PA PSRS Patient Saf Advis 2006 Sep;3(3):21-4.
Pressure Ulcers: A Look at Reports to PA-PSRS
Dermatology; Gerontology; Nursing
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Introduction

In the 18 months between June 28, 2004, and December 31, 2005, PA-PSRS received 10,913 reports of pressure ulcers, medically known as decubitus ulcers and colloquially known as bed sores. There is little in these patient safety reports that add to the large existing body of knowledge about the accurate assessment of patients for risk of developing this complication, effective preventive measures, or effective treatments (see Pressure Ulcer Resources). However, pressure ulcers have been a traditional marker for medical care quality and, more recently, have been a patient safety indicator. Therefore, facilities may wish to analyze their patient safety reports of pressure ulcers as a monitor of quality and may want to have those reports as accurate as possible for that reason.

Analysis of the Reports to PA-PSRS

  • Pressures ulcers were reported in patients of all ages, although the elderly predominated, with an average age of 73 and a median age of 77. Not surprisingly, 55% were female.
  • The pressure ulcers were noted to be present on admission in 66% of the reports and developed after admission in 34% of the reports.
  • Among the pressure ulcers reported as present on admission, 12% were classified as stage I, 44% stage II, 9% stage III, and 7% stage IV; 27% of the reports did not report a stage. Further, 16% were reported as Serious Events and 84% as Incidents.
  • Among reports involving pressure ulcers that developed after admission, 16% occurred in patients assessed to be at low risk and 45% in patients assessed to be at high risk; 39% did not report a risk assessment.
  • Among reports involving patients assessed to be at low risk, 28% of pressure ulcers were classified as stage I, 54% stage II, 2% stage III, and less than 1% stage IV; 16% of the reports did not note the stage. Further, 38% were reported as Serious Events and 62% as Incidents.
  • Among reports involving patients assessed to be at high risk, 27% of pressure ulcers were classified as stage I, 62% stage II, 3% stage III, and 1% stage IV; 7% of the reports did not note the stage. Further, 20% were reported as Serious Events and 80% as Incidents.
  • Among reports involving patients who did not have an initial assessment noted, 11% of pressure ulcers were classified as stage I, 36% stage II, 1% stage III, and less than 1%  stage IV. Not surprisingly, 51% of these reports also did not note the stage. Only 5% were reported as Serious Events and 95% as Incidents.
  • Among reports of pressure ulcers that developed after an initial documented assessment and in which the stage was reported, 30% were stage I, 66% stage II, 3% stage III, and 1% stage IV. Though there was a correlation between the risk of pressure ulcers and the reporting of the subsequent ulcer as an unanticipated Serious Event, there was no correlation between the stage of the ulcer documented in the report and the classification of the report as a Serious Event or Incident. This is consistent with the interpretation that it is events involving the care (such as not turning the patient)— not the resulting unanticipated injury per se—that determines if a report is that of a Serious Event. For instance, if an elderly patient fell at home and was wedged between the tub and radiator overnight, unable to move, stage IV pressure ulcers might be predicted at the contact points and would not meet the definition of unanticipated injury if they occurred.
  • There were inconsistencies between reporting the events as having been present on admission, occurring in the first 24 hours, or developing later in the admission when we compared those sub-classifications of this event type with the dates of admission and the dates the events were reported to have occurred. While we accepted that the date of “occurrence” might be later, because of delayed detection or documentation, there were logically inconsistent reports of pressure ulcers occurring after admission but being reported to have occurred on the date of admission.

Conclusions

  • Facilities are reporting pressure ulcers present on admission from other venues.  Most of the reports were of pressure ulcers present on admission (65%).
  • Facilities are reporting stage I and II pressure ulcers.  Most of the pressure ulcers with stages reported were stage II (63% overall) and almost all of the pressure ulcers with stages reported were either stage I or stage II (84% overall).
  • As would be expected, the percentage of pressure ulcer complications reported as Serious Events was much higher among patients initially assessed to be at low risk (38%) than among patients initially assessed to be at high risk (20%).
  • There is a significant number of reports in which the valuable stage information is not reported (26% overall).
  • Facilities should develop quality control standards to ensure consistency between the dates of occurrence, relative to the date of admission, and the sub-classifications of the pressure ulcer event type as being present on admission or occurring subsequently.
  • There is a significant number of reports that do not document any assessment of the patient’s risk of developing a pressure ulcer (39% of those without a pressure ulcer on admission).  If assessments are not being made, this is a potential area for improvement in the quality of care.  There was a disturbing correlation between not documenting any assessment of the patient’s risk of developing a pressure ulcer, not documenting the stage of the ulcer, and not reporting the subsequent pressure ulcer as an unanticipated Serious Event: 20% of pressure ulcers not present on admission had neither assessments nor stage documented, and only 3% of those were reported as unanticipated Serious Events. (In contrast, of the patients assessed – and anticipated – to be at high risk for subsequently developing pressure ulcers, with stages documented, 19% were reported as unanticipated Serious Events.)

