Catching It In Time

More than one million people are afflicted with bedsores in United States' hospitals each year, according to the National Decubitus Foundation. The scope of this problem only magnifies when at-home and nursing home patients are added to this figure.

Pressure ulcers can be painful, serious and costly. The cost of bedsores in hospitals reaches into the billions each year, and the number of patients afflicted with bedsores is expected to rise as the population ages. For the elderly, pressure sores can be a life-threatening condition if untreated.

Fortunately with the right education and the right products pressure ulcers are largely preventable. In cases where a pressure ulcer forms, if the patient has the right product the pressure ulcer does not have to get worse. By providing adequate information and a variety of products to consumers, home medical equipment (HME) providers of support surfaces have an important objective in helping to eradicate the problem of pressure sores.

Yet it is not a simple task. Many people do not realize the potential severity of developing a pressure ulcer, and many do not know what products are available until a pressure sore has already developed. HME providers work to educate consumers about products for both the prevention and treatment of pressure ulcers. They also educate physicians, nurses and end-users regarding what product is most applicable in each individual situation.

"When someone has a pressure sore or multiple pressure sores it is very serious, and it is something that should be taken care of immediately," said Ron Resnick, president, Blue Chip Medical, Suffern, N.Y. "Anything we can do, and that is anybody, to prevent pressure sores with quick intervention is urgent without question."

Blue Chip Medical manufactures many support surfaces including alternating air-floatation mattresses, alternating pressure pads and pumps, low air-loss mattress systems, gel mattresses and overlays, static-air mattress overlays, and water mattress overlays.

Pressure ulcers - also referred to as decubitus ulcers, bedsores, pressure sores and dermal ulcers - are an injury usually caused by unrelieved pressure that damages the tissue and the underlying skin. Since they can range in severity from skin reddening to severe craters down to the muscle and bone, having the right products is critical to prevent bedsores from developing.

"When someone has a pressure sore or multiple pressure sores it is very serious, and it is something that should be taken care of immediately," said Ron Resnick

"It is preventable in most cases and treatable if intervention is quick. Like anything else, if you let something go too long, it will fester and become very costly," Resnick said.

Although pressure ulcers can occur at any age the elderly are more susceptible, and prevention can be critical for older patients. Most patients are in their 70s and 80s, according to the National Decubitus Foundation. For these patients pressure ulcers can lead to longer stays in nursing homes, hospitals or slower recovery from health care problems.

Marketing Prevention

With more patients opting to remain at home, at-home patients who are bed or chair confined may not be aware of the risk of developing pressure ulcers especially if a nurse or caretaker only visits once a week. If they are not informed of the risk factors and the importance of preventing bedsores, the risk of development increases. Those providing at-home care need to inform patients of risk factors and the products that are available for prevention.

"Let's face it, anyone who is bed ridden is somewhat susceptible, but it depends on their skin condition, their physical make-up, there are a lot of contributing factors, definitely someone spending a lot of time in bed with circulation problems, that would point to that person being at risk for a skin breakdown," said Jim Westfall, director of product management for Graham-Field, Bay Shore, N.Y. Graham-Field manufactures gel overlays, low air-loss mattress systems and alternating pressure mattress systems.

Since prevention is such an important market for support surface companies in terms of patient health, it also expands the customer base. HME providers market to patients with existing pressure ulcers, but they also market to at-risk patients who do not yet have bedsores.

Many factors are known to be associated with the risk of bedsore development such as advanced age, immobility, poor nutrition, poor circulation, respiratory problems and incontinence. Anyone confined to a bed or wheelchair due to illness or injury or anyone supported in a manner where there is obstruction of blood flow can get pressure ulcers.

"It not only adds a large market for us, but the prevention of pressure ulcers is an essential piece of health care," Westfall said.

Reaching customers who are at risk for the development of pressure ulcers is beneficial for all involved. HME providers sell more products and provide a valuable service to the end-users. And billions of dollars spent on health care costs could be largely reduced through education and the correct usage of support surface equipment.

"One of the problems of pressure sores is that it is costly to treat because in addition to the mattress or whatever product they are using as a source to reduce interface pressure and that is the pressure between the patient and the surface of the skin, is all the dressings, cleanings and debrevement and the nursing care that is necessary to do the job," Resnick said. "It can reduce pain and suffering and reduce costs down the road to have these products at a preventative stage."

Pressure Ulcer Intervention

"The National Pressure Ulcer Advisory Panel (NPUAP) Reston, Va., is an organization working for the prevention and management of pressure ulcers. Formed in 1987, the NPUAP includes a board of directors of health care professionals who educate and work with professionals, government, the public and health care agencies to reduce the incidence and prevalence of pressure ulcers.

Supported by corporations, the NPAUP works with the Health Care Financing Administration (HCFA) to improve the quality of pressure ulcer care and with other organizations to bring quality of care issues to Congress. In addition, NPUAP collaborates with the Centers for Disease Control and the Healthy People 2010 Consortium - a national health promotion and disease prevention initiative - to collect data and disseminate information.

Healthy People 2010 builds on initiatives pursued during the past 2 decades and NPUAP is a part of the initiative, working to decrease the number of patients afflicted with pressure sores.

Treatment Options

In order to prevent pressure ulcers from occurring those at risk need to be aware of the products that are available and they need to know the right questions to ask. HME providers use pamphlets, newsletters and Web sites to educate consumers.

