Skin Assessment and Pressure Ulcer Care in Hospital-Based Skilled Nursing Facilities

   Pressure ulcer prevalence varies by setting, but recent data suggest it may as high as 17% in acute care, 28% in long-term care, and 29% in home care settings.¹ Regardless of the type of patient care environment, pressure ulcers are a significant healthcare problem because they increase the amount of nursing care required, the resident's length of stay, and healthcare costs.²

Prevention is the key to reducing pressure ulcer prevalence. The first step to pressure ulcer prevention is a thorough and complete initial nursing assessment of the patient upon admission. In order to prevent or reduce pressure ulcers, nursing staff must have an initial skin and pressure ulcer risk assessment on which to base their care.

   In 1990, the Minimum Data Set (MDS) instrument was developed as a comprehensive assessment tool for residents in nursing homes receiving Medicare or Medicaid funding. The state of Missouri has been collecting data from the MDS on all residents in certified nursing home facilities since July 1992.³ In 1998, the federal government mandated that MDS data be submitted nationally to the Health Care Financing Administration (now the Center for Medicare and Medicaid Services, [CMS]). The MDS is currently used as a basis for clinical decision-making, as a research instrument, and as a basis for Medicare and Medicaid reimbursement. The MDS also provides information regarding the potential quality of nursing homes.⁴

   Hawes and colleagues⁵ conducted an extensive study on the reliability of the MDS. Through their three field tests, revisions were made to the original MDS. After the revisions were completed, additional testing was done. Most recent testing showed that the MDS was reliable and that the explicit questions and use of multiple sources to score the MDS added to the validity and reliability of the tool.⁵ The average reliability of the stasis and pressure ulcer item (Section M, Items 2a and 2b) was 0.62.⁵

   Within the MDS, pressure ulcer risk is "triggered" for further assessment by eight findings, including fecal incontinence, immobility, bedfast status, peripheral vascular disease, presence or history of a pressure ulcer, use of restraints, and desensitized skin.⁶ The MDS provides information regarding the number of pressure ulcers present, but it is beyond the scope of the instrument to identify how the assessment process and subsequent decisions about treatment are done. A modest amount of research has started to examine skin and wound care practices using the MDS in nursing homes.^7-13 However, scant data are available regarding the prevalence and care of pressure ulcers in hospital-based skilled nursing facilities. Information regarding hospital-based skilled nursing facilities' methods to assess skin integrity and pressure ulcer risk and subsequent skin/pressure ulcer care is also lacking.

   Hospital-based skilled nursing facilities are small, licensed nursing homes within a hospital or medical center. They are used in the continuum of care for hospitalized patients who need extended physician monitoring and are not sufficiently medically stable to go home or be transferred to a freestanding skilled nursing facility. By allowing such patients to stay within the hospital complex, the physician can continue to see the patient on a regular basis and have access to hospital auxiliary support services (x-rays, laboratory, and the like).

   The purpose of this study was two fold: 1) to determine pressure ulcer prevalence upon admission to hospital-based skilled nursing facilities using the MDS, and 2) to determine the methods of assessment, treatment, and documentation of skin and pressure ulcer care in hospital-based skilled nursing facilities. Of particular interest was the type of assessment tools used by the individual facilities, protocols for treatment of skin breakdown, and who was performing the actual wound care. Specific research questions were as follows: 1) What is the prevalence of pressure ulcers upon admission to hospital-based skilled nursing facilities? 2) Are hospital-based skilled nursing facilities that have a high prevalence of pressure ulcers upon admission more likely to use the Braden or Norton Scale for pressure ulcer risk assessment? 3) Is there a relationship between pressure ulcer prevalence upon admission and the number of pressure ulcer treatment interventions utilized by hospital-based skilled nursing facilities? 4) Is there a difference in the proportion of hospital-based skilled nursing facilities that utilize specific interventions for residents at risk for pressure ulcers versus residents who actually have a pressure ulcer?

