News

Study Challenges Notion of Pressure Ulcers as a 'Never Event'

Publish date: February 1, 2011
Author(s):
Doug Brunk

Major Finding: On logistic regression analysis, only use of mechanical ventilation and vasopressors were significantly associated with the development of pressure ulcers in the ICU (odds ratios of 4.55 and 2.17, respectively).

Data Source: A study of 824 patients who were admitted to the ICU at two separate hospitals between Dec. 15, 2009, and Dec. 12, 2010.

Disclosures: Ms. Mullen-Fortino said that she had no relevant financial conflicts to disclose.

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Pay Held Hostage to the Unattainable

This is one of the first well-conducted, observational studies that would suggest that in some severely ill individuals, host factors outweigh any approach taken for the prevention of pressure ulcers in hospitalized patients.

On a larger scale, the findings suggest that the use of the hospital-acquired conditions list by the Centers for Medicare & Medicaid Services is putting the cart before the horse. The simple reality is that you can do everything right to prevent pressure ulcers and yet they still will occur in some patients.

Of course, we have observational evidence that with really good nursing care and the use of preventive devices before the skin begins to break down, you can indeed prevent ulcers. But even with those interventions, you're never going to prevent all of them. Expecting a 100% prevention rate is misguided.

We simply do not have an infinite amount of resources to deploy in the prevention of this so-called "never event". And even if we did have infinite resources, reimbursement would still be docked when pressure ulcers inevitably developed in the most severely ill patients.

There are other examples of this disparity between CMS's expectations and the evidence regarding outcomes. Despite randomized controlled trial data showing that even with the very best care a certain percentage of patients discharged after hip or knee arthroplasty will be readmitted within 30 days for venous thromboembolism, hospitals are penalized when the unavoidable occurs.

It would appear that in these circumstances, the government is cutting its costs under the guise of quality. And they are penalizing providers even when the highest quality of care is given.

Franklin Michota, M.D.,, is the director of academic affairs in the department of hospital medicine at the Cleveland Clinic.


 

FROM THE ANNUAL CONGRESS OF THE SOCIETY OF CRITICAL CARE MEDICINE

SAN DIEGO – The development of hospital-acquired pressure ulcers may be unavoidable in patients who present with respiratory and hemodynamic medical problems that impede optimal oxygenation to tissues, results from a study of more than 800 patients showed.

Margaret Mullen-Fortino

The findings challenge the position of the Centers for Medicaid and Medicare Services that pressure ulcers in this setting are a so-called "never event," Margaret Mullen-Fortino, R.N., said at the annual congress of the Society of Critical Care Medicine.

"They are categorized as a never event because it’s believed that these are reasonably preventable through the application of evidence-based guidelines," said Ms. Mullen-Fortino, operations director of the surgical/trauma ICU at the Hospital of the University of Pennsylvania, Philadelphia. "The evidence-based guidelines include the acronym SKIN, with the S standing for surface selection such as low-air-pressure mattresses. The K stands for keep turning patients, the I stands for incontinence management, and the N stands for nutrition – making sure that patients are adequately nourished with enough protein."

However, she continued, "There is a large population of practitioners who believe that pressure ulcers are not a never event, that there are comorbidities that increase the chances of patients developing pressure ulcers. Much like a patient experiences a myocardial infarction because blood does not get to the heart muscle, we believe that pressure ulcers develop because adequate blood supply does not get to the skin, which is the largest organ in the body. Our hypothesis is that there is an association between the severity of illness and the development of pressure ulcers."

To test this hypothesis, Ms. Mullen-Fortino and her associates conducted a prospective cohort study of 824 patients who were admitted to the 20-bed surgical/trauma ICU at the Hospital of the University of Pennsylvania and to the 20-bed medical ICU at the Christ Hospital, Cincinnati, between Dec. 15, 2009, and Dec. 12, 2010. Variables assessed included age, length of stay, APACHE score, Braden score, readmission, and use of mechanical ventilation and vasopressors.

Ms. Mullen-Fortino reported that of the 824 patients studied, 221 (26.8%) developed pressure ulcers. Of these patients, 144 (65.1%) were ventilated and 67 (30.3%) required vasopressor support.

Among the entire study population, the median APACHE score was 74, with a range of 26-153. The median length of stay was 2 days, with a range of 1-91 days; the median Braden score was 14, with a range of 7-20; and the median patient age was 63 years.

All of the variables studied had a statistically significant association with the development of pressure ulcers with the exception of the use of vasopressors, "which was a surprise," Ms. Mullen-Fortino said.

She and her associates then performed logistic regression analysis that was limited to ICU length of stay, APACHE score, use of mechanical ventilation, and use of vasopressors. The Braden score was excluded "because that’s a predictive model for skin integrity, not really for severity of illness," she explained. In this analysis, only use of mechanical ventilation and vasopressors were significantly associated with the development of pressure ulcers (odds ratios of 4.55 and 2.17, respectively).

Next, the researchers intend to prospectively examine the cohort using the Sequential Organ Failure Assessment, which quantifies the severity of the patient’s illness based on the degree of organ dysfunction serially over time, "as opposed to the APACHE score, which provides you severity of illness on admission," Ms. Mullen-Fortino said. "We’re hoping to see if the progression of the severity of illness correlates with the development of pressure ulcers. The compilation of this evidence will hopefully serve to inform future policy."

In 2007, she said, more than 250,000 hospitalized patients were reported to have stage 3 and 4 pressure ulcers. The cost of treatment is about $43,000 per pressure ulcer, and the condition demands "a tremendous amount of nursing resources and time," she said.

Ms. Mullen-Fortino said that she had no relevant financial conflicts to disclose.