FOCUS ON INFECTION PREVENTION Skin and Soft-Tissue Infections in Long-Term Care ABSTRACT INTRODUCTION Skin and soft-tissue infections (SSTIs) Skin and soft-tissue infections (SSTIs) are the third most common infection in long- occur frequently in the elderly as skin term care facility (LTCF) residents, with a reported prevalence of 1% to 9% and an integrity becomes more compromised incidence rate of 0.9 to 2.1 cases per 1,000 resident-days.1 Cellulitis and infected pres- with advancing age. SSTIs are the third sure/decubitus ulcers are two of the most common types of SSTIs in the nursing most common infection in nursing home home population.2 residents nationally, with a prevalence SSTIs result when breaks in skin or mucosa occur as a consequence of trauma, the rate that varies between 1% and 9%. presence of moisture, pressure, or the use of medical devices. Wounds may become Cellulitis and decubitus ulcer infection secondarily infected with endogenous pathogens from the resident’s own skin or are two of the most common types of exogenously by the hands of healthcare workers or other residents or by contact with SSTI in this national population. During contaminated objects in the environment.2 a 12-month period, July 2009 through June 2010, Pennsylvania nursing homes Cellulitis reported a total of 5,881 SSTI events, Cellulitis is an acute spreading infection of the skin, which primarily involves the or a rate of 0.26 per 1,000 resident subcutaneous tissue. It can occur at the site of a previous skin break such as a cut, lac- days. Consistent with national data find- eration, puncture wound, and pressure ulcer, or it may arise spontaneously. Cellulitis is ings, these reports reflect that cellulitis characterized by redness, pain, edema, and tender lymph nodes and may include such and decubitus ulcer infections were the systemic findings as fever, malaise, and delirium. Elderly residents have a high risk of most predominant among the specific developing bacteremia from cellulitis, which is associated with high morbidity and mor- etiologies. This article focuses on evi- tality.3 Thrombophlebitis may result from cellulitis of the lower extremities. Cellulitis dence-based practices for maintaining often spreads rapidly in residents with chronic-dependent edema. overall skin integrity as well as strategies for pressure ulcer prevention. Barriers that impede skin integrity maintenance Pressure Ulcers are also addressed. (Pa Patient Saf Pressure ulcers (also known as decubitus ulcers or bedsores) are localized areas of tis- Advis 2011 Mar;8[1]:34-8.) sue necrosis involving the skin and underlying structures (e.g., subcutaneous tissues, muscles, bones). Pressure ulcers occur most commonly on lower body parts, such as the sacrum, coccyx, ischial tuberosities, and greater trochanter. Approximately 20% to 25% of LTCF residents experience pressure ulcers, which are typically associated with extended length of stay and increased mortality.4 Reddy et al. cites that 2.5 million pres- sure ulcers are treated each year in the United States, at an approximately $11 billion expense.5 Infections occur in up to 65% of pressure ulcers and may lead to osteomyelitis and sepsis, requiring costly and aggressive therapy.6 The Centers for Medicare and Medicaid Services (CMS) established the reduction of pressure ulcers as a goal in nursing homes and mandated that each state’s quality improvement organization address pressure ulcers in long-term care. LTCFs are required to comply with federal guidelines for the treatment of pressure ulcers in order to receive payments from Medicare and Medicaid. CMS provides guidance to state and federal sur- veyors (Federal Tag 314) evaluating pressure ulcer care in LTCFs. The regulation states that the facility is to take the following actions: (1) ensure that a resident who enters a facility without pressure ulcers does not develop pressure ulcers unless the individual’s clinical condition demonstrates that pressure ulcers were unavoidable, (2) promote the prevention of pressure ulcer development, (3) promote the healing of pressure ulcers that are present (including the prevention of infection), and (4) prevent the develop- ment of additional pressure ulcers.7 PENNSYLVANIA DATA Twelve months’ worth of preliminary data on SSTIs from Pennsylvania nursing homes reflect a rate of 0.26 infections per 1,000 resident days, which is lower than the Page 34 Pennsylvania Patient Safety Advisory Vol. 8, No. 1—March 2011 ©2011 Pennsylvania Patient Safety Authority national average. The most likely reason restore, or heal skin breakdown are vital collaborative, which comprises 150 hos- for the lower rate is the unique set of