health care is resumed after rehospitalization, when the recertification Outcome Assessment Information Set (OASIS)33 is completed, and at other intervals specified by agency policy. For patients who are deemed at risk for PU, the skin should be assessed at each home visit. Usually, professional home health staff teach "at risk" patients and their lay caregiver(s) skin inspection and signs of skin breakdown. Patient and caregivers are counseled to report suspected skin alterations to home health care staff who monitor these reports at each home visit. The patient's skin is visually inspected when the patient or caregiver reports or expresses concern about skin integrity, when the patient is deemed at high risk for pressure ulceration, or when the patient is bed-bound.
Most of the study participants agreed that all patients should be assessed for risk of PU development on admission for home health care services. Many participants used the Braden Scale34 to assess PU risk; others evaluated clinical factors to determine patient risk status. The decision to use a validated risk assessment tool was agency specific. Participants acknowledged the importance of routine PU risk reassessment but reported variability in the frequency of the reassessment and inconsistencies in practice. One participant reported reassessing risk weekly, but others reported reassessment every 60 days on recertification for home health care. Reassessment was also advocated on resumption of home health care after rehospitalization and with a significant change in patient condition.
Several participants identified difficulty in monitoring Braden Scale scores within the computerized documentation system. Comments included "[horizontal ellipsis]Unfortunately the system doesn't trigger the nurses to do it [the Braden Scale][horizontal ellipsis] and it [Braden Scale score] gets lost in the system. It's not easily accessible afterwards to go back and view it and just compare." Computer prompts for routine risk assessment and alerts to a patient's "risk score" were proposed as possible solutions to the problem.
Preventive Interventions
Since PU prevention in the home health setting is dependent on the patient and caregiver, education is a key element of care. Participants reported that teaching is commonly oral, and it is augmented by written materials tailored to the educational background of the patient and caregiver. Several participants reported new efforts toward consistent patient and caregiver education across the continuum of care.
Minimizing Pressure, Friction and Shear
Participants reported that appropriate use of pressure redistribution surfaces in home health care is sometimes limited by Medicare guidelines regulating coverage. When a patient meets Medicare criteria for a surface, home health staff contact the physician and work to obtain the bed and/or chair surface that Medicare will cover most or part of the cost. For patients with private primary or secondary insurance, home health care staff work with the physician, patient, and family to obtain the pressure redistribution surface covered by the policy. If the cost is not covered by third party reimbursement, patients are asked to purchase the bed or chair surface as an out-of-pocket expense. If the individual cannot afford this purchase, home health staff collaborate with health care vendors or charity organizations to obtain a donated device. Some nonprofit home health care agencies will provide the redistribution surface for selected patients without cost. On occasion, participants reported that home health staff may pay for these items on behalf of their patients.
Many participants reported that working with staff to ensure proper selection of pressure redistribution surfaces created multiple challenges. One participant stated, "[horizontal ellipsis] it is a tremendous challenge to educate all of our staff on the appropriate types of products." Another noted, "I find the majority of the time they [home health care staff] rely on me as the agency CWOCN to decide[horizontal ellipsis] and it is not always possible for me to see every patient to make that determination." Several participants stated they have developed algorithms to assist staff with decision making regarding pressure redistribution surfaces.
Focus group respondents stated that home health care staff teach caregivers to reposition patients deemed at risk for PU every 2 hours or more often. However, participants also acknowledged that this intervention is impacted by caregiver resources. For example, they reported that professional staff may need to negotiate a nighttime schedule that balances the frequency of repositioning with the need for caregiver rest. As one participant reported, "Because there may only be one primary caregiver in the home, it is not realistic [to expect] that they are going to be up all night long every two hours turning the patient." Participants also stated that some caregivers may refuse to reposition the patient at night, and added that an evaluation of patient and caregiver willingness to reposition is an integral component of PU prevention in the home care setting.
