Hospital Acquired Pressure Ulcers: The Risks
Contact
Med League if you are in need of a nursing expert to
evaluate a pressure ulcer case.
See
also our webinar, "Complex
Wound Care with Negative Pressure Wound Therapy: Adverse
Events and Litigation" with Dr. Diane Krasner.
 Litigation
over hospital-acquired pressure ulcers represents a significant
fraction of a medical malpractice attorney’s case
load. We frequently receive requests for nursing experts
to review liability issues associated with pressure sores.
The issues have shifted since October 1, 2008 when the Centers
for Medicare and Medicaid Services and several private payors
began denying reimbursement for care related to hospital-acquired
stage III and IV pressure sores (defined below). Prior to
October 2008, the experts battled over whether a pressure
sore was avoidable. Now, they still do, but plaintiff attorneys
and their experts can point to the government’s stance
that pressure ulcers are avoidable, “never events”.
Defense experts must assert that everything possible was
done to avoid the ulcer, or it was not really caused by
pressure.
What
a pressure ulcer is and is not
The National Pressure
Ulcer Advisory Panel defines a pressure ulcer as an area
of localized injury to the skin and/or underlying tissue
usually over a bony prominence, as a result of pressure,
or pressure in combination with shear and/or friction.1
Note this definition allows for tissue damage without skin
damage, known as “deep tissue injury”.
Standardized
set of definitions to stage an ulcer
These definitions do not apply to tissue or skin
damage caused by circulatory changes (arterial or venous),
skin tears unless caused by friction or shear, or diabetic
wounds. Lesions from herpes, fungal infection, or moisture
are also not pressure sores. The battle over ulcers that
start in the feet is usually simplified by looking at the
location of the wound. Gangrenous toes are usually not caused
by pressure. Ulcers on the side of the foot may be caused
by prolonged pressure. Ulcers on the heel, which lacks a
deep layer of fat, are often due to pressure and failure
to elevate the heels off the mattress or apply protective
cushioning boots.
Definitions
Simplified descriptions of pressure ulcer stages
are presented here. Please consult Black 1
for the full definitions. Suspected deep tissue injury may
precede the appearance of an ulcer on the skin. It is defined
as a purple or maroon localized area of discolored intact
skin or blood-filled blister due to damage of underlying
soft tissue from pressure and/or shear. The area may be
preceded by tissue that is painful, firm, mushy, boggy,
firm, warmer or cooler as compared to adjacent tissue.
Stage
I ulcers are defined as intact skin with nonblanchable
redness of localized areas, usually over bony prominences.
Darkly pigmented skin may not have visible blanching; its
color may differ from the surrounding area.
Definitions
- Shear:
stretching of the tissues when a patient’s
body is dragged up in bed
- Slough:
dead tissue that separates from living tissue,
often a yellow color
- Eschar:
black tissue, often forms a hard shell over
an ulcer.
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Stage
II ulcers have partial thickness loss of dermis
presenting as a shallow ulcer with a pink-red wound bed
without slough. They may also present as an intact or open/ruptured
serum-filled blister.
Stage
III ulcers are defined as full thickness tissue
loss. Subcutaneous tissue may be visible but muscle, bone
or tendon are not. Slough may be present but does not obscure
the depth of tissue loss. The ulcer may have undermining
and tunneling.
Stage
IV ulcers have full-thickness tissue loss with
exposed bone, tendon and muscle. Slough or eschar may be
present on some parts of the wound bed. The ulcer may often
have undermining and tunneling.
Unstageable
wounds have full-thickness tissue loss in which
the base of the ulcer is covered by slough (yellow, tan,
grey, green or brown) and/or eschar (tan, brown or black)
in the wound bed.
Implications
of pressure ulcers
Studies have revealed that pressure ulcers produce
endless pain, restrict life activities and require a significant
amount of coping on the part of the patient. The persistent
pain is caused by the increase in pain that occurs as a
result of moving (leading patients to lay still), the pain
associated with dressing changes and debridements, and the
pain caused by alternating air mattresses. Pressure ulcers
cause depression, anxiety, feelings of being burdensome,
powerless, and inadequate. Wound odor affects the patient
and others.
