Pressure Ulcer Brochure - Oklahoma Foundation for Medical Quality

“Doctor, Please Talk To Me.”
Communicate with patients, family members and nursing staff about appropriate prevention and treatment techniques. Use the expertise
of specialists/nurses certified in wound care and consider a referral to a wound center.
When The Threat Of Litigation Arises:
Take steps to reestablish trust with the family, reassess the patient, reevaluate the care plan, document problem behaviors, and incorporate
Quality Improvement principles 7 . If you use and document accepted standards of care for prevention and treatment and communicate
with the patient and family, you are less likely to be at risk for litigation.
“Doctor, Please Notice Me”
1
Russo, CA, Steiner C, Spector W. Hospitalizations related to pressure ulcers 2006. HCUP Statistical Brief #64, December 2008. Agency for Healthcare
Research Quality
2
Armstrong DG, Ayello EA, Capitulo KL, et al. New opportunities to improve pressure ulcer prevention and treatment: implications of the CMS inpatient
hospital care present on admission (POA) indicators/hospital-acquired conditions (HAC) Policy. J Wound Ostomy Continence Nursing. 2008;35(5):485-
492.
3
Centers for Medicare & Medicaid Services, Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment System and Fiscal Year
2009 Rates; Proposed Changes to Disclosure of Physician Ownership in Hospitals and Physician Self- Referral Rules; Proposed Collection of Information
Regarding Financial Relationships Between Hospitals and Physicians; Proposed Rule Federal Register. 2008;73(84):23550.
4
Hanging Wet-to-Dry Dressings Out to Dry, Liza G. Ovington, PhD, CWS; Home Healthcare Nurse, p 477, vol 19 no 8 August 2001; ©2001 Lippincott
Williams & Wilkins, Inc
5
Bryant, 2007
6
AHCPR, 1994; WOCN Society 2001
7
Risk management for pressure ulcers: when the family shows up with a camera. Levine JM, Savino F, Peterson M Wolf CR; Journal of the American
Medical Directors Association. 9(5):360-3, 2008 Jun.
Your Patient’s Largest Organ Needs Your Attention.
Insights For Reducing Costs, Pain And Suffering And Physician Risk.
This material was prepared by Oklahoma Foundation for Medical Quality, the Medicare Quality Improvement Organization for Oklahoma, under contract with the Centers
for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
962PU-1034-OK-510

Physicians, Reduce Your Risk And Improve Care
2.5 million patients are treated for pressure ulcers every
With these formidable costs, pain and suffering, and potential
year 1 . The national cost of care exceeds $11 billion each
for litigation, it’s time to give the skin the attention it
year 2 , with an average DRG payment of $43,180 per patient deserves, and reduce your risk. This guide presents the latest
for treatment. 3 Serious pressure ulcers are considered a “never science and recommendations for incorporating principles of
event” among hospital-acquired conditions with payment
pressure ulcer prevention into everyday practice and
implications.
using appropriate treatment methodology. For more detailed
information, visit http://www.ofmq.com/sos-tools.
“Doctor, Please Look At Me”
Skin assessment for high-risk individuals should be part of
your routine practice. It doesn’t take an expensive CAT Scan,
MRI, endoscopy or even a lab test! Almost 90% of pressure
ulcers occur in the posterior pelvic region and the heel/ankle
region. It is particularly essential to assess these pressure points
on elderly and immobile patients. It takes 2-3 minutes to assess
as preventable and primarily reversible affliction.
Pressure ulcers that
reach full thickness
damage (stages 3&4) will
never heal beyond 80%
tensile strength. Assess
the skin early and often
to prevent worsening of
pressure ulcers.
The Best Treatment Is Prevention
Who Is At Risk
High Risk Factors for Pressure Ulcer Patients
• Elderly
• Immobile
• Neurologically Impaired
• Prolonged OR Time
• Time in ER
• Complicated Hospital Course
• Co-morbidities (diabetes, vascular diseases, renal compromise)
• Chronically Ill
• Obese/Malnourished
• Post-Surgical
• Incontinent
• Chronic Pain
Where To Look
Key Areas Susceptible To Pressure Ulcers
• Bony Prominences
• Posterior Pelvic Region
• Heels and Ankles
What To Look For
Conditions That Will Alter Your Plan Of Care
• Be familiar with latest staging guidelines
(http://www.npuap.com)
• Notice reddened areas.
• Learn to differentiate pressure ulcers from other types of
wounds.
• Wounds such as diabetic and neuropathic ulcers and
venous arterial insufficiency ulcers are often incorrectly
classified as pressure ulcers. Misidentifying wound etiology
can lead to an incorrect treatment plan.
• For example: Treating an exudating venous ulcer as a
pressure ulcer will be fruitless. Applying full compression
on a leg without establishing arterial status, such as
with an ankle-brachial index (ABI) or toe-brachial index
(TBI) is negligent.
Opportunities For Assessment
• On admission into acute care - Preform a head to toe,
front to back assessment. Physician should document
breakdown on admission (consistent with nurse documentation).
• In office - Check sacral area when doing exams such as
rectal and hemocult testing. Assess pressure points on
elderly and immobile patients.
• Before dictating discharge summary from acute care
- Check for skin breakdown. Make arrangements for
wound care if needed.
• Post surgery - as patient is moved to gurney
“Doctor, Dress Me Up And Treat Me Right”
Gauze For Alarm
Bacteria can pass through 64 layers of gauze. The infection rate with gauze dressings is nearly 3x higher than with moisture retentive
dressings 4 . Wound care experts agree that the use of wet-to-dry mechanical debridement should be restricted to heavily necrotic
wounds and discounted when viable tissue is present 5 .
Modify Don’t Toxify
Do thy patient’s proliferating cells no harm. “Let’s dry them bugs up with betadine and kill ‘em,” is old thinking, not quality wound
care. Historically, antiseptics were used for decontaminating infected wounds. Today, (routine use of alcohol, betadine, hydrogen
peroxide, saline solution or acetic acid) is generally discouraged because their cellular toxicity exceed their bactericidal (bacteria killing)
activity 6 .
Time For A Change
No, not likely. Advances in dressings allow us to minimize the frequency of dressing changes. Every time a pressure ulcer dressing is
changed, it takes 4 to 6 hours to regain the ideal healing temperature. Don’t order twice a day or even daily dressing changes unless
they are really needed. However, if a wound has failed to progress over a 2-4 week period, reassess the wound and consider a different
treatment plan. For example, a topical antibiotic or treatment of the epibole may need to be considered.