Methods

   Design. A survey design was used to determine the self-reported skin integrity and pressure ulcer assessment, prevention, and treatment practices in hospital-based skilled nursing facilities. To determine pressure ulcer prevalence, a retrospective analysis of the MDS database was done.

   Sample and setting. The population consisted of all 88 hospital-based skilled nursing facilities in the state of Missouri. A list of hospital-based skilled nursing facilities was obtained from the Missouri Division of Aging and the MDS database as of 1999. The database did not list hospital-based facilities separately from long-term care facilities. The hospital-based facilities had to be extracted from the master list according to facility name. Surveys were sent to the director of nursing or nurse manager at each of the 88 hospital-based skilled nursing facilities. Sixty-eight (68) completed surveys were returned, representing a 77.3% return rate.

   Pressure Ulcer Prevention and Treatment Practices Survey. As part of a larger study examining the pressure ulcer prevention and treatment practices in long-term care facilities,¹⁴ a survey was developed based on a review of the pressure ulcer literature. Two critical pieces of literature were utilized: the Agency for Health Care Policy and Research (AHCPR, now the Agency for Healthcare Research and Quality [AHRQ]) Pressure Ulcer Prediction and Prevention Guideline¹⁵ and Pressure Ulcer Treatment Guideline.¹⁶ The survey consisted of 16 multiple-choice questions. The questions focused on the following areas: 1) skin integrity assessment, 2) pressure ulcer risk assessment, 3) pressure ulcer prevention and treatment strategies, 4) documentation of care wound/skin care, and 5) wound care providers.

   Initially, members of the MU MDS and Nursing Home Quality Research Team reviewed and critiqued the survey. Subsequently, an expert panel of four doctorally prepared nurse researchers with expertise in wound care research evaluated the content validity of the survey. The survey was then reviewed for clarity and readability by a sample of five directors of nursing at skilled and long-term care facilities. The survey was revised as necessary based on the feedback.

   Procedure. Before initiating data collection, the Health Sciences Center Institutional Review Board of the University of Missouri-Columbia approved the study as an exempt project. Facility information was obtained from the MDS computerized database for the state of Missouri, to which the investigators had access through a cooperative agreement with the Missouri Department of Health and Senior Services. The data were obtained from the MDS submissions from April 1 through September 30, 1999. This coincided with the time frame of the survey mailing.

   The surveys were mailed with a cover letter and self-addressed stamped envelope to all directors of nursing/nurse managers in hospital-based skilled nursing facilities in Missouri. Two follow-up surveys were sent out at 3- to 4-week intervals, if necessary, to those who had not responded to the initial survey.

   Variables. A pressure ulcer is defined in the Health Care Financing Administration (HCFA) MDS Version 2.0 Users' Manual⁶ as "any lesion caused by pressure resulting in damage of underlying tissues. Other terms used to indicate this condition include beds sores and decubitus ulcers." The presence or absence of a pressure ulcer was obtained from the MDS Section M, item 2a (pressure ulcer). Pressure ulcers were dichotomized as present or absent. Each pressure ulcer was staged (MDS Section M, item 1) on a scale of 1 (persistent redness of skin) to 4 (full-thickness wound with exposure of muscle or bone). For this study, pressure ulcer prevalence was defined as the number of residents with a pressure ulcer on admission to the hospital-based skilled nursing facility divided by the total number of residents admitted during the study period (April 1, 1999 to September 30, 1999).

   Data analysis. All data from the survey were coded to ensure confidentiality and double entered into an Excel 7.0 spreadsheet (Microsoft Corp, Redmond, Wash.). Electronic data files were stored in a password-protected personal computer with access restricted to the principal and co-principal investigators. After the data were checked for accuracy and cleaned, the Biostatistics Group of the School of Medicine, University of Missouri-Columbia performed the data analysis using SAS 8.0 statistical software (SAS, Cary, NC). Demographic and pressure ulcer prevalence and staging information regarding the participating facilities were obtained from the MDS database. Data were analyzed using descriptive statistics using measures of central tendency such as proportions, means, and standard deviation (SD). Data are presented as means ± SD except where noted. A median one-way analysis was performed to examine the relationship between the use of a valid and reliable (ie, Braden and/or Norton Scale) pressure risk assessment tool and the prevalence of pressure ulcers. A Spearman's correlation was performed to explore the relationship between actual pressure ulcer prevalence and the number of self-reported pressure ulcer treatment interventions utilized when a pressure ulcer develops. McNemar's tests were done to compare the percentage of facilities that utilized specific interventions for those residents at risk for pressure ulcers versus those residents who actually developed a pressure ulcer. To be conservative, the level of significance was preset at P < 0.01.

