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The SKINny on Pressure Ulcer Prevention

Jan Rebstock, RHIT, LHRM, CPHRM
2-3-2 Pressure ulcers remain a common problem in all health care settings. It is estimated that 1.3 million to 3 million adults develop pressure ulcers with an estimated cost of $500 to $40,000 to heal each ulcer.1 Failure to prevent or heal avoidable pressure ulcers can also result in costly litigation.   The Agency for Healthcare Research and Quality (AHRQ) prevention guidelines indicate that most pressure ulcers can be prevented and that early stage pressure ulcers need not worsen under most circumstances.2 This does not mean that every pressure ulcer is preventable or avoidable.  The Centers for Medicaid and Medicare (CMS) State Operations Manual for long term care describes a pressure ulcer as unavoidable when a patient develops a pressure ulcer even though the facility has evaluated their clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with their needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate.3   It is also important to recognize that not all skin ulcers are “pressure ulcers” and an accurate diagnosis is very important from a risk management/claims perspective. Pressure ulcers are defined as “any lesion caused by unrelieved pressure that results in damage to the underlying tissues(s).”4    However, clinically prone patients also develop arterial skin ulcers, diabetic skin ulcers, venous insufficiency, or stasis skin ulcers that are unrelated to skin ulcers caused by unrelieved pressure. Improper classification of a skin ulcer can make a legal team’s ability to defend an alleged pressure ulcer claim more difficult.   Because the development of pressure ulcers is often perceived as poor quality of care even though it may not be, it is imperative that the health care team focus on the prevention of pressure ulcers through early identification of “at risk” patients, implementation of proactive, aggressive care interventions and thorough documentation of both.   Some basic recognized preventive strategies include, but are not limited to5: • Assessing a patient’s pressure ulcer risk factors on admission and at regular intervals (should include post-surgery).  Prediction tools such as the Braden or Norton scales are commonly used, and both look at broad clinical categories such as sensory perception, incontinence, mobility, nutrition, friction, and shear to identify “at risk” patients.

• Thorough daily skin inspections. (Physicians should be sure to include the integumentary system in the admission history and physical and address skin integrity in their progress notes and discharge summary.)

• Development and implementation of an appropriate skin care plan based on patient needs.

• Removing or redistributing the pressure sensitive areas of the body at least every two hours.

• Use of appropriate pressure reduction support surfaces (intraoperatively as well).  For “at risk” patients this could mean static devices such as air, foam, gel overlays or mattresses, or dynamic surfaces such as alternating and low air loss mattresses or air fluidized beds. Keep in mind specialty beds are not a substitute for turning and repositioning the patient.

• Use of devices that totally relieve pressure on the heels.

• Obtaining a nutrition consult and implementing recommendations for nutritionally compromised patients.

• Instituting a rehab program to maintain or improve mobility.

• Monitoring and documenting interventions and outcomes.

• Implementing educational programs for the prevention of pressure ulcers that are structured, organized, comprehensive, and directed at all levels of health care providers, caregivers, patients, and family.

  When unavoidable pressure ulcers do occur, accurate, timely documentation of risk identification, preventive care, and treatment measures provide a basis for justification and defense.   1Courtney, H. Lyder, N.D.; Pressure Ulcer Prevention and Management; JAMA, January 8, 2003, Vol 289, No. 2. 2,5AHCPR Clinical Practice Guidelines, Pressure Ulcers in Adults; Prediction and Prevention, No. 92-0047, 1992. 3CMS Manual System, Pub. 100-07 State Operations, Provider Certification, Transmittal 4, November 12, 2004. 4Cuddigan, J., Ayello, E.A., Sussman, C., Baranoski, S. (Eds.). (2001). Pressure Ulcers in America: Prevalence, Incidence, and Implications for the Future.  National Pressure Ulcer Advisory Panel Monograph (pp. 181). Reston, VA: NPUAP