Abstract

OBJECTIVE: This survey was conducted to assess the presence of skin ulcers within a home health agency population in the United States.

DESIGN: This voluntary survey was conducted by 177 home health agencies. A single observation of each patient within the agency's active caseload formed the cohort examined. Patients deemed to be at low risk (Braden Scale score >19) were eliminated from further evaluation, while those with skin ulcers were evaluated for wound- and caregiver-related factors. Surveys were conducted between March 1, 1996, and December 31,1997.

SETTING: Home health agencies in 19 states throughout the United States, with no restrictions on the type or acuity of the patients served.

RESULTS: A total of 21,529 patients were surveyed, with a prevalence of pressure ulcers (inclusive of all stages) of 6.8% (n = 1455). Rates for each agency ranged between 0.5% and 35.7%. The total number of ulcers reported was 2526 (average per patient was 1.7), with 36% (n = 919) found on the sacrum and the buttocks.

CONCLUSION: Pressure ulcers were the most frequently reported reason for admission to the agency's caseload. Survey results are similar to rates reported in other segments of the health care industry. However, among the home health care population, the primary caregiver is unlikely to be a health care professional. This survey found that the patient's spouse was the primary caregiver in 30% (n = 437) of the 1450 responses received regarding the relationship of the primary caregiver to the patient.

ADV WOUND CARE 1999;9:459-67

SINCE THE INTRODUCTION OF THE Prospective Payment System in the early 1980s, health care in the United States has experienced a fundamental shift toward wellness management and a move away from illness intervention as the primary focus of care. Management of chronic illnesses, patient and family education, and postacute care are now routinely provided through home health agencies (HHAs). In 1997, the National Association for Home Care estimated that more than 20,000 providers delivered home health care services to 7 million patients, with an annual cost of more than $42 billion.1 That approximation represents an 18-fold increase since 1963 in the home health care segment of the US health care system.

Home health agencies provide services that span a wide variety of acuity, serving individuals requiring skilled nursing support for acute illnesses as well as for those needing assistance with activities of daily living (ADLs). The primary diagnosis most frequently cited (26.6%) for home health care patients in a 1994 National Home and Hospice Care Survey was diseases of the circulatory system. I In 1987, nearly half of the patients receiving home health care services were over age 65. The survey also found that approximately 40% of all home health care recipients had functional limitations in I or more ADLs, suggesting a diminished level of mobility among this population.' Such factors signal increased risk for pressure ulcers, yet little is known about the prevalence or incidence of pressure ulcers in the home environment.

Since 1989, Hill-Rom has coordinated several pressure ulcer prevalence surveys. These surveys have provided a framework for health care facilities to conduct benchmark assessments of their own pressure ulcer prevalence, allowing them to institute improvement programs. This paper reports data from the home health care portion of the prevalence surveys.

Literature Review

A community-based survey of pressure ulcer prevalence and incidence was conducted by Oot-Giromini in 1993.2 This convenience sample of 103 home health care subjects in Broome County, NY, demonstrated a pressure ulcer prevalence rate of 29% (n = 30). The majority (45%, n = 19) of the 42 ulcers found were Stage 11 (1.4 per person). The mean age of those found to have ulcers was 76 years.2

Barczak et al published results of the Fourth National Pressure Ulcer Prevalence Survey in July 1997,3 detailing pressure ulcer prevalence in acute care. Table I summarizes the results of that survey, as well as the results of a prevalence survey conducted by Hill-Rom in long-term-care facilities (unpublished data).

Methodology

Participation in the pressure ulcer prevalence surveys was voluntary. One hundred seventy-seven HHAs in 19 states participated (Northeast, n = 4; West, n = 4; South, n = 8; and Midwest, n = 3). The average number of patients served by HHAs included in this survey was 12 (.63 per branch, with an average of 10 branch offices per HHA. The majority of HHAs in the US report between 101 and 300 visits per week.1

Home health agencies that participated in these convenience sample prevalence surveys received extensive training in conducting and recording the results of their observations using the provided data collection instrument. Sample patients were presented in a narrative form during the in-service training sessions. This tool was used to validate each nurse's comprehension of the discrete fields of the Scantron form. That form, consisting of 2 sides with a total of 24 fields, comprised the data collection instrument for all prevalence surveys reported in Table 2. All active cases admitted no later than the first day of data collection were included in the initial risk assessment for the presence of pressure ulcers. Assessment was completed on the entire caseload of each participating HHA by trained prevalence survey nurses. This took an average of 30 days.

Pressure ulcers were defined as "any lesion caused by unrelieved pressure resulting in damage of underlying tissue, usually found over bony prominences" (Hill-Rom study methodology, unpublished). All patients of the participating HHAs were assessed using the Braden Scale.4 The Scantron form also allowed the HHAs to record the score from any routinely used risk assessment tool for the purpose of internal scoring outcomes. Only the Braden Scale score, however, was used for computing the risk assessment level of participating patients in this study. Scores were recorded on Side 2 of the Scantron form, regardless of ulcer status, establishing the denominator for the prevalence calculation. Patients deemed at low risk for pressure ulcers (Braden Scale score >19) were then eliminated from any further assessment. For those patients assessed to have ulcers, Side 2 of the form was then completed and included caregivers in the household, the patient's continence status, history of recent hospitalizations (within the past 6 months), Braden and non-Braden risk assessment scores (if applicable), type of support surface utilized, stage and location of existing pressure ulcers, and type of topical management being used for each wound.

Side I of the Scantron form was completed only for those patients who had at least I pressure ulcer. Side I captures demographic, nutritional, and wound documentation information and diagnosis data. A designated nurse within each HHA collected these data elements through retrospective chart review. Classification of the origin of ulcers documented during the survey was based on chart review of admission skin status for those patients found to have ulcers. The pressure ulcer staging system used for the survey was devised by the National Pressure Ulcer Advisory Panel (NPUAP) and adopted by the Agency for Health Care Policy Research (AHCPR).5

Two additional wound description options-Stage V and Stage VI-were provided to allow further delineation of observed ulcers, based on presenting characteristics. Stage V was used to capture ulcers that presented with an eschar covering and were therefore unstageable. Stage VI was used for wounds that were neither hyperemic nor covered with eschar. The ecchymotic designation was defined to include those wounds that presented with visible hemorrhagic damage but with intact skin. In participating HHAs, the standard was to complete physical assessments within 24 hours of admission and included the determination of the presence of any manner of skin breakdown. If ulcers were not included in documentation within 24 hours of admission, they were considered nosohusial6 (ie, acquired in the home, not in the community or hospital) in origin. In-service instructions for completion of Side I of the Scantron form were provided to designated individuals within the HHA responsible for completing the data fields.

The Scantron form design, consistent with the approach taken in both the longterm care and acute care prevalence surveys conducted through Hill-Rom, provides for information to be recorded on wounds found only over bony prominences. This form design feature is utilized to reduce the potential artifact of including wound data for ulcers that are not principally influenced or caused by pressure. Although other ulcers may appear over bony prominences, such as diabetic and arterial ulcers, they are most likely to have had pressure as a significant factor in their development.

After completion of Side 2 by the visiting nurses within each HHA, the forms were submitted to another designated nurse within each HHA for completion of Side I for those patients found to have 1 or more ulcers. After completion, the HHAs submitted the Scantron forms to Hill-Rom for data calculation and report preparation. The total number of patients assessed for this survey form was the denominator for calculations used to define the period prevalence of pressure ulcers reported here. The results include all reporting agency findings for studies conducted between March 1, 1996, and December 31, 1997. Agencies were able to report the prevalence of pressure ulcers among their entire caseload within an average of 30 days, conducting assessments for each patient during a regularly scheduled home visit. Once a patient was assessed and a Braden Scale score determined, no additional or follow-up assessments were conducted for the purposes of this survey. Each HHA that conducted a prevalence survey was provided a written summary of the results.

Results

In 1995, a wound care quality improvement program that included a structured methodology for conducting pressure ulcer prevalence surveys in home health care was established by Hill-Rom. To date, a total of 207 HHAs with more than 26,000 patients have participated in home health pressure ulcer prevalence surveys. For purposes of the present report, data collected before March 1996 have been excluded from analysis because of changes made to the Scantron data collection instrument. This study, therefore, includes results from 177 HHA branches and reports the prevalence among a total of 21,529 patients.

Table 2 presents summaries of the pressure ulcer prevalence surveys conducted between March 1, 1996, and December 31, 1997. Prevalence is defined as "the number of cases of a disease present in a population at one point in time,"7 and for this report includes skin breakdown over bony prominences and other vulnerable skin surfaces exposed to excessive pressure. The point in time for this project included I observation for each active case of each participating HHA, with an average of 30 days per agency. Assessment of the body surfaces described above was completed by participating HHA visiting nurses during routine visits to all agency patients. This period prevalence generally was completed within a 30-day time frame (range 25 to 30 days) for all 177 participating HHAs.

The pressure ulcer prevalence, inclusive of all stages of ulcers for the 21,529 patients assessed, averaged 6.8% (n = 1455), with a range between 0.5% to 35.7% for the individual participating HHAs. The average prevalence rate among all participating HHA branches was 5.4% (n = 1169) when Stage I ulcers and hyperemia were excluded. The average number of ulcers per patient assessed by this survey was 1.7; when hyperemia was excluded, the number fell to 1.6. The majority of individuals assessed to have ulcers (59%, n 856) were women, and most (79%, n 1156) were found to be over age 65. Pressure ulcer was the primary reason for admission for 381 (29%) of the 1324 patients for whom a basal diagnosis was known. The greatest percentage of ulcers occurred on the sacrum and the buttocks combined (36% of the 2526 ulcers identified, n = 919). Stage II ulcers presented most frequently, representing 36% (n = 918) of the total (Table 3).

The assessment of ulcer origin indicated that a total of 35% (n = 878) of all ulcers found were nosohusial and reported to have occurred after admission to the HHA, The remaining 65% (n = 1648) of ulcers were charted as being present on admission to the HHA. The most frequent sites for nosohusial ulcers were the buttocks (44%; 195 of 443 ulcers documented for the site). The sacral nosohusial ulcers represented 36% of ulcers documented for the site (173/476).

A variety of interventions were used to manage all stages of pressure ulcers (Table 4). Evaluation of the use of therapeutic support surfaces revealed that a total of 28% of patients with skin breakdown (n = 402) were on some form of pressure-reducing device. Of the 126 patients on specialty beds-including air fluidized, low-air loss, and lateral rotation-73% (n = 93) had full-thickness Stage III or Stage IV ulcers.

All home care patients included in the pressure ulcer prevalence survey were evaluated for level of risk for skin breakdown using the Braden Scale. The Braden Scale score ranges used for reporting this analysis were based on the findings of Ramundo in a study evaluating the reliability and validity of the Braden Scale in the home setting.9 Scores between 6 and 12 were defined as high risk; scores of 13 to 14 were moderate risk; scores of 15 to 16 were low risk; scores of 17 to 18 were considered a possible risk for pressure ulcers; and scores between 19 and 24 were considered not at risk. The overwhelming number of individuals evaluated-15,161 (70%)-were found not to be at risk for pressure ulcers, with Braden Scale scores between 19 and 23. Of those patients, 3% (n = 462) were found to have ulcers. Of the remaining patients, 12% (n = 2503) scored in the low-to moderate-risk range (risk scores between 13 and 16), and 2% (n = 419) presented with ulcers. A total of 13% (n = 2738) of patients scored in the possible pressure ulcer risk range (scores between 17 and 18), and 9% (n = 222) of this group presented with skin breakdown. Patients assessed to be within the high-risk range (5%, n = 1127) included 352 (31 %) with pressure ulcers (Figure 1).

Among patients with pressure ulcers, 38% (n = 563) were found to be incontinent of both urine and stool, 20% (n = 296) were incontinent of urine only, 3% (n = 43) were fecally incontinent only, and 39% (n = 563) were fully continent. Responses regarding diagnosis were received on 1324 (91%) of the 1455 patients found to have pressure ulcers. The primary reason for admission of those patients to the participating HHAs was, not surprisingly, pressure ulcers. Diabetes mellitus was recorded as a coexisting condition in 278 (9.6%) of the 2904 coexisting conditions listed on individuals found to have skin breakdown (Figure 2).

Among patients for whom the information was recorded (1450), 30% (n = 437) of those with ulcers had their spouse/partner as their primary caregiver. Responses were received from 95% (n = 1376) of the pressure ulcer population regarding age of the identified caregiver population: 62% (n = 859) were over age 50.

Discussion

The evaluation of pressure ulcers within the home health care setting is becoming increasingly important for planning, education, and determination of effective early intervention measures. Home health agencies, like their acute care counterparts, need benchmarking information in order to assess areas of focus required to maintain the highest standards possible. The barriers presented in trying to determine pressure ulcer prevalence among a geographically diverse population, using multiple data collectors, are significant. The results presented here are the product of a methodology developed to facilitate survey performance in concert with the ordinary routine of visiting nurses. This approach resulted in a modification of the standard definition of prevalence as defined above. The prevalence surveys reported here include information on the presence of pressure ulcers within a finite period of time, usually 30 days, for each of the 177 HHAs that collected data between March 1996 and December 1997.

Although the data collection instrument was designed to record data on wounds found predominantly over bony prominences, definitive diagnosis of ulcers as pressure-related is not possible. To reduce the risk of reporting ulcers with a different primary origin than unrelieved pressure, surveyors excluded skin breakdown found over non-bony skin surfaces that were not likely to have been exposed to excessive amounts of pressure and other physical forces such as shear, friction, and maceration. This survey focused on capturing those ulcers that, at a minimum, have pressure as a mitigating factor to healing. For those ulcers recorded in this study that may in fact have co-morbidities such as vascular disease, diabetes, or others, the distinction has significance primarily in designing interventions and treatment.

Information related to topical management of the reported ulcers indicated a lack of standardization related to the approaches taken for the various stages and conditions of ulcers. Hydrocolloid dressings represented the most frequently used form of topical management. A total of 17% (n = 433) of ulcers of all stages, including Stage I (n = 105) were managed with this category of dressing. A surprising finding was that no topical management of any kind was reported for 15% (n = 370) of all reported pressure ulcers, including 8 (1%) full-thickness Stage III and Stage IV ulcers.

The AHCPR pressure ulcer treatment guideline recommends that the treatment of existing pressure ulcers include use of dressings that keep the ulcer bed continUOUSly MoiSt.5 For those ulcers with existing necrotic or unhealthy tissue, the guideline recommends that some form of debridement and cleansing be instituted in order to establish a healthy wound bed for healing. However, the lack of treatment or dressings for some heel wounds is consistent with recommendations made by AHCPR.5

The findings from this survey indicate that pressure ulcer education updates on pressure ulcer management could be beneficial for HHA personnel. The results demonstrate that the majority of ulcers being treated in the home (65%, n = 1642) were present upon admission to the agency. The continued compression of acute care admissions into increasingly shorter lengths of stay would imply that the acuity of ulcers to be managed outside the hospital and in the home will increase. Consistent and effective management of pressure ulcers within the home care segment of the industry must be prioritized in order to achieve an overall reduction in prevalence, incidence, and severity of ulcers.

The finding that pressure ulcer management was the most frequent reason for admission to the HHA among patients with pressure ulcers requires further evaluation. It may be more closely associated with the need to manage an immediate clinical problem than with the identification of any underlying chronic conditions. A 1994 survey found the most frequent diagnostic category (26.6%) of current HHA patients for admission diagnosis was diseases of the circulatory system.' Their presence creates a risk factor for pressure ulcers as well as for arterial and venous ulcers.

A total of 177 HHAs, with an average of 25 to 30 visiting nurses per agency, participated in the pressure ulcer prevalence surveys reported here. This number presented a formidable task in achieving uniformity in data reporting. Given both geographic and timing variables among the surveys conducted by different HHAs, no formal testing of interrater reliability was feasible. However, every participating agency underwent the same in-service training for use of the data collection instrument; use of the Braden Scale; ulcer recognition; and the procedural rules of the prevalence surveys. Return demonstrations of sample patient scenerios were included in each survey in-service.

Support of clinical and quality improvement efforts throughout the health care industry is an important goal. It is hoped that monitoring and reporting the prevalence of pressure ulcers within the growing home care segment will focus future education, funding, and support efforts throughout the health care industry.

Implications

As previously stated, little information exists in the literature to describe the acuity or types of medical management issues that dominate the home health care setting. This study was conducted to contribute to a body of knowledge about the issues facing the home health community. Projecting the pressure ulcer prevalence rate found among the 177 agencies in this survey suggests a national pressure ulcer population among HHAs totaling some 406,000 patients. Many of these patients may not be receiving appropriate management and/ or have a definitive diagnosis of ulcer causation. Difficulties associated with a changing reimbursement environment for home health services are likely to exacerbate this problem, making management options more difficult to achieve. Pressure ulcers, as well as other chronic ulcers, are not likely to be resolved within an acute care environment; instead, the recognition, diagnosis, and determination of management protocols will take place primarily in the subacute environment. The assessment skills of the home health nurse must include the ability to accurately assess, describe, and report skin breakdown.

Development of treatment algorithms based on both medical diagnosis and treatment goals must be available to home health nurses. The AHCPR pressure ulcer treatment guideline4 offers a significant foundation upon which specific care plans and algorithms can be devised. However, more research and focus must be brought to bear in order to adequately manage and prevent skin breakdown throughout the health care continuum. Continued participation in agency-specific and multiagency prevalence studies to track the presence and severity of skin breakdown offers a too] for monitoring quality improvement initiatives.

References

1. National Association for Home Care. Home care basic statistics. Washington, DC: National Association for Home Care; 1997. p 1- 12.

2. Oot-Giromini BA. Pressure ulcer prevalence,

incidence, and associated risk factors in the community. Decubitus 1993;6(5):24-32,

3. Barczak CA. Fourth National Pressure Ulcer Prevalence Survey. Adv Wound Care 1997; 10(4):18-26.

4. Bergstrom N, Demuth PJ, Braden BJ. A clinical trial of the Braden Scale for Predicting Pressure Sore Risk. Nurs Clin Nor Am 1987;22:417-28.

5. Bergstrom N, Bennett MA. Carlson CE. et al. Treatment of pressure ulcers. Clinical Practice Guideline, No 15. AHCPR Publication No 95-0652. Rockville MD: Agency for Health Care Policy and Research; December 1994.

6. Graham DR. Nosohusial infections: complications of home intravenous therapy. Infectious Diseases in Clinical Practice 1994;2:158-61.

7. Dorland's illustrated medical dictionary, 28th ed. Philadelphia, PA: WB Saunders Company: 1994; p 1351.

8. Ramundo JM. Reliability and validity of the Braden Scale in the home care setting. J Wound Ostomy Continence Nurs 1995;22:128-34.

Marge Meehan, RN, MIM, Lucy O'Hara, RN; and Yolanda M Morrison

Marge Meehan. RN, MIM, is Vice President of Healthcare Concepts, Inc, Annapolis, MD. Lucy O'Hara, RN, is Clinical Services Manager, Home Care Division, and Yolanda M Morrison is Prevalence Coordinator at Hill-Rom, Charleston. SC. The data presented in this paper are from a study sponsored by Hill-Rom. Submitted May 19, 1998: accepted in revised form January 25, 1999.