Results

   Facility demographics. The demographics of the hospital-based skilled nursing facilities in Missouri that participated in the study (n = 68) were obtained from the MDS database. The majority of admissions to the skilled nursing facilities were from an acute care hospital (96.1%). The number of admissions per month ranged from 2 to 160, with an average of 30 ± 29. The mean age of admissions to hospital-based skilled nursing facilities was 78.0 ± 12.0 years. Female residents comprised 65.8% and male residents 34.2% of the sample. Most residents were either widowed (48.9%) or married (36.3%). The majority of admissions were Caucasian (92.9%), and the largest remaining number were African American (7.2%).

   Prevalence of pressure ulcers. Prevalence of pressure ulcers in the participating hospital-based skilled nursing facilities was obtained from the MDS database. Based on MDS assessments from 11,965 residents, pressure ulcer prevalence upon admission to Missouri hospital-based skilled nursing facilities was 18.4% ± 8.0%. The majority of pressure ulcers were Stage II upon admission (see Figure 1).

   Survey results.
   Skin assessment. All (100%) of the participating facilities (n = 68) reported assessing skin integrity on admission. A majority of the facilities reassessed skin integrity either daily (60.3%) or weekly (23.5%). Other reassessment patterns accounted for 16.2% of responses and included reassessing when the residents' condition changed, two times per week, or every 12 hours.

   Pressure ulcer risk assessment. All hospital-based skilled nursing facilities reported using some form of pressure ulcer risk assessment tool. The Braden Scale was the most frequently utilized risk assessment tool (48.5%). Individual facility-developed tools (35.2%) were also commonly used (see Table 1). Many facilities used more than one tool for assessing pressure ulcer risk. A trend was noted toward a relationship between the use of a valid and reliable pressure ulcer risk assessment tool and pressure ulcer prevalence (P = 0.08). These data suggest that facilities with a higher percentage of residents admitted with a pressure ulcer are more aware of the need to use a valid and reliable pressure ulcer risk assessment tool than those having fewer residents admitted with a pressure ulcer.

   The majority of facilities reported assessing pressure ulcer risk initially within 24 hours of the resident's admission (86.8 %). For those residents at risk for a pressure ulcer, 49.2% of the facilities reported weekly reassessments and 25% performed at least daily reassessments. Similarly, when residents were not at risk for pressure ulcers, they were reassessed for pressure ulcer risk weekly (53.7%). Other reassessment patterns accounted for 37.3% of the responses and included reassessment every shift, daily, two times a week, and when a change in the resident's condition occurs. Thus, the survey revealed that, regardless of the resident's risk or lack of risk, most facilities perform the reassessment of pressure ulcer risk once a week (49.2% and 53.7%, respectively).

   Pressure ulcer prevention and treatment interventions. Standardized protocols (facility or corporation specific) were the most frequently reported (73.5%) intervention for residents who are at risk for pressure ulcers. An individualized care plan (66.1%) and physician orders (64.7%) were also common responses. Nursing orders (41.4%) and the MDS Pressure Ulcer Resident Assessment Protocol (RAP) (32.3%) were less frequently utilized methods for selecting pressure ulcer interventions. Only 10.3% of facilities reported using the AHCPR Pressure Ulcer Prevention Algorithm.

