No Easy Answers to LTC Conundrums: Pressure Ulcer Controversies

by Jacqueline Vance, RNC

Nowhere is the lack of basic research on clinical syndromes in long-term care patients more evident than in the case of pressure ulcers. Controversy abounds where science is lacking. Are pressure ulcers preventable? If so, what preventive strategies should be used? Are some pressure ulcers unavoidable? If so, how can this be documented so that practitioners who provide appropriate care are not confused with those who may be providing suboptimal care?

The fact is, there are little data to indicate which risk factors are important in pressure ulcer development and which treatments are most effective. In this vacuum, various approaches have surfaced and found favor. Because the general public, consumers, lawyers, and regulators view pressure ulcers as a sign of compromised care, their presence has become a proxy for determining if a facility offers good quality care.

Many believe that pressure ulcers are caused by an interaction between an external force (pressure or friction, for example) and inherent characteristics--e.g., heart disease or immobility--that confer risk. For the most part, pressure to body areas can be reduced by the diligent efforts of caregivers, some inherent characteristics cannot be removed, changed, or modified no matter how diligent the efforts of treating physicians and caregivers.

Thus, the quality-of-care debate continues about whether or not pressure ulcers result from poor care on the part of caregivers, or from risk factors inherent to the patient, or a combination of both.

Quality Indicator Questioned

Pressure ulcers are a common occurrence among debilitated patients. Pressure ulcers are also represented on the Centers for Medicare and Medicaid Services' quality indicators (QIs). But is the pressure ulcer QI really indicative of a facility's care process or quality? The QI looks at pressure ulcer prevalence, not incidence; therefore, it includes not only pressure ulcers that occur in the facility, but also those that occur prior to admission to the facility. The result: a facility that has a wound-care program and seeks to admit patients with pressure ulcers would have a high prevalence of patients with pressure ulcers.

It's difficult for facility staff show that a pressure ulcer is unavoidable when the minimum Data Set (MDS), from which the QIs are derived, is limited in that it captures only the most basic risk factors for the development of pressure ulcers. Based on current evidence, "it's clear that the use of pressure ulcer prevalence is not an appropriate measure of quality," says Jacob Dimant, MD, CMD, President of the American Medical Directors Association. The use of an additional validated scale could provide more information--for example, details on sensory perception, skin moisture, and friction and shear--suggests Dr. Dimant, who is also a member of Caring's Editorial Board, adding that the Braden and Norton scales have some published data showing that they have good predictive values.

Role of Risk Assessment

There is a lack of evidence for much of what is done to predict and treat pressure ulcers. Yet, certain practices are accepted and become de facto standards that are carried out in facilities nationwide. Those practices lie mainly in the areas of risk assessment, prevention, and management.

It's a fact of life that risk assessment for pressure ulcers must be done in long-term care. Assessments are required upon admission, and at least quarterly after admission. One generally agreed-upon principle is that pressure ulcers are most likely to occur in patients with chronic pre-existing conditions (see "Risk Factors for the Development of Pressure Ulcers" and "Risk Factors for the Development of Pressure Ulcers" in Part 2 of this article). The severity of pre-existing illnesses may strengthen the case for the unavoidability of a pressure ulcer and can sometimes be a successful and effective defense against an accusation of negligence (see box at right).

For more than 30 years, health care professionals have been trying to find a way to assess the risk of pressure ulcer development in individual patients, identify those at risk, and carry out preventive approaches for those individuals¹. Nevertheless, argues David R. Thomas, MD, CMD, a Geriatrician in the Division of Geriatric Medicine at Saint Louis University [MO] Health Sciences Center, despite "mountains" of geriatrics text books that state that risk assessment is the first course of action for pressure ulcer prevention, no controlled trial has shown that doing a risk assessment actually leads to a reduction in the incidence of pressure ulcers.

Although Dr. Dimant agrees that the value of risk assessment has not been tested in well-designed controlled trials², he notes that some evidence suggests that risk assessment using standard scales has a predictive value for the development of pressure ulcers³; therefore, he advocates for risk assessment as a key factor in pressure ulcer prevention.

Preventive Strategies

If risk assessment is accepted as a predictive measure for the development of pressure ulcers, what does this mean for preventive interventions?

The case for an "unavoidable" pressure ulcer will most likely be judged against caregiver efforts to prevent skin breakdown⁴. Federal regulations require nursing facilities to ensure that a resident who enters the facility without pressure ulcers does not develop any, unless the individual's clinical condition demonstrates that pressure ulcer development was unavoidable. A facility's care processes are the main focus of discussion when investigating quality of care once pressure ulcers do occur in a facility.

Regulatory agencies expect facility staff to prevent pressure ulcers from forming and to prevent them from worsening, even with residents admitted with pressure ulcers.

Nevertheless, the published data on the prevention of pressure ulcers do not support the assumption that all pressure ulcers are preventable if preventive measures are taken. What's more, the data suggest that many of the known risk factors for the development of pressure ulcers cannot be modified by current treatments⁵.

Also noteworthy is the fact that while the awareness and improvement in the understanding of the prevention and treatment of pressure ulcers as well as regulatory oversight have markedly increased in the last decade, the incidence of pressure ulcers has only slightly decreased over the same period^5,6.

CMS expects facilities to do preventive care even though no data support the efficacy of such care. "The problem," asserts Dr. Thomas, "is that there is a huge amount of junk out there telling us that we have to do all this stuff to prevent pressure ulcers when there often are no data proving that all this actually prevents ulcers from developing. For example, even though most care processes teach that skin should be kept moist, no clinical trail has been done showing that treatments for dry, scaly skin eliminate the risk of pressure ulcers."

In addition, notes Dr. Thomas, although many care processes stress the importance of two-hour repositioning of immobile patients, no published data support the view that passive repositioning can prevent pressure ulcers.

"Don't get me wrong," he stresses. "Everyone agrees that you have to assess patients, relieve pressure, apply appropriate nutritional intervention and wound care, and so forth, because you'll get crucified if you don't. But what I want is for people to step back and look at the data. Just because we do something doesn't mean that there is actual cause-and-effect evidence to support it. Knowing that is key if you're going to dialogue with surveyors and lawyers."

In fact, adds Dr. Dimant, "recommendations are based on the work of expert panels of, among others, the American Healthcare Policy and Research (now AHRQ), AMDA, the National Pressure Ulcer Advisory Panel (NPUAP), and the Assessing Care Of Vulnerable Elders (ACOVE) report⁷. Note that each one of them cites the others as support."

To show that a facility is following a good care process (see box, below), Dr. Dimant, who chaired the workgroup that developed AMDA's guidelines on pressure ulcer treatment, suggests using the AMDA guidelines or a similar tool to assess and document the likelihood that a new or additional pressure ulcer is unavoidable despite appropriate care.

Follow this link to Part 2 of the article

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