Summary

Facilities are reporting pressure ulcers, even when they pre-date that facility’s care and are not severe.  Those who report assessments are accepting responsibility for Serious Events even in high-risk patients and more so in low-risk patients.  Facilities may be missing useful information for tracking their own quality improvement and patient safety program if they do not collect information about the stage of the pressure ulcer.  Facilities that are not assessing patients for their risks of developing pressure ulcers are missing an opportunity for improving the quality of their care.  By recording information about patient assessments for risk and the stages of pressure ulcers, facilities can more accurately track their progress in improving the very common and important problem of pressure ulcers.

Supplemental Material

Pressure Ulcer Resources      

Prevention of hospital-acquired pressure ulcers is the goal of every acute care facility and nursing department. Recognized risk scales by the National Pressure Ulcer Advisory Panel (NPUAP) are the Braden, Norton and Gosnell Scales.1 Each scale provides for assessing and calculating a patient’s risk. Based on the determined risk score, appropriate preventative interventions are implemented. The selection and use of support surfaces are frequently associated with the calculated risk status of the patient. Any change in the patient’s condition necessitates a reassessment. The Braden Scale for Predicting Pressure Ulcer Risk is “the most widely used tool for predicting the development of pressure ulcers.”2  This scale is available in a Chart or a Narrative Format.

Upon admission, skin integrity is routinely assessed, with attention to bony prominences and any other areas subject to pressure, friction or shearing. If tissue injury is identified, the wound is described and typically staged between I and IV.

The current practice of staging pressure ulcers is under review by the NPUAP. A survey of clinicians comparing current and proposed definitions of the stages of pressure ulcers was conducted by the NPUAP on their website and closed May 31, 2006. This survey was the result of an early 2005 consensus conference that discussed deep tissue injury and limitations of the current staging system.3

The currently accepted definitions for the four stages of pressure ulcers can be found on the NPUAP web site:

  • Stage 1 - pressure ulcer is an observable pressure-related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.
  • Stage 2 - partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
  • Stage 3 – full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
  • Stage 4 – full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage 4 pressure ulcers.

Early preventative interventions mitigate the threat of pressure ulcer formation in patients identified to be at-risk. Both intrinsic and extrinsic etiologic factors contribute to pressure ulcer development. Assessing patient characteristics, improving tissue tolerance and protecting skin from the damaging effects of pressure, shear and friction are the cornerstones of a skin integrity plan of care. An NPUAP fact sheet, “Pressure Ulcer Prevention Points” summarizes key points and is available at the NPUAP web site.

A number of clinical practice guidelines have been developed in the area of pressure ulcer prevention and treatment. Summaries of many of these guidelines are available at the National Guideline Clearinghouse (www.guideline.gov), including:

The NPUAP provides two competency-based curricula to educate registered nurses “with the minimum competencies” for pressure ulcer prevention and treatment. Both curricula (Prevention and Treatment) provide case studies followed by questions and answers and are available from the Advisory Panel.

Notes
  1. National Pressure Ulcer Advisory Panel (NPUAP). Statement on Pressure Ulcer Prevention. 1992 [cited 2006 May 31]. Available from Internet: http://www.npuap.org/positn1.html.
  2. Ayello E, Braden B. How and why to do pressure ulcer risk assessment.  Adv Skin Wound Care. May/Jun 2002; 15(3):125-32.
  3. Doughty D, Ramundo J, Bonham P. Issues and challenges in staging of pressure ulcers. J Wound Ostomy Continence Nurs. Mar/Apr 2006;33(2):125-30.
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