Participants reported that proper patient positioning is relatively easy to implement in home health care. They stated that soft items such as towels, pillows, blankets, and comforters can be used to aid in positioning. Participants noted that the cost of these devices is typically less than those associated with obtaining traditional pressure redistribution surfaces. However, respondents went on to state that staff must occasionally collaborate with health care vendors or charity organizations for donations of needed positioning supplies.
Focus group respondents also noted that caregivers and patients at risk for pressure ulceration are taught to avoid the shear and friction associated with dragging the patient's skin across bed or chair surfaces when repositioning and transferring. They advocated consultation with physical or occupational therapy to help teach patients and caregivers appropriate transfer techniques. They also observed that while draw sheets are useful in the hospital and nursing home settings, caregivers of home health care patients may find it difficult to avoid friction and shear injury with their use. One participant stated, "You have a 100 pound wife who's trying to move her 200 pound husband and the only way she can move him is to drag him across the bed; it [may be] impossible to do it any other way." Group participants also identified that a trapeze or lift may be effective in select cases, provided the patient can obtain the device and the home can accommodate the equipment.
Focus group participants agreed that improving activity and mobility in home health care patients at risk for PUs was most often accomplished through collaboration with physical therapists. Participants stated that they often refer patients for physical therapy and monitor their adherence to the recommended program. In some agencies, participants reported that case conferences or team meetings are conducted by e-mail or phone every 1 to 4 weeks or as needed to monitor patient activity/mobility status.
Nutrition and Hydration
Focus group respondents concurred that improving nutrition and hydration for at risk patients is a particular challenge in the home health care setting. Participants identified the importance of early nutritional assessment for patients at risk for PU development, but activities to assess nutrition risk varied from agency to agency. Most often, participants stated that agencies use a screening tool or scale to assess nutritional status, while others perform a 24-hour dietary recall or, on occasion, a 3-day food diary. Patients and caregivers are taught daily nutrition and fluid intake needs. Some participants reported consulting a dietician or nutritionist to review the recorded dietary intake of patients with PU and nutritional risk and make recommendations for improving the patient's nutritional status. Others could request the staff dietician or nutritionist make a phone or home visit to perform a complete nutritional assessment and develop a plan for nutritional support. Respondents reported that the family's economic status often influences nutritional support. One respondent identified that when the patient must pay for the cost of the nutritionist's home visit, "[horizontal ellipsis]most patients choose not to go that route." Another respondent noted, "A big box of powdered milk is like $7, and some people say, well, I can't afford that. So trying to get enough calories in [horizontal ellipsis] is a hard thing." Participants also reported that persuading patients and caregivers to adhere to prescribed programs is challenging. Nutrition and hydration are monitored at each home visit.
Skin Care
Participants stated that patients and caregivers should be taught the importance of keeping the patient clean and dry, cleansing the skin at the time of soiling, and other strategies to manage moisture and prevent PU development. Cleansing the skin with plain warm water or nondeodorant, nonscented mild soap and applying a moisturizer to prevent dry skin were typically recommended by staff in the participants' agencies. Use of absorbent products for containment of incontinence, including reusable underpads and external collection devices in men with incontinence, was recommended. Application of a skin protectant was strongly encouraged; participants observed that Medicaid or Medicare sometimes covers the cost of a skin protectant, but these products must frequently be purchased without reimbursement from an insurance provider.
Participants identified the importance of assessing community resources for obtaining cost-effective supplies. One participant stated,
I think a big part [horizontal ellipsis] is knowing what resources you have in your community and what things are in neighborhoods. And so, you know, if I'm in an area of town, I can say, "Oh!! the Walgreen's has Vaseline for a dollar" and that kind of thing to help guide people to an area that's close to them where they can get things that are economical.
