Pressure ulcers require seamless treatment plan throughout care continuum

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Dr. James G. Spahn
Dr. James G. Spahn
Understanding the seriousness and complexity of pressure ulcers relating to continuum of care requires addressing government regulations, legal responsibilities, appropriate medical practice guidelines and financial responsibility. To accomplish this goal, pressure ulcer management must occur not only from admission through discharge, but continued to the next level of care by all medical facilities and homecare agencies.

Governmental regulations are well-defined in the Social Security Act of 1965 through the Deficit Reduction Act of 2005. (1,2) The conditions of participation mandate that hospitals, long-term care facilities and homecare agencies all comply with the Social Security Act regulations. These governmental regulations require a seamless continuum of care for patients deemed to be at risk or who have an existing pressure ulcer. Federal and state agencies have been charged with oversight responsibilities.

Other organizations such as JCAHO have deemed status and thus act as an agent for Medicare and other governmental organizations. Two recent activities relating to pressure ulcers involving HA/POA (Hospital Acquired/ Present on Admission) affect acute care facilities and future exposure into all levels of care, and consumers are recognizing that pressure ulcers may represent poor medical care. (3)   

The details in federal statutes and regulations have outlined an easily identifiable industry standard for the care of pressure ulcers. This standard, and survey results applying it, have made negligence cases involving pressure ulcers easier to prove. Therefore, it is not surprising that facilities cited with violations involving pressure ulcers have lost significant cases. (4)  Pressure ulcers remain an area in medicine where worst practices are more common than best practices. (5) With that said, it is paramount that facilities and staff, both clinical professionals and non-clinical administrators, understand their fiduciary responsibility to the patient.

With growing pressure for quicker hospital discharges and increasing patient acuity, pressure ulcer assessment and management are important areas for education and quality improvements at all levels of care. It is estimated that 30% of all admissions to homecare are at serious risk of new pressure ulcers. Patients at risk of developing pressure ulcers and those who had existing pressure ulcers were found to be under treated. (6) The problem of pressure ulcers among older adults receiving home healthcare rivals the problem of pressure ulcers among other adults in hospitals and long-term care facilities. (7)

Once the awareness of the problem has been noted, an understanding of the problem must be addressed. A pressure ulcer is a mechanical stress (pressure, shear, friction) that causes ischemic necrosis of at-risk soft tissue. Candidates are predominately nutritionally impaired and immovable individuals who have been placed on a support surface. Predicting pressure ulcer development in patients is difficult. The few studies conducted found that urine or fecal incontinence, altered levels of activity and mobility, recent discharge from an institutional setting or more functional impairments directly related to the presence of a pressure ulcer. (8)

In understanding the relationship between soft-tissue injury and support surfaces, we must accept that the human body is three-dimensional, and when a support surface delivers a gradient pressure and/or shear mechanical stresses, the soft tissue will then become distorted. This distortion causes a change in the velocity and flow pattern of the circulation, resulting in endothelial cell damage. This damage can result in ischemia and possibly infarction of the soft tissue at risk that is trapped between the bony prominence of the skeletal press and the extrinsic support surface.

Ischemic events combined with reperfusion injury and lack of reactive hyperemia reserve in an at-risk patient allow for better understanding of deep tissue injury and/or necrosis.  Most importantly, healthcare providers need to understand that there is a time delay up to two to seven days for most pressure ulcers to be clinically recognized from time of the caused event.  

This understanding enables healthcare providers to better recognize and document medical conditions that can and cannot be modified. This allows the clinician to determine avoidable versus non-avoidable pressure ulcers. This not only has a tremendous clinical outcome but also carries with it regulatory, legal and public relations ramifications.

Once the pathophysiology of pressure ulcer formation is understood, the basic science relating to the support surface should be addressed. The scientific disciplines of chemistry, physics and mechanics can help clinicians understand mechanical stresses delivered to the patient at risk for pressure ulcer development. The media from which the support surface is made must be evaluated based upon scientific facts and studied by three-dimensional, not two-dimensional means. Pressure mapping relies on a two-dimensional measurement. For a more accurate evaluation, three-dimensional volumetric measuring techniques such as CT or MRI scanning should be conducted on the soft tissue at risk.  

Volumetric support can only be delivered by a static fluid (gas, liquid, solid). It must be an appropriate container that is properly filled or inflated and is pliable yet durable. Mother Nature has chosen a static fluid environment for the development of the fetus and life in an atmosphere (gas) or water (liquid). A properly made and used static fluid product creates an equalized distribution of the body's weight. This allows the patient's physiologic system to auto-regulate itself obtaining the best level of health. Thus, if homeostasis is maintained, the patient has a better chance of not developing a pressure ulcer. Selection of a proper support surface is a modifiable factor when trying to prevent or treat a pressure ulcer. No one product type is appropriate for every patient's needs. This requires and understanding of how products work and how they affect the patient at risk.

