PRESSURE ULCER RISK ASSESSMENT SCALES--
THE MISSING LINK
Kenneth Olshansky, MD
Copyright 1998 Springhouse Corporation.
Used with permission from Advances in Wound Care 22 (2):90.
A RECENT ARTICLE IN ADVANCES IN WOUND CARE (1) leads me to conclude that we, as clinicians, still are not being honest with ourselves about the etiology of pressure ulcers. Several aspects of the article are worthy of discussion.
The principal investigator determined a Braden Scale score for each patient admitted to the study, then recorded subsequent nursing interventions. There was, however, no discussion of the type of interventions used. The results of the study showed 28% of the patients developed pressure ulcers--11 Stage I and 3 Stage II. Four patients with Braden Scale scores that indicated they were not at risk for a pressure ulcer eventually developed Stage I ulcers, and six patients who were believed to be at risk did not develop pressure ulcers.
The authors conclude that their study is "further evidence of the predictive validity of the Braden Scale" but that investigation is needed to determine why those six patients did not develop pressure ulcers. "Three of these patients had the following factors in common. All three were placed on alternating pressure air mattresses at admission or within 24 hours of admission. One of the three was also placed on a turning schedule and given topical skin treatments. A third patient was also given heel protectors." (Should these not be routine interventions for all at-risk patients?)
The article further indicates, "Three of the first 25 patients (12%) developed pressure ulcers compared with 11 of the final 25 patients (44%) ... the Hawthorne effect may have caused nurses, aware that a pressure ulcer study was being conducted, to respond initially with more preventative actions. As this study progressed, this effect may have decreased."
Predicting pressure ulcers
After reading this study, I am convinced that there is no accurate predictive value in pressure ulcer assessment scales. There is, in my opinion, only one predictive factor that will determine whether at-risk patients will develop pressure ulcers: who is caring for these patients. Like most risk assessment scales, the Braden Scale measures only the patient. It does not measure the staff. The incidence of pressure ulcers is related directly to the care given by the nursing staff.
Let us assume that there are 100 sets of identical twins with the lowest possible Braden Scale scores. One-half of the at-risk twins are admitted to an understaffed facility with poorly prepared personnel and no pressure-relieving beds. The other half are admitted to the finest facilities with well-prepared nurses, fully staffed shifts, pressure-relieving beds for each patient, and enough staff to turn each patient every 2 hours. It is my contention that the latter group will have dramatically fewer pressure ulcers than the former, despite identical Braden Scale scores.
We, as health care professionals, continue to blame our patients for their pressure ulcers, and most of the assessment scales do the same. In other words, the scales imply that at-risk patients are expected to develop pressure ulcers. When are we going to accept responsibility? If one of my patients develops a pressure ulcer, and some of them certainly do, I take responsibility. At some time during the patient's course in the hospital or nursing home, the nursing staff and I fell down on the job, pure and simple. The sicker and more at risk the patient, the harder we must work to prevent ulcers.
When I say this to hospital and nursing home administrators, I hear complaints that they are understaffed, overworked, have too many patients, too little money, and not enough specialty beds. My answer is that they are probably right. However, we need to acknowledge this and stop blaming patients because they have low Braden Scale scores. The time has come to be honest. A patient develops a pressure ulcer because, at some point, he or she had inadequate pressure relief.
Preventing pressure ulcers
The Braden Scale is an excellent nursing assessment tool for evaluating a patient's general condition. It should alert us that a patient requires our utmost vigilance. However, implementing preventive measures should be similar to implementing universal precautions - every at-risk patient, no matter what the Braden Scale score, should be afforded the best preventive care possible. There should be zero expectation that any patient will develop a pressure ulcer. The Braden Scale has no predictive validity unless the assumption is that the care is going to be inadequate.
Pressure ulcer prevention, to use the old cliche, is a 24-hour-a-day job. On a daily basis, we are entrusted with the care of thousands of at-risk patients. Are we honestly up to the challenge?
Reference
1.Capobianco ML, McDonald DD.. Factors affecting the predictive validity of the Braden Scale. Adv Wound Care 1996;9(6):32-6.
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Kenneth Olshansky, MD, is a clinical professor of plastic surgery at Virginia Commonwealth University-Medical College of Virginia, Richmond.
MEDICARE POLICIES - THE GREAT INSULT
Physicians take a vow that says "First, do no harm". Patients enter hospitals suffering from cancer, diabetes, kidney failure, heart disease, and many other serious ailments. They do not expect to be subjected to the additional horrible affliction of the decubitus ulcer because of their stay in the hospital. Yet an astounding one in ten do suffer this horror along with attendant infections that develop in hospitals in these open wounds. The elderly suffer a disproportionately increased rate of bedsore incidence.
In 1983, the Congress enacted a prospective payment system (PPS), under which Medicare pays a fixed predetermined amount for inpatient hospital services for each patient. Under PPS, each hospital patient is assigned to a single diagnosis related group (DRG) based on the principal diagnosis of the patient. Under PPS, hospitals know in advance how much they will be paid based on the DRG to which the patient has been assigned. The hospital gains a profit or suffers a loss depending on whether they can keep costs below PPS payments. Thus, hospitals have strong incentives for efficiency.
But, to add insult to injury, there is no DRG for a bedsore. No hospital patient is ever assigned the primary diagnosis of decubitus. Few, if any, are ever recorded as dying from their pressure wounds, yet many do. Medicare allows payment to hospitals for rental of air fluidized therapy, the only engineering solution that removes the cause of the pressure wound, only after the wound has developed and reached life- threatening dimensions. Yet even when that stage is reached, few hospitals and doctors will call for the therapy because it will cut into their profits. Congress has designed a cost containment system that insures the debasement of the patient unlucky enough to land in a hospital that gives him or her a bedsore.
The following is taken from Section 14.24, "Pressure Reducing Support Surfaces", of the Medicare Manual.
"Definition: An air fluidized bed is a device employing the circulation of filtered air through silicone coated ceramic beads creating the characteristics of a fluid.
The staging of pressure ulcers used in this policy is as follows:
Stage I nonblanchable erythema of intact skin
Stage II partial thickness skin loss involving epidermis and/or dermis
Stage III full thickness skin loss involving damage or necrosis of subcutaneous tