LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

Tag 314 309 Quality of Care Part 6 Pressure Ulcer Infections





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    Current literature reports that all Stage II, III, and IV pressure ulcers are colonized with bacteria but may not be infected. Identification, diagnosis and treatment of infection, when present, are critical to healing a pressure ulcer.38 The infection occurs when the bacteria have invaded the tissue surrounding or within the pressure ulcer. As with any infection, classic signs and symptoms of infection may include purulent exudate, peri-wound warmth, swelling, induration or erythema (erythema may not be readily determined in individuals with dark skin pigmentation),
    increasing pain or tenderness around the site or delayed wound healing. These classic signs may not be as evident in someone with a granulating, chronic wound or an immuno-compromised or aged resident. Some infections may present primarily with pain or delayed healing without other typical clinical signs of infection.39 Clinicians have developed some tools, which may facilitate identifying and assessing an infection40, 41 and documenting progress toward healing.
    Wounds may be classified as infected if the signs and symptoms of infection are present and/or a wound culture (obtained in accord with accepted standards, such as sterile tissue aspirate, a “quantitative surface swab� using the Levine technique or semiquantitative swab) contains 100,000 (105) or greater micro-organisms per gram of tissue. A superficial swab may show the presence of bacteria, but is not a reliable method to identify infection. Findings such as an elevated white blood cell count, bacteremia, sepsis, or fever may signal an infection related to a pressure ulcer area or a co-existing infection from a different source.
  • PAIN
    The assessment and treatment of a resident’s pain are integral components of pressure ulcer prevention and management. “The goal of pain management in the pressure ulcer patient is to eliminate the cause of pain, to provide analgesia, or both.�42 Pain that interferes with movement and/or affects mood may contribute to immobility and contribute to the potential for developing a pressure ulcer or for delayed healing or nonhealing of an already existing ulcer. It may be difficult to assess the degree of pain in a resident who is cognitively impaired. Some strategies and tools exist to help determine the presence and characteristics of pain (e.g., nature, intensity and frequency).43, 44 Recent research suggests that a resident with a Stage IV pressure ulcer can feel as much pain as those with a Stage I or II ulcer.45 The relationship of pain to the pressure ulcer healing process is not yet clear. Pain is an individual perception and response and an individual’s report of pain is a generally valid indicator of pain. One resident may experience pain of varying intensity and frequency (e.g., continually or periodically) or episodically in association with treatments (e.g., debridement, dressing changes) or movement or infection, while another resident may not have or report pain.
    Research has found that chronic wounds such as pressure ulcers heal differently from acute wounds, primarily because of differing biochemical and cellular characteristics. Current clinical practice indicates that Stage III and Stage IV ulcers should be covered. Determination of the need for a dressing for a Stage I or Stage II ulcer is based upon the individual practitioner’s clinical judgment and facility protocols based upon current clinical standards of practice. No particular dressing promotes healing of all pressure ulcers within an ulcer classification.46
    For those pressure ulcers with significant exudate, management of the exudate is critical for healing. A balance is needed to assure that the wound is moist enough to support healing but not too moist to interfere with healing.47 Since excess wound exudate generally impairs wound healing, selecting an appropriate absorptive dressing is an important part of managing chronic wound exudate.
    Product selection should be based upon the relevance of the specific product to the identified pressure ulcer(s) characteristics, the treatment goals, and the manufacturer’s recommendations for use. Current literature does not indicate significant advantages of any single specific product over another, but does confirm that not all products are appropriate for all pressure ulcers. Wound characteristics should be assessed throughout the healing process to assure that the treatments and dressings being used are appropriate to the nature of the wound. Present literature suggests that pressure ulcer dressing protocols may use clean technique rather than sterile, but that appropriate sterile technique may be needed for those wounds that recently have been surgically debrided or repaired.48
    Debridement of non-viable tissue is frequently performed to reduce the amount of wound debris or non-viable tissue and to reduce the risk of sepsis. A variety of debridement methods (e.g., mechanical, sharp or surgical, enzymatic, autolytic, MDT) are available. Removal of necrotic tissue should enhance wound healing. Ongoing monitoring (and timely intervention in case of change in the character of the wound) is critical for areas with eschar and those areas that have been debrided.49 Many clinicians believe that stable, dry, adherent and intact eschar on the foot/heel should not be debrided, unless signs and symptoms of local infection or instability are detected.50 Some facilities may use “wet to dry gauze dressings� or irrigation with chemical solutions to remove slough. The use of wet-to-dry dressings or irrigations may be appropriate in limited circumstances, but repeated use may damage healthy granulation tissue in healing ulcers and may lead to excessive bleeding and increased resident pain. A facility should be able to show that its treatment protocols are based upon current standards of practice and are in accord with the facility’s policies and procedures as developed with the medical director’s review and approval.
    (For more information on the references below, visit the CMS Sharing Innovations in Quality website: www.cms.hhs.gov/medicaid/survey-cert/siqhome.asp.
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