crite- to providing quality care. For provision pitals, nursing homes, and home care ria that was developed in Pennsylvania for of optimal skin care, LTCFs can develop agencies, reported a 70% reduction in the purpose of mandatory reporting.8 The a formal skin breakdown and ulcer the incidence of new pressure ulcers criteria do not include infections such as prevention program that would include over a 12-month period.11 In 2003, staff conjunctivitis, ear infections, and herpes the following strategies:9 and administrators of a 151-bed skilled zoster, which are included in national — Conduct skin breakdown risk assess- nursing facility in the Midwest began an data. The criteria also narrow the risk of ments for all residents initiative to reduce the incidence of facil- reporting noninfected decubitus ulcers ity-acquired pressure ulcers. A goal of zero — Reassess risk on a regular basis as infections and hospital/ambulatory- facility-acquired pressure ulcers in nursing surgery-associated surgical-site infections — Inspect skin daily home residents was achieved by the sixth as SSTIs. The following subtypes compose — Optimize nutrition and hydration month of the facility’s initiative; this was the events: cellulitis, decubitus ulcer, vas- — Manage moisture maintained at zero or close to zero every cular or diabetic ulcer, device-associated — Minimize pressure month for four years.12 events, burn-associated events, and other/ The application of these measures has unspecified (see the Table for sums and demonstrated significant and sustainable Conduct Risk Assessments for rates of these infection types). Consistent All Residents reductions in the incidence and prevalence with national findings, these reports The most important component of skin of skin breakdown, particularly in the reflect that cellulitis and decubitus ulcer breakdown and pressure ulcer prevention studies conducted on residents at risk for infections were the most predominant is risk assessment. A comprehensive assess- pressure ulcers. In 2003, the National among the specific etiologies. ment will evaluate the resident’s extrinsic Nursing Home Improvement Collaborative The other/unspecified category includes recruited 52 nursing homes in 39 states risk factors, the skin condition, and other reportable SSTIs that do not fit under the to implement recommended practices causal factors that place the resident at subtypes and those for which the etiology to reduce pressure ulcer incidence risk. Factors that predispose the resident was not declared. and prevalence. The number of new to general skin breakdown and place him healthcare-associated stage III to IV pres- or her at risk for SSTIs such as cellulitis MAINTAINING SKIN INTEGRITY: sure ulcers declined 69% over a 10-month and pressure ulcers include immobility, EVIDENCE-BASED BEST period.10 The New Jersey Hospital Associa- pressure, friction, shear, moisture, incon- PRACTICES tion’s Pressure Ulcer Collaborative was tinence, steroids, malnutrition, sensory developed in 2005 to apply best practices deficiency, vascular compromise, and Maintaining skin integrity (intact skin) infection.4 The assessment will need to and preventive techniques to reduce the in institutionalized residents is one of identify which risk factors can be modi- occurrence of pressure ulcers in patients the most fundamental and critical goals fied or eliminated. throughout various care settings. The of nursing practice. Measures to prevent, The Braden Scale is a common tool used to identify at-risk residents and includes Table. Rate of Nursing Home Skin and Soft-Tissue Infections Reported to the Pennsylvania assessment of six domains: activity, dietary Patient Safety Authority, July 2009 through June 2010 intake, friction, mobility, sensory percep- INFECTIONS PER 100,000 tion, and skin moisture.13 Residents with SKIN AND SOFT-TISSUE RESIDENT DAYS* a score of less than or equal to 18 have the INFECTION TYPE INFECTIONS (95% CONFIDENCE INTERVAL) highest risk of developing a pressure ulcer. Cellulitis 2,849 12.68 (12.21 - 13.14) Reassess Residents on a Decubitus ulcer 419 1.86 (1.69 - 2.04) Regular Basis Vascular or diabetic ulcer 288 1.28 (1.13 - 1.43) The National Pressure Ulcer Advisory Device-associated 200 0.89 (0.77 - 1.01) Panel (NPUAP) recommends using a stan- dardized pressure ulcer risk assessment Burn-associated 10 0.04 (0.02 - 0.07) tool to assess pressure ulcer risks at admis- Other/unspecified 2,115 9.41 (9.07 - 9.81) sion, weekly for the first four weeks after * Rates represented in infections per 100,000 resident days for readability. admission for each resident at risk, then Vol. 8, No. 1—March 2011 Pennsylvania Patient Safety Advisory