   The overall mean number of pressure ulcer prevention strategies used for residents at risk for a pressure ulcer was 6.4 ± 2.1. The three most frequent interventions reported for residents at risk for a pressure ulcer were a dietitian referral, use of barrier ointments, and written turning and repositioning schedules. Less than 30% of hospital-based skilled nursing facilities reported limiting the head of bed to <30 degrees as pressure ulcer prevention strategy for those at risk. The fundamental nursing intervention for incontinence management (a toileting plan) was reported by fewer than 60% of facilities. Figure 2 compares the frequency of pressure ulcer prevention interventions used for those residents at risk for developing a pressure ulcer with the frequency of pressure ulcer treatment interventions in residents who have a pressure ulcer.

   The mean number of pressure ulcer treatment strategies for residents who actually have a pressure ulcer was 8.3 ± 2.7. The most common pressure ulcer treatment intervention selected for residents with a pressure ulcer was the application of barrier ointments (91.2%). Other frequent responses included a dietitian referral (90.0%), application of a dressing (88.2%), and more frequent turning and repositioning (85.3%). Again, the nursing intervention of limiting the head of bed to <30 degrees was utilized by less than 32% of the facilities. Furthermore, incontinence management using a toileting plan was reported by less than 56% of the facilities. A trend toward a positive relationship between the prevalence of pressure ulcers and the number of self-reported pressure ulcer treatment interventions utilized was observed (r = 0.26, P = 0.06). These data suggest that hospital-based skilled nursing facilities with a larger percentage of residents admitted with a pressure ulcer have a tendency to utilize more pressure ulcer treatments than facilities with a lower pressure ulcer prevalence rate upon admission.

   An analysis was performed to compare the interventions used as prevention strategies to those used for treatment of pressure ulcers (see Figure 2). Indwelling catheters were reported to be used significantly more often (P <0.001) in residents with a pressure ulcer than those residents who were at risk for a pressure ulcer. Use of a fecal incontinence pouch (P = 0.04) and use of a low-air-loss mattress or bed (P = 0.04) once a resident develops a pressure ulcer also approached significance. All other interventions were utilized by a similar proportion of facilities, regardless of pressure ulcer risk or pressure ulcer present status.

   Documentation of wound characteristics.
   Documentation of wound characteristics was quite thorough. All facilities (n = 68) reported documenting length and width of the wound. Other frequently documented characteristics included odor (98 %), drainage (97.7%), depth (95.5%), tissue color (91%), and necrotic tissue (91%). Tissue type was the least frequently charted characteristic (67.2%). Wound pain was reported to be documented by 74.6% of the respondents. Most facilities (80.9%) used a standardized assessment form for the documentation of wound status. Other methods of wound status documentation included photographs (52.9%), narrative nursing notes (48.5%), and nursing flow sheets (36.7%). Reassessment and documentation of the pressure ulcer were most commonly done on a weekly basis (57.3%). In addition to the weekly documentation, nearly one-half (47%) of the facilities reported reassessment and documentation of wound status on a daily basis.

   Wound care providers. Facilities having a designated skin care nurse reported that the most frequent professional practice level was a registered nurse (85.1%). The most common professional practice level of the staff performing routine skin and wound care treatments was again a registered nurse (66.1%). A variety of specialists was available for consultation on wound care. The most frequently utilized specialists cited were physical therapists (85.1%). The least commonly available specialists were advanced practice nurses such as Gerontology Clinical Nurse Specialists (6%) and Geriatric Nurse Practitioners (6%). Other specialists available are listed in Table 2. These data suggest that hospital-based skilled nursing facilities are in need of advanced practice nurses for clinical consultation and education in the area of wound and skin care.

Discussion

   This is the first study to report pressure ulcer prevalence in hospital-based skilled nursing facilities using the MDS database. Pressure ulcer prevalence upon admission to hospital-based skilled nursing facilities in Missouri was 18.4%. This is almost equivalent to 1 in 5 residents being admitted with a pressure ulcer and suggests that pressure ulcers are a major problem in these facilities. Because the overwhelming majority of residents was admitted from acute care facilities, this high pressure ulcer prevalence is reflective of the quality of care in the acute care portion of the hospital. Additional research is needed to examine the incidence of pressure ulcers following admission to evaluate the quality of nursing care provided in hospital-based skilled nursing facilities.