Interventions Unique to Home Health Care
The focus group discussion revealed several interventions for PU prevention in home health that are not included in currently available clinical practice guidelines (Table 3). Participants frequently assessed the patient's economic and third-party reimbursement status to determine options for obtaining supplies and devices to assist with PU prevention. They also stated that knowledge of resources within their practice communities is essential to PU prevention in the home health care setting, as is patient and caregiver willingness and ability to manage preventive care. In contrast to practice in acute or long-term care settings, participants agreed that home health care professionals must contact community groups and organizations to arrange for needed supplies and/or they refer patients to these community resources. Participants also reported the need to collaborate with health care vendors for donations of materials and supplies for PU prevention among selected patients.
Discussion
Based on our review of the literature, we believe this is the first published study to examine how PU prevention has been adapted for use in home health care. Results suggest that home health care staff implement an array of interventions to prevent PU that are similar to those recommended by clinical practice guidelines and commonly used in acute and long-term care settings. Results also suggest that health care professionals must adapt these interventions to the home care setting. This study found that activities to implement PU prevention interventions in home health care are clinically different from those performed in hospitals and nursing homes.
Partnering with patient and caregivers for PU prevention care is crucial to reducing PUs in home health care. For example, assessment of patient status is a shared responsibility between the home caregivers and the home health staff. In the acute and long-term care settings, skin and PU risk assessment are completed on admission and the skin of patients deemed at risk for ulceration is inspected daily thereafter by staff within these facilities.15,17 In contrast, focus group participants report that while professional staff assess PU risk and the skin on admission, follow-up assessment is completed in partnership with the patient and caregivers. The professional staff-patient and caregiver partnership is essential for continuity of care during the time staff are not in the home and fundamental to the goals of home health service that include maximizing patient and caregiver independence in caregiving.35 Nevertheless, the division of responsibilities between these partners for PU prevention requires clarification. Consensus surrounding when professional home health staff should inspect the skin rather than complete the assessment by monitoring the patient or caregiver report of skin integrity is needed. Studies should also establish the effectiveness of skin assessments completed by patients and caregivers relative to skin inspection performed by home health staff and patient and caregiver factors that may modify the reliability of their report. Moreover, validated tools must be developed to help patients and their caregivers accurately identify indicators of impending breakdown, especially in darkly pigmented skin. In addition, we suggest clinical practice guidelines acknowledge the partnership between the health care professional and patient/caregiver unit for skin assessment in home health care.
While participants agreed that regular assessment for PU risk and skin status is needed, they also reported variability in techniques used for evaluating risk on admission and implementation of prevention protocols. For example, home health care patients typically receive less frequent reassessment of PU when compared to patients managed in acute and long-term care settings. Some agencies reassessed PU risk only with completion of the OASIS for recertification of home health care or at other points in care when necessary to meet OASIS requirements. Bergquist and Franz36 evaluated 1711 patients receiving home health care services and found that 50% of the 108 patients who developed a PU did so within 24 days of admission. They further reported that nearly 75% of PU developed by day 62 of care. Data analysis also revealed that the Braden Scale performed on admission only identified patients who developed PU during the first week of home health care (70% sensitivity and 62% specificity). Based on these findings, they recommended that PU risk status in persons at risk should be assessed weekly for 4 weeks and every 2 weeks thereafter until day 62 when reassessment every subsequent 60-day recertification period may be sufficient. Alternately, Ayello and Braden37 suggested patient risk be reassessed with each home visit.
Participants may not have implemented these evidence-based recommendations due to difficulties tracking risk assessment scores within the electronic medical records. Revisions to OASIS in OASIS version C,33 released in early 2010, may ameliorate this tracking issue. OASIS C includes new questions on PU risk. However, scores from specific tools to risk such as the Braden Scale are not recorded. Moreover, the required intervals for completing OASIS C items may unintentionally lead to an assumption that PU risk need only be assessed when mandated by Medicare policy. Additional research and development of best practice guidelines addressing the frequency of PU risk assessment in the home setting are needed.