A systematic risk assessment can be accomplished by using a validated risk assessment tool such as the Braden Scale or Norton Scale. Pressure ulcer risk needs to be reassessed periodically.

Resnick said it is important for the providers to be proactive and go directly to the referral source, the physicians, case managers or nurses who will be recommending the products to the end-user.

"It is best to go to the bottom line of who is caring for the patient," Resnick said.

Since these products are prescribed by physicians, the physicians and nurses need to know the products that are available and how they are most effectively used. Alternating pressure pads and pumps and gel overlays are typically prevention products. Full replacement mattresses are used for treatment.

Using an alternating pressure therapy mattress is good as a first step, for prevention or for early intervention of a bed sore. For someone with an existing or severe pressure sore an alternating/low air loss mattress is used for treatment. Resnick said that whenever a mattress includes both low air loss and alternating therapy the patient has the benefits of both.

Blue Chip Medical develops products that combine clinical requirements with patient needs. Resnick said they continually improve quality and make their products user-friendly.

Blue Chip Medical offers the Supreme Air, a full replacement mattress with an alternating air floatation system that includes clinical requirements and features that consumers' request, Resnick said.

With home being the environment of choice for many patients, support surface companies are answering that need with products specifically for that market.

"The dealer can now provide many therapies at home that used to only be provided at hospitals by making products that are more portable," Resnick said.

HME providers work to educate consumers regarding what support surface products are best for each situation.

"Dealers need to let the referral source understand and know the difference between products and why one would be better for a patient than the other," Westfall said.

Most providers have a nurse or a wound care specialist on their staff. Resnick said many companies have one or two nurses on staff or per diem who do home assessments, or visiting nurses who make home visitations to determine the effectiveness of the product.

Reimbursement

Support surface products are typically covered under Medicare and coded by the Health Care Financing Administration (HCFA) Common Procedure Coding System (HCPCS) under Group 1, 2, or 3. Each group has different guidelines based on the severity of the condition and includes different support surface products. Medicare is specific in its guidelines of selecting a support surface product.

Patients are assessed to determine the stage they are classified under according to the severity of their condition. According to the Supplier Manual of the Region C Durable Medical Equipment Regional Carrier (DMERC) the stages are as follows:

  • Stage 1: nonblanchable erythema of the skin
  • Stage 2: partial thickness skin loss involving epidermis or dermis
  • Stage 3: full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia
  • Stage 4: full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle bone or supporting structures.

The stage that a patient fall under determines if the patient is eligible for products under Group 1, 2, or 3. Medicare Part B applies to patients who are eligible for home health care services but not to patients in acute, long-term or hospice care. Although covered under Medicare, costs can be reduced if timely treatment or preventative treatment is implemented.

"If prevention products were left to cash pay very few people would be using them, verses if prevention type products are covered through funding sources like Medicare, private insurance, managed care, they are helping to control their cost by not having to pay the big bill when it comes time when someone gets a breakdown," Westfall said.

Prevention is essential to cut health care costs.

"It is much more expensive for funding sources, Medicare, private insurance, HMO's and all the managed care organizations to have to pay for treating pressure sores then it would be if they had prevented it in the first place," Westfall said.

Although saving costs is beneficial, more importantly, the products have a significant impact on quality of life.

"A person does not want to get a skin breakdown and if we have funding sources that can prevent it, that is a win/win situation. It keeps the patient from getting a pressure ulcer and to improve and maintain quality of life, while keeping the funding sources from having to spend a lot of money to treat an existing wound," Westfall said.

A misconception that many consumers have is that pressure ulcers is a normal part of aging when it does not have to be. In 20 to 30 years the number of patients with pressure ulcers is expected to rise due to the aging population but with the right education and the right products, this increase could be avoided and quality of life could be improved.

NPUAP promotes educational programs directed at all health care providers in its efforts to decrease the numbers of patients afflicted with pressure ulcers. The following are Care By Risk Factors provided by NPUAP:

Risk Factor Preventative Actions
Bed or Chair Confinement

Inspect skin at least once a day

Bathe when needed for comfort or cleanliness

Prevent dry skin

For a person in bed:

Change position at least once every two hours

Use a special mattress that contains foam, air, gel or water

Raise the head of the bed as little and for as short a time as possible

For a person in a chair:

Change position every hour

Use foam, gel or air cushion to relieve pressure

Reduce friction by:

Lifting rather than dragging when repositioning

Using corn starch on skin

Participate in a rehabilitation program
Inability to Move

Persons confined to chairs should be repositioned every hour if unable to do so themselves

For a person in a chair who is able to shift his or her own weight, change position at least every 15 minutes

Use pillows or wedges to keep knees or ankles from touching each other

When in bed, place pillows under legs from mid calf to ankle to keep heels off the bed
Loss of Bowel or Bladder Control Clean skin as soon as soiled

Assess and treat urine leaks

If moisture cannot be controlled use absorbent pads and/or briefs with a quick-drying surface and protect the skin with a cream or ointment
Poor Nutrition Eat a balanced diet

If a normal diet is not possible talk with a health care provider about nutritional supplements
Lowered Mental Awareness - caused by health problems, medicationa or anesthesia Choose preventative actions that apply to the person with lowered mental awareness, when they cannot act to prevent pressure ulcers on their own behalf

Bienkowski is managing editor for Home Health Products

This article originally appeared in the June 2000 issue of HME Business.

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