Pressure
ulcers can cause significant emotional distress in patients.
Pressure ulcers are associated with long lasting pain and
suffering. The healing process can take months and involve
elaborate surgical procedures such as flap creation, and
impose a severe financial and social burden on families.
The annual cost to treat pressure ulcers is 1.68 to 6.8
billion dollars annually. The cost of treating ulcers is
at least 2.5 times the cost of preventing them. This does
not even include the cost of litigation.
Development
of Stage II and IV pressure ulcers raises issues of liability
These are the questions our experts are often asked
to evaluate.
Did
the nursing staff recognize the risk factors associated
with the development of pressure ulcers? They include
poor nutrition, limited mobility, incontinence, dehydration,
and other illnesses.
Did
the staff use a standardized risk assessment according to
the policy of the facility? Acute care patients
in ICU should be reassessed daily with unstable patients
being reassessed every shift. Medical surgical and other
patients should be assessed at least every 48 hours. Many
facilities do this more often because patient status can
change rapidly. The Institute for Healthcare Improvement
recommends daily assessment. New data shows that 15% of
elderly patients will develop pressure ulcers within the
first week of a hospital admission. There should be clear
expectations of staff conducting the risk assessment, which
include which nurse is responsible for the first assessment
and for subsequent assessments. This should be defined as
to who and which shift is responsible for doing the assessment.
There should be a permanent method of denoting a patient
at risk for pressure sore development and the means of communicating
that risk status to all who care for the patient.
Did
the nursing staff perform a standardized skin assessment?
Did
they assess skin color, temperature, sensation, moisture,
integrity, and turgor?
Was skin breakdown present on admission to the hospital?
This can be a hotly contested battleground if there are
discrepancies in the description of the skin of a patient
who is sent to a hospital from a nursing home. “Present
at the time” means the order for inpatient admission
has occurred, which is often a decision made in the emergency
department. Patients must be assessed within a narrow window
of time after admission - two days - with no provision for
weekends or holidays.
If
the patient’s skin was intact at the time of admission
to the hospital, but was at risk for skin breakdown, did
the nursing staff institute a plan of care to prevent skin
breakdown?
Did
the staff address nutritional deficits, relieve pressure,
and control incontinence?
Did
they use appropriate lifting techniques to avoid shearing
skin when lifting the patient up in bed?
Did
they use outdated methods of prevention, such as sheepskins,
donuts or massaging bony prominences? The failure
to prevent skin breakdown is usually the central component
of liability.
When
the patient’s skin began to break down, did the nursing
staff promptly recognize the change, communicate it to the
physician, protect the skin from further damage, and address
the factors that caused the skin breakdown to occur?
Was
the plan of care changed?
Did
the staff collect applicable information about the ulcer,
such as dimensions, stage, presence of tunneling, undermining,
drainage, wound edges, and odor?
Was
the charting consistent, legible, and complete?
Although there may be inconsistency in how staff stage a
pressure ulcer, there should not be wide variation. Education
should be provided to keep staff current with the NPUAP
(National Pressure Ulcer Advisory Panel) pressure sore staging
system.
Did
the interdisciplinary staff select the correct treatment
for the stage of the ulcer?
Did
they consult with a reputable source of information about
products, such as woundsource.com?
Did
the staff update the medical record to reflect the new plan,
chart the interventions, perform periodic re-assessments
of the skin, and look for healing? Studies have
shown that if a wound with the ability to heal is not 30%
smaller at week 4, despite optimal local wound care, it
is unlikely to heal by week 12. Advanced therapies should
be considered. If a wound is unlikely to heal because of
inadequate vasculature or a coexisting illness, advanced
therapies are seldom indicated and their chance of success
is minimal.
Stage
I and II pressure ulcers, when treated appropriately, need
not deteriorate if adequate, proper and timely preventive
measures and treatment are given.
Contact
Med League if you are in need of a nursing
expert to evaluate a pressure ulcer case.
1.
(back to article)
Black, J., Mona Baharestani, M, Janet Cuddigan, J. et al,
“National Pressure Ulcer Advisory Panel’s updated
pressure ulcer staging system,” Dermatology Nursing.
2007;19(4):343-349
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