A recent position paper by the Wound Ostomy and Continence Nurses Society discussed avoidable versus unavoidable pressure ulcers. The paper concluded that there are clinical circumstances in which a pressure ulcer is unavoidable. The rationale behind this statement was that pressure ulcer formation is a complex process that may not be halted, even with excellent multidisciplinary care. Further, the skin is the largest organ in the body and its integrity is dependent upon the function of all other organs systems for nutrition, circulation, and immune function. Often the disease process can overwhelm the skin and interrupt nutrition, circulation, and immune functions to the skin. The statement of position states that it is the responsibility of the healthcare facility to adopt best practices aimed at pressure ulcer prevention. The rationale for this is that there are increasing reports of success in reducing the prevalence and incidence of pressure ulcers by implementing evidence-based clinical practice guidelines.
The following are the definition of avoidable and unavoidable pressure ulcers from the Centers of Medicare and Medicaid:
- · Avoidable Pressure Ulcer: Avoidable means that the resident developed a pressure ulcer and that the facility did not do one or the more of the following: evaluate the resident’s clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with residents needs, resident goals, and recognized standards of practice; monitor and evaluate the impact of the intervention; or revise the intervention as appropriate. (483.25c/TagF314).
- · Unavoidable Pressure Ulcer : Unavoidable means that the resident developed a pressure ulcer even though the facility had evaluated the resident’s clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitor and evaluated the impact of the interventions; and revised the approaches as appropriate. (483.25c/TageF314)
So how does this position paper impact pressure ulcer malpractice cases?
- · One of the recommendations of the position statement is accurate documentation of preventive measures targeted at the reduction of risk. Also, the clinical reasons why prevention interventions are not appropriate or feasible should be documented. If the pressure ulcer is determined to be unavoidable, the rationale must be evident.
- · So in screening your pressure ulcer cases pay close attention to the documentation. A risk assessment tool should be done upon admission. Many hospitals have in their policies that skin assessment along with a risk assessment should be done daily. Most nursing homes do weekly skin audits. The skin should be consistently assess and the results of this assessment should be well documented.
· If the patient’s score on the skin risk assessment puts them at risk for pressure ulcer, a pressure ulcer prevent protocol should be started. This should be documented on the chart.
- · In screening your case, see if these protocols were followed. Was the patient turned every 2 hours? Were pressure relieving devices used? Was nutrition consulted? Was preventive skin care initiated?
- · If a pressure ulcer did develop, was it adequately treated and monitored? Pressure ulcers should be re-assessed weekly to assess if treatment is working effectively. If not, was a new skin care regimen ordered?
- · Was the pressure ulcer assessed weekly as to size, characteristics, odor, etc.?
- · Were lab values related to nutrition and infection being monitored? If these lab values were outside of normal limits, were the appropriate medical professionals notified? Was the problem adequately addressed?
- · If the pressure ulcer was malodorous or had an exudate, was the wound cultured?
- · If the pressure ulcer developed past a Stage I, was a wound care nurse consulted?
In the end, these cases come down to assessment and documentation. The position paper cannot be used as an excuse for pressure ulcers to develop. Most pressure ulcers can be prevented with good, effective, and early interventions.