   Simple inexpensive measures for pressure ulcer prevention and treatment such as minimizing the head of bed (HOB) elevation to <30 degrees are not utilized in hospital-based skilled nursing facilities. Unfortunately, similar results were noted in a recent survey of inpatient rehabilitation facilities¹⁷ and in long-term care facilities.¹⁴ Collectively, these data suggest a basic disregard on the part of nurses, regardless of setting, of the underlying cause of pressure ulcers - that being pressure. When the HOB is elevated >30 degrees, increased pressure intensity occurs over the bony prominences underlying the gluteal muscles, as well as increased shearing forces to the gluteal tissue due to gravity-related sliding.¹⁸ More expensive interventions, such as dietitian evaluation, barrier ointments, and nutritional support, may have limited efficacy in treating a gluteal pressure ulcer if increased pressure intensity and shearing forces are allowed to continue. Staff education regarding the importance of minimizing the HOB elevation is needed in hospital-based skilled nursing facilities.

   Another important finding was that only 55% of hospital-based skilled nursing facilities are using a valid and reliable pressure ulcer (PU) risk assessment tool (ie, Braden or Norton scale). Other researchers have found similar results in the US and abroad. For example, Stotts and colleagues¹⁹ found that less than 25% of California patients were assessed with either the Braden or Norton Scale. In addition, studies in Europe²⁰ and Australia²¹ have found that nurses generally do not use a PU risk assessment tool to document PU risk. Similarly, Pase and Hoffman²² found that facility-developed PU risk assessment tools are commonly used in extended care facilities in the US. While the current study data suggest that hospital-based skilled nursing facilities report using the Braden and/or Norton Scale more than previous studies, it is still not used by a majority of facilities in day-to-day nursing practice.

   The Braden and Norton scales are recommended by the AHCPR pressure ulcer prediction and prevention guidelines,¹⁵ the Canadian Association of Wound Care Best Practices for the Prevention and Treatment of Pressure Ulcers,²³ and the Clinical Practice Guideline for Pressure Ulcers published by the American Medical Directors Association (AMDA).²⁴ The Braden and Norton scales are recognized risk assessment tools that have been extensively researched. Both scales have been studied in a variety of settings such as rehabilitation facilities, long-term care facilities, acute care hospitals, and intensive care units.

   Use of a valid and reliable PU risk assessment tool is not, in and of itself, sufficient to prevent pressure ulcers. Rather, it is only the first step toward identifying the major pressure ulcer risk factors for a specific resident and developing the appropriate individualized care plan that addresses these risks.²³ Nonetheless, previous work has found that if nurses use a formal PU risk assessment tool, they are more likely to use PU prevention strategies²⁵ and PU incidence decreases.^26-28

   This study found that many facilities were using multiple methods to assessment pressure ulcer risk. No data are currently available in the literature to suggest that multiple methods of risk assessment improve pressure ulcer prediction. Using multiple methods to assess pressure ulcer risk does, however, increase nursing paperwork; thereby, decreasing the amount of time available for fundamental, preventive nursing interventions such as turning, repositioning, and incontinence management.

   Similarly, 47% of the participants in this survey indicated that they document wound assessments daily. If these data accurately reflect clinical practice, it implies one of three options: 1) Pressure ulcers are not being covered by a dressing, 2) gauze-based products (ie, normal saline "damp-to-damp" dressings) are being utilized and changed one or more times per day, or 3) other moisture-retentive dressings are being utilized but are being changed daily. Any and all of these practices are worrisome. First, all pressure ulcers require a dressing in order to minimize friction, maintain a moist environment, and facilitate healing. Second, unless copious drainage in combination with an active infection is evident, gauze-based dressings typically are not recommended in extended care and home care settings because they are labor intensive for the staff and, consequently, expensive for the institution. Third, daily changing of moist environment dressings (eg, transparent films, hydrocolloids, and hydrogels) is a costly and unnecessary wound care practice. Finally, because the process of healing by secondary intention, which all pressure ulcers Stage II or greater undergo, is not a rapid process, daily documentation of wound status in a subacute setting is likely a labor-intensive practice that yields limited useful information. In fact, the AHCPR pressure ulcer treatment guideline recommends that assessments be performed "at least weekly" and "if the condition of the patient or of the wound deteriorates"; it does not recommend daily wound assessment and documentation.¹⁶