While participants argued that evaluation of nutritional status is essential for PU prevention in the home health care setting, they also observed differences in resources available for such assessments. Hospitalized and nursing home patients with PU and nutritional risk factors are typically referred to a registered dietician for a comprehensive assessment.12,13 In contrast, home health care agencies may not have a registered dietician on staff and patients may refuse a dietary consultation referral owing to associated costs. As a result, home health staff may be obliged to evaluate nutritional status and develop a plan of care without the level of support seen in acute and long-term care.
Strategies such as telehealth and Internet services may improve patient access to a registered dietitian in home health care agencies without one on staff. Expanded third party reimbursement to cover nutrition therapy services for home health patients with PU risk and nutritional risk may also facilitate use of these services. Alternately, we know little about the multidisciplinary team approach to nutritional assessment and support endorsed by clinical practice guidelines.12 Studies to examine the effectiveness of this approach in the home health setting are warranted including nurse and registered dietician or nutritionist consultations for patient nutritional assessment and support. Documentation of specific recommendations to improve nutritional status and discussions with the patient and caregivers are crucial to a preventive care program.
Study findings revealed clinically relevant differences in use of pressure redistribution surfaces. While the hospital or nursing home is financially responsible for acquiring and supplying the appropriate device,38 home health care patients with Medicare must meet established criteria for need before this cost is covered by Medicare Part B or a private insurance provider.39 In addition, the home health care agency is not responsible for supplying the appropriate product if the patient does not qualify for insurance coverage. Home health care staff often must encourage patients to pay for the device themselves or collaborate with health care vendors or other community resources to donate needed supplies. Since the use of a pressure redistribution surface is an essential component of PU prevention, we recommend that Medicare broaden Part B coverage to include home health patients deemed at risk based on OASIS C assessment.
Our study identified that PU prevention in the home health care setting requires consideration of economic resources and reimbursement issues, as well as patient and caregiver willingness and ability to manage preventive care in the home. Home health nursing responsibilities historically include care of the patient and concern for the health of all family members, and especially lay caregivers. The home health nurse also assists the family to manage resources needed to provide care, makes referrals, and collaborates with others for patient care.35 Our findings align with those of Henriksen and colleagues,40 who proposed a model for safety and high-quality home health care that depends on the consideration of available community services and resources, reimbursement guidelines, the nature of the home health care task, and patient and caregivers characteristics. According to this model, it is reasonable to expect that adverse events can be kept to a minimum when model components interact and function well together. Application of this model to PU prevention suggests that clinical practice guidelines should include directions for implementing the ancillary interventions important to home health care.
Limitations
Focus group participants were drawn from the eastern and midwestern United States; no participants from the southern or western United States were enrolled. Only one focus group with 9 participants was conducted, potentially limiting the range of responses anticipated from a more diverse sample. Further, the focus group technique relied on individual reports of performance rather than direct observation of home health care agency practice. Certified wound care nurses were recruited for the study, expecting they had knowledge of guideline recommendations for PU prevention. However, many agencies do not have a certified wound care nurse and practice in these agencies, which were not represented in the study, may be different from those reported.
Conclusion
Results of this study suggest that home health care staff employ an array of interventions to prevent PU that are similar to those recommended by clinical practice guidelines and employed in acute and long-term care settings. However, factors integral to home health care result in clinically relevant differences in the application of these interventions to patients in this setting. Preventive interventions unique to home health care included assessment of the patient's insurance and economic status to determine supply options, assessment of caregiving resources and caregiver ability to manage preventive care, and assessment and collaboration with community resources needed for materials and supplies for patients with limited resources.
KEY POINTS
Additional research is needed to determine how clinical practice guidelines on PU prevention have been adapted for use in home health care.
Results of this study confirm that PU prevention used in the home health care setting included those recommended by clinical practice guidelines.
Results of this study suggest that implementation of preventive interventions differed from those commonly used in hospitals and nursing homes.
Study findings also identified PU preventive interventions unique to the home health care setting.
ACKNOWLEDGMENT
This project was supported by grant R03HS017353 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.
References