People who suffer strokes enter the hospital with their skin intact. Whether they leave that way depends on how hard the staff works to make sure that an immobile or unconscious patient doesn't develop a pressure ulcer.
Pressure ulcers, or bedsores, cost the U.S. healthcare system about $1.3 billion every year. People develop bedsores in the hospital or nursing home; they don't normally arrive with them. With proper care, bed-bound or wheelchair-bound patients shouldn't be vulnerable to bedsores at all. Thus, it's the ultimate preventable affliction.
IPRO, the Medicare peer review organization in New York state, wants to educate healthcare workers to prevent bedsores. It has created a "tool kit" to pass around to hospitals and is holding conferences for nurses, all part of a comprehensive educational program. Funding comes from HCFA.
"Our nation's $1 billion bedsore burden is created in a clinical setting and can be prevented in a clinical setting," says Mary Hibberd, M.D., IPRO's senior medical director.
To get the project started, IPRO sent letters to hospitals in New York inviting them to participate. Sixty-seven hospitals enlisted. IPRO then analyzed Medicare Part A data from 1994 to construct a baseline. It examined 1,253 patient records of admissions with cerebral bleeds, or strokes.
Certain patients have higher risk of developing bedsores than others, and stroke victims top the list. People who have suffered strokes may be paralyzed on one side of the body and unable to roll over or walk or sit up. They may be incontinent as well.
And they come into the hospital without bedsores, yielding the "cleanest baseline" for statistics, Hibberd says.
The baseline showed that risk assessments were carried out in just 56% of cases, when 88% of cases were at risk. Of those who did receive an initial risk assessment, 38% got a reassessment. Every at-risk patient should have had a follow-up assessment. Caregivers intervened with pressure relief in 27% of cases.
A severe bedsore extends the patient's time in the hospital and requires "an incredible amount of staff time" before it heals, Hibberd says. An ulcer that goes all the way to the bone takes four to six months to heal. Total costs can easily be upward of $50,000.
Hibberd used to work with a skilled nursing facility. "We would get patients back from the hospital all the time (with ulcers). Patients go into the hospital without a pressure ulcer and come back with a pressure ulcer," she says. The financial obligation to treat it falls on the nursing home.
IPRO's tool kit includes self tests, diagrams on prevention and treatment, posters and a slide show for teaching. Plus, it includes guidelines from the Agency for Health Care Policy and Research, part of the Public Health Service, on how to prevent and predict pressure ulcers.
IPRO asks participating hospitals to draw up quality improvement plans based on their weaknesses shown in the initial assessment. "Some may be poor at repositioning; some may be poor at skin care," Hibberd says. "We look it over. We give them suggestions."
IPRO will give the hospitals and nursing homes six to 12 months to change their practices; then it will do a second measurement. Those are scheduled for the end of this year.
IPRO, based in Lake Success on Long Island, found a willing collaborator in Winthrop-University Hospital, in nearby Mineola. Barbara Scharf, a registered nurse, runs Winthrop's home health agency. Winthrop conducted an ulcer-prevalence study with Hill-Rom, a maker of durable medical equipment.
"We used the AHCPR guidelines to develop pressure-ulcer treatment protocols specific to our agency," Scharf says. "When it came time to present and educate the staff about protocols and wound-care practices, we used the kit-the teaching materials, posters and slide show."
On June 17 about 75 nurses and other caregivers visited the home-care agency for a pressure-ulcer education day. The IPRO tool kit was "wonderful," Scharf says. "We could focus our attention on getting the message to the nurses rather than go back to square one and research the best practices."
The survey Scharf did with Hill-Rom covered 420 agency patients, 31 of whom had bedsores. That's a baseline rate of 7.4%. Hill-Rom's national bedsore rate was 7.3%, she says.
Nurses loved the program, especially the self-learning format, she says. Also invited were 15 wound-care and moisture-control vendors, which demonstrated their products.
"This was the first step in the education," she says. "Now we have to do some more group teaching, then get more field visits and chart reviews to make sure the nurses are absorbing the new information."
The Winthrop agency intends to repeat the survey in a year or two to gauge improvement. At the HCFA regional office in Boston, which oversees the New York PRO, there's considerable excitement about this project, especially the way it fosters continuous quality improvement in the hospital.
"It's not just the tool kit," says Doris West, branch chief in the division of clinical standards and quality. "Also they're having periodic phone calls among the hospitals so they can share things. The PRO (staff are) making themselves available."
She and medical officer Diana Ordin, M.D., say they are especially pleased that so many hospitals are collaborating on the bedsore study. It's unusual to get so many participants in a statewide project, they say, and that will provide more credibility.
If the remeasurement later this year shows the kind of results they're hoping for, the project design would be a good candidate for dissemination to other states, West and Ordin say.