Page 35 ©2011 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION quarterly or whenever there is a change LTCFs can create tools that prompt daily wipes so that staff can easily care for in cognition or functional ability.14 This skin inspection (e.g., during bathing, the resident’s skin after each episode frequent assessment of risk allows staff the during repositioning), document the of incontinence. opportunity to adjust the prevention strat- results, and initiate prevention strategies egies according to the resident’s needs. if necessary.18 Minimize Pressure While this tool is primarily used to assess It is important to relieve pressure, pressure ulcer risks, it is also applicable to Optimize Nutrition and especially over bony prominences. Two general skin breakdown, which can result Hydration strategies that have proven effective in in cellulitis with or without decubitus Nutritional factors (e.g., impaired intake, preventing the development of pressure ulcer development. low body weight, weight loss, dehydra- ulcers are as follows:17 To ensure completion of a risk assess- tion) may impair residents’ skin integrity; Turn/reposition resident every two hours. ment, Joint Commission recommends these factors are included in standard risk Relieving the pressure on susceptible areas the following:15 assessment tools. If dietary intake is inad- maintains circulation and prevents tissue — Include a visual cue on each admis- equate, nutritional supplements may be ischemia. Avoid placing the resident on sion documentation record for the required. Unless contraindicated, nutri- the trochanter unless the resident has completion of the skin and risk tional goals for an at-risk resident include both sacral and ischial pressure ulcers. Do assessment. a protein intake of approximately 1.2 to not raise the head of the bed more than 1.5 gm/kg body weight daily.19 Residents 30 degrees. Pillows may be used to reduce — Use the same risk assessment tool at high risk would benefit from a dietician pressure and placed under the calves throughout the facility for every consult. Educate staff about the need for to raise the resident’s heels off the bed point of entry as well as level of care. ensuring optimal nutrition and hydration; surface. Some LTCFs post a “turn clock” — Use multiple methods to visually for example, staff could offer water to a on the doors to the rooms of high-risk cue staff as to which residents are at resident when he or she is repositioned. residents. The clock reminds staff that risk. Some facilities place stickers on at each two-hour interval, the patient is a resident’s door or in the medical Manage Moisture to be repositioned according to the posi- chart to allow for quick identifica- tion indicated on the clock. For example, Wet skin breaks down easily. Proper care tion of at-risk residents. from noon to 2 p.m., the patient is to be can reduce the exposure of the skin to Use of an eye-catching motto and logo sources of moisture, including that which positioned on his or her back; from 2 to has been successful in some LTCFs in is produced by incontinence, perspiration, 4 p.m., on the right side, and so forth. decreasing the incidence of pressure ulcer or wound drainage. Cleanse skin as soon Other strategies that can prompt staff to development. For example, a comprehen- as soiling occurs and at routine intervals. turn/reposition all at-risk residents are sive plan developed by Ascension Health Use a mild cleansing agent to minimize sounding staff beepers every two hours to reduce pressure ulcers includes the irritation and dryness. Use moisture- or developing a “turn team,” which auto- “SKIN” (i.e., Surfaces, Keep the patient absorbing underpads if moisture cannot be matically meets and turns residents every turning, Incontinence management, contained. Apply topical agents to the skin two hours. Appropriate documentation in Nutrition) bundle,16 a graphic of which to act as a barrier and provide moisture.17 the medical chart includes noting that the is available on the Authority's website. resident was instructed about the impor- Again, this plan, while concentrating Opportunities to protect the skin can tance of repositioning and encouraged on pressure ulcer prevention, is also be built into daily activities, such as the to change positions frequently, as well as applicable to general skin integrity and following:17 noting the frequency of repositioning. prevention of skin breakdown. — Create a protocol that includes Support surfaces and pressure reduction. repositioning, assessing for wet skin, Specialized support surfaces (e.g., mat- Inspect Skin Daily applying barrier agents, and offering tresses, beds, cushions) help