   In this study, it was found that regardless of level of PU risk, most hospital-based skilled nursing facilities reassessed residents for PU risk weekly. Although currently recommendations for frequency of PU risk reassessment for acute care, long-term care, and home care exist,²⁹ no such recommendations are available for hospital-based skilled nursing facilities. According to Bergstrom and colleagues,^30-31 frequency of PU risk reassessment should depend upon 1) the acuity of the residents, 2) when most PUs typically occur in the particular setting, and 3) how rapidly the resident's condition is changing. Unfortunately, no data are available about when PUs are most likely to develop in hospital-based skilled nursing facilities. Additional research is needed to determine when PUs typically occur in this setting. In the meantime, given that the acuity of residents in hospital-based skilled nursing facilities is at least as high as that in the typical long-term care facility, PU risk reassessment should be no less than weekly.

   It also was interesting to note that the majority of skin and wound care in hospital-based skilled nursing units is being performed by RNs. This is in contrast to findings by other researchers. For example, skin and wound care typically is performed by nursing assistants in rehabilitation facilities¹⁷ or LPNs in extended care or free standing long-term care facilities.^14,32 Because residents in hospital-based skilled nursing units tend to have a higher level of acuity than clients in rehabilitation units or residents of free-standing long-term care facilities, a higher percentage of RN staffing and the provision of more direct care by RNs is to be expected. Because hospital-based skilled nursing units have more Medicare patients, higher staffing levels, and/or are more likely to be non-profit institutions, the quality of care may be higher (ie, in hospital-based skilled nursing units compared to free-standing, long-term care facilities).³³ Although pressure ulcer incidence (which would be an indicator of the quality of care in the hospital-based skilled nursing units) was not examined, current data suggest that although RNs perform the majority of skin and wound care in the hospital-based skilled nursing units, the established, evidence-based pressure ulcer prevention and treatment guidelines are largely ignored.

   Some problems exist with section M, Skin Condition, of the MDS. Specifically, the MDS requests information on the staging of pressure ulcers. In the current system, the facilities are required to "back stage" or "down stage" a pressure ulcer as a method to monitor PU healing. By definition in the MDS, ulcers heal or improve by going from one stage to another, for example Stage IV to a Stage III. The National Pressure Ulcer Advisory Panel (NPUAP), at the Fourth National Conference, recommended that pressure ulcers should not be "down staged" as they improve.³⁴ Xakellis and Frantz³⁵ noted that, "... ulcers heal through a process of granulation, wound contraction, re-epithelialization, and scar formation." Thus, down staging or reverse staging is based on the inaccurate assumption that the body is able to replace the tissue that was lost (eg, muscle, connective tissue, and the like), which it is not. The implications of the reverse staging system are that as a pressure ulcer "improves," the patient may no longer require skilled nursing care because of the lesser stage, and reimbursement for the care of the patient decreases even though he/she is at great risk for the reoccurrence of a pressure ulcer.³⁶

   With the controversy surrounding reverse staging, several pressure ulcer-healing scales have been developed.^37-40 A task force of the NPUAP has been working on the Pressure Ulcer Scale for Healing (PUSH) Tool (see Figure 3). Validation studies have been done.^41-42 Stotts and colleagues⁴³ recently reported on two studies conducted to assess the validity of the PUSH tool 3.0 and concluded that the tool provides clinically valid data about pressure ulcer healing. The PUSH tool is recommended for use in the Pressure Ulcer Therapy Companion Clinical Practice Guideline.⁴⁴ The PUSH tool 3.0 is currently used in the IRF-PAI (In-Patient Rehabilitation Facility-Prospective Payment Assessment Instrument), a tool similar to the MDS used in acute rehabilitation facilities for payment.