The lower extremity cannot be completely protected from pressure ulcer development by only using a support surface.  This is not to say that the support surface is bad, but the recumbent physiological changes resulting in hemodynamic variations, coupled with the anatomy of the ankle/heel/foot complex, makes it very difficult to prevent and treat pressure ulcers of the lower extremity. Additional devices may be required depending on various factors such as mobility and ambulation along with other general medical problems such as the cardiovascular health of the patient.

Using pressure reducing devices alone can cause an increase in the incidence of pressure ulcer development while protocols decrease the incidence by 50% or greater. (9) Protocols are crucial in developing and implementing a seamless continuum of care. A standardized protocol should be individualized so that a care plan can be developed and followed for each individual patient.  Factors to be considered for developing a standardized protocol might include cognitive impairment, nutrition and hydration, mobilization and ambulation, support surface selection, lower extremity protection, incontinence care, wound care, care of other general medical conditions and continuum of care responsibilities. For the continuum of care to be properly implemented, the individualized care plan must be understood and followed by all caregivers combined with a timely assessment and risk analysis upon admission. The care plan must continue after admission with scheduled assessments throughout the patient's stay and discharge to the next level of care.  

Health impaired individuals are susceptible to pressure ulcer development as long as the risk factor remains. Prevention and treatment strategies for pressure ulcers are found to be limited before admission to various medical settings. Since a patient can develop a pressure ulcer on any surface in a short period of time, support surface protection should occur immediately. And the patient must remain on the surface throughout the continuum of care within a facility as well as inter-facility transfer.  

Unfortunately, only 54% of patients with pressure ulcers are placed on a pressure reducing device upon discharge and only 18% of those at risk for developing new pressure ulcers receive pressure reduction devices at time of discharge. (10) A care plan should follow a patient to the next level of care. To accomplish this, adequate medical staffing with the necessary training must be combined with appropriate material resources. Informing, educating and helping patients or caregivers to understand the risk of pressure ulcer development and how to heal an existing pressure ulcer is not only appropriate medical care, but is required by government regulations.  This seamless continuum of care compares to a well-trained relay race team that practices and communicates with each other so as not to drop the baton.

Appropriate staffing levels and skills have been studied to determine the appropriate levels needed to decrease the risk of pressure ulcer development. The selection of appropriate products is difficult at times do to profit motivations by some facilities to use low cost, ineffective products or expensive products that are reimbursed at higher levels with no proven improvement in care. Difficult requirements to obtain insurance reimbursements, even though there is a medical necessity for the use of specific products, creates a disconnect in care if products cannot be obtained at a reasonable cost. A new medical product delivery system utilizing patient direct sales will evolve as the medical industry goes from a reimbursement driven system to a consumer driven system for the purchasing of products period.

In conclusion, the pressure ulcer problem must be addressed by an individualized care plan that considers multiple risk factors. This care plan is the glue to a seamless continuum of care for that patient. Continuum of care must have a skilled staff with access to products and services that are cost effective-not the cheapest or the best profit generating. Until this seamless process is accomplished, avoidable pressure ulcer development, patient morbidity and death, citations, civil penalties and litigation will continue.

References

(1) Federal Register; Rules and Regulations, Vol. 72, No. 162: Wednesday, August 22, 2007

(2) Federal Register, Vol. 73, No. 161, Tuesday, August 19, 2008/Rules and Regulations

(3) Federal Register; Proposed Rules, Vol. 73, No. 84: Wednesday, April 30, 2008

(4) Bennett, RG, O'Sullivan, J, DeVito EM, Remsburg, R. (2000). The increasing medical malpractice risk related to pressure ulcers in the United States. American Geriatrics Society. Vol 48: 73-81.

(5) Ferrell BA. Josephson K, Norvid P, Alcorn H (2000).
Pressure ulcers among patients admitted to home care.
American Geriatrics Society.  Pg.1046.

(6) Ferrell BA. Josephson K, Norvid P, Alcorn H (2000).
Pressure ulcers among patients admitted to home care.
American Geriatrics Society.  Pg.1046.

(7) Bergquist S. (2002)Pressure ulcer prediction in older adults receiving home health care:  Implications for use with the OASIS.Advances in Skin and Wound Care. Pg. 139.

(8)  Moody BL, Fanale JE, Thompson M, Vaillancourt D, Symonds G, Bonasoro C. (1988)
Impact of staff education on pressure sore development in elderly hospital patients.
Archives of Internal Medicine.  124: 2241-2243.

(9) Lyder CH, Preston J, Grady JN, Scinto J, Allman R, Bergstrom N, Rodeheaver G. (2001)
Quality of care for hospital medicine patients at risk for pressure ulcers.
Archives of Internal Medicine.  161: 1549-1554.

(10) Ferrell BA. Josephson K, Norvid P, Alcorn H (2000).
Pressure ulcers among patients admitted to home care.
American Geriatrics Society.  Pg.1046.

James G. Spahn, MD, FACA, is the president and CEO of EHOB Inc., a company specializing in wound and pressure ulcer care products.

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