reduce or Skin integrity may deteriorate rapidly in toileting and oral fluids every eliminate the pressure that can lead to institutionalized patients. Residents at two hours. ulcer formation. Pressure-reducing sur- risk of developing skin breakdown and — Provide a bundle of supplies at the faces can be classified as static or dynamic. subsequent pressure ulcers need a daily bedside of each at-risk resident who Static-support surfaces include air, water, assessment of all skin surfaces with special is incontinent. The bundle may gel, or foam mattresses or overlays. attention given to the sacrum, ischium, contain items such as underpads Dynamic-support surfaces (e.g., alternat- trochanters, heels, elbows, and occiput.17 and premoistened disposable barrier ing-pressure air mattress) require a motor Page 36 Pennsylvania Patient Safety Advisory Vol. 8, No. 1—March 2011 ©2011 Pennsylvania Patient Safety Authority or pump and electricity to operate. LTCFs program. Lancellot describes how com- is to provide nurses trained in wound care can rent or buy specialty pressure-redistri- munication failure has been reduced by management, who can devote their time bution devices for high-risk residents. designating a clinical nurse specialist to and expertise to assist with maintenance channel communication regarding pres- of skin integrity. ELIMINATING BARRIERS TO SKIN sure ulcer prevention throughout the BREAKDOWN AND PRESSURE facility.23 Complexity of Program Design ULCER PREVENTION PROGRAMS and Wording Lack of Education and Training The complexity of the design and word- Results of a study by Xakellis et al. sug- gest that failing to address barriers to skin Providing continuous learning opportuni- ing of prevention policies were perceived breakdown and pressure ulcer implemen- ties is essential to ensure that prevention to strongly influence the degree of tation plans can result in less-than-optimal efforts are maintained. Develop educational implementation for specific guidelines long-term clinical outcomes.20 Barriers to material that targets all disciplines, nonpro- in a 2007 study by Thomason et al.22 the successful implementation of these fessional staff, and residents. Offer short, Include clear simple concepts in preven- programs include organizational factors, frequent, focused education to staff at mul- tion policies, with precise wording and lack of education and training, lack of tiple times. NPUAP recommends including quantifiable objectives. To accomplish resources, and complexity of program information about the following:17 this, establish a workgroup to define mea- design and wording. — Etiology and risk factors for surement criteria, goals, and definitions, pressure ulcers and develop a toolkit that contains best Organizational Factors practices, implementation techniques, — The risk assessment tool and how and documentation tools. Instituting a facilitywide program to to use it prevent skin breakdown and pressure — How to perform skin assessment CONCLUSION ulcers requires systemwide support. Form — Use of support surfaces a multidisciplinary team to develop the An SSTI is painful, expensive, and — Nutritional support program and include facility executives. unnecessary, as well as associated with For example, during implementation at — Program for bowel and bladder an increase in morbidity and mortal- the Ottawa Hospital, the vice president management ity. Maintenance of skin integrity is an of patient services addressed efforts with — How to develop and implement indi- ongoing process in LTCFs and is vitally the hospital board members and execu- vidualized programs of skin care important to preserve the resident’s long- tives while other staff (e.g., educators, — Demonstration of positioning to term health and well-being. A preventive managers) advanced the activity with their decrease risk of tissue breakdown approach includes identifying high-risk peers.21 Successful hospitals have created residents and initiating a prevention and enabled skin care champions who Lack of Resources plan. Programs can be designed to pro- encourage staff ownership and buy-in of The beginning stages of a skin breakdown mote best practice in maintaining the change at all levels.22 Many such champi- prevention and pressure ulcer initiative resident’s skin integrity and ensure the ons develop expert knowledge in skin care are time and resource intensive. The consistency of clinical practices related management and are often consulted by team will need uninterrupted time from to the prevention and management their peers. other responsibilities, which helps to send of skin breakdown. Finally, successful a clear message of leadership support. implementation includes identifying the Communication is a vital component The organization will have to dedicate barriers to change such as organizational to success and extends to every level of resources to the goal of preventing these factors, lack of education/training, lack care. Input should be solicited from staff conditions. An option for nursing homes of resources, and complexity of program through all stages in the implementation design and wording. Vol. 8, No. 1—March 2011 Pennsylvania Patient Safety Advisory Page 37 ©2011 Pennsylvania Patient Safety Authority NOTES 1. Nicolle LE. Infection control in long- 9. Institute for Healthcare Improvement. 5 17. National Pressure Advisory Panel. Pres- term care facilities. Clin Infect Dis 2000 Million Lives Campaign. Getting started sure ulcer prevention points [online]. Sep;31(3):752-6. kit: prevent pressure ulcers how-to guide 2009 [cited 2010 Feb 11]. Available 2. High KP, Bradley SF, Gravenstein S, [online]. 2008 [cited 2010 Dec 17]. Available from Internet: http://www.npuap.org/ et al. Clinical practice guidelines for the from Internet: http://www.ihi.org/IHI/ PU_Prev_Points.pdf. evaluation of fever and infection in older Programs/Campaign/PressureUlcers.htm. 18. National Pressure Ulcer Advisory Panel. adult residents of long- term care facilities: 10. Lynn J, West J, Hausmann S, Cuddigan J, Ayello EA, Sussman C, 2008 update by the Infectious Diseases et al. Collaborative clinical quality eds. Pressure ulcers in America: prevalence, Society of America. J Am Geriatr Soc 2009 improvement for pressure ulcers in incidence, and implication for the future. Mar;57(3):375-94. nursing homes. J Am Geriatr Soc 2007 Reston(VA): NPUAP; 2001. 3. Laube S, Farrell AM. Bacterial skin Oct;55(10):1663-9. 19. Thomas DR. The new F-tag 314: preven- infections in the elderly: diagnosis and 11. Werkman H, Simodejka P, DeFilippis J. tion and management of pressure ulcers. J treatment. Drugs Aging 19(5):331-42, 2002. Partnering for prevention: a pressure ulcer Am Med Dir Assoc 2006 Oct; 7(8):523-31. 4. Garcia AD, Thomas DR. Assessment and prevention collaborative. Home Health 20. Xakellis GC, Frantz RA, Lewis A, et management of chronic pressure ulcers Nurse 2008 Jan;26(1):17-22. al. Translating pressure ulcer guide- in the elderly. Med Clin North Am 2006 12. Tippet AW. Reducing the incidence of lines into practice: it’s harder than it Sep;90(5):925-44. pressure ulcers in nursing home residents: sounds. Adv Skin Wound Care 2001 Sep- 5. Reddy M, Gill SS, Rochon PA. Preventing a prospective 6-year evaluation. Ostomy Oct;14(5):249-58. pressure ulcers: a systematic review. JAMA Wound Manage 2009 Nov;55(11):52-8. 21. Harrison MB, Mackey M, Friedberg E. 2006 Aug;296(8):974-84. 13. Braden B, Bergstrom N. Braden Scale Pressure ulcer monitoring: a process of 6. Yoshikawa TT, Norman DC. Approach to for predicting pressure sore risk [online]. evidence-based practice, quality, and fever and infection in the nursing home. J 1988 [cited 2010 Feb 11]. Available from research. Jt Comm J Qual Patient Saf 2008 Am Geriatr Soc 1996 Jan;44(1):74-82. Internet: http://www.bradenscale.com/ Jun;34(6):355-9. 7. Department of Health and Human Ser- images/bradenscale.pdf. 22. Thomason SS, Evitt CP, Harrow JJ, et vices. Centers for Medicare and Medicaid 14. National Pressure Advisory Panel. Pres- al. Providers’ perceptions of spinal cord Services (CMS) guidance to surveyors in sure ulcer treatment. Quick reference injury pressure ulcer guidelines. J Spinal long-term care facilities. [CMS manual guide [online]. 2009 [cited 2010 Feb 11]. Cord Med 2007;30(2):117-26. system, state operations provider certifica- Available from Internet: http://www. 23. Lancellot M. CNS combats pressure tion]. DHHS Pub. 100.07. 2004 Nov 12. epuap.org/guidelines/Final_Quick_ ulcers with skin wound assessment 8. Reporting requirements for nursing Treatment.pdf. team (SWAT). Clin Nurse Spec 1996 homes under chapter 4 of the Medical 15. Duncan KD. Preventing pressure ulcers: May;10(3):154-60. Care Availability and Reduction of Error the goal is zero. Jt Comm J Qual Patient Saf (MCARE) Act. PA Bulletin. 38 Pa.B. 2007 Oct;33(10):605-10. 5239 [online]. 2008 Sep 20 [cited 2009 16. Gibbons W, Shanks HT, Kleinhelter P, et Jul 28]. Available from Internet: http:// al. Eliminating facility-acquired pressure www.pabulletin.com/secure/data/ ulcers at Ascension Health. Jt Comm J vol38/38-38/1740.html. Qual Patient Saf 2006 Sep;32(9):488-96. Page 38 Pennsylvania Patient Safety Advisory Vol. 8, No. 1—March 2011 ©2011 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 8, No. 1—March 2011. 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