Limitations

   This study is limited by the specific definition of the facility and somewhat limited size of the sample. The researchers determined the hospital-based facilities by facility name. Thus, the findings may not reflect the entire group of hospital-based skilled nursing facilities in the state of Missouri and could potentially include facilities that are not hospital-based.

   The pressure ulcer prevalence data are based on the computerized MDS 2.0 database and are limited by the thoroughness and accuracy of the assessment, documentation, and data entry at each hospital-based skilled nursing facility. Direct assessment and observation of residents might yield different pressure ulcer prevalence information.

   The survey portion of the study was based on self-reporting by one individual in each of the hospital-based skilled nursing facilities, and responses may not necessarily depict what actually occurs in practice. Staffing ratios and individual practice were not accounted for in this study. The optimal study would be performed using non-participative observation methods to assess actual assessment processes and care delivery routines.

Conclusions

   Although data are available on the benefits of using evidence-based PU risk assessment tools and modalities of care, they are not being used in hospital-based skilled nursing facilities. Of particular concern was the finding that fundamental nursing routines such as toileting residents and keeping the HOB <30 degrees were not recognized as important interventions. These data suggest that additional education is needed regarding the prevention and treatment of pressure ulcers both in clinical practice settings and educational institutions. Specifically, the findings suggest nurses need to be educated about the importance of minimizing HOB elevation, actively managing incontinence, and using the Braden or Norton Scale for PU risk assessment. Nursing needs to remember that basic nursing care is pivotal to the success of pressure ulcer prevention programs. In addition, implementing comprehensive prevention and treatment protocols requires a team approach using an individualized patient plan of care within hospital-based skilled nursing facilities in order to be successful.

   The data from the MDS can be used for monitoring quality skin and pressure ulcer care, but the issue of reverse staging is a serious breach of the standard of practice and needs to be addressed. Reverse staging causes great confusion among nursing staff and continues to seriously compromise the ability of researchers to use this data in a meaningful fashion. Further study is necessary about the actual treatments used to care for the pressure ulcers as well as the associated outcomes. As clinicians become more outcome oriented, the care provided needs to show a positive resident response. To improve their credibility, facilities must use proven research-based nursing assessment tools and clinical care practices.

Acknowledgments

   The authors wish to thank Richard Madsen, PhD, Gregory Petroski, MS, and Ashley Sherman, MS, for their assistance with data analysis, and Alice Kuehn, PhD, RN, CS, FNP/GNP, for her thoughtful review of the manuscript. The authors wish to recognize the contribution of members of the MU MDS and Nursing Home Quality Research Team, including Vicki S. Conn, PhD, RN; Victoria T. Grando, PhD, RN; Lanis L. Hicks, PhD; Meridean Maas, PhD, RN; and David R. Mehr, MS, MD. The authors also gratefully acknowledge the support of the Missouri Department of Health and Senior Services staff. The research was funded by a Convatec Nursing Research Scholarship to Deidre Wipke-Tevis, PhD, RN, BC, and a Scholarly Pursuit Award by the Alpha Iota Chapter of Sigma Theta Tau to Carol Siem, RN, MSN, CS, GNP. Research activities also were partially supported by a contract from the Missouri Department of Health and Senior Services to the Sinclair School of Nursing and Biostatistics Group of the School of Medicine, University of Missouri-Columbia, Contract #C-5-35662. A portion of these data were presented as a research poster at the 24th Midwest Nursing Research Society Graduate Research Poster Exchange, March 2000, Dearborn, Mich.; at the Symposium on Advanced Wound Care and Medical Research Forum, April 2001, Las Vegas, Nev.; at the 27th Annual Education Conference of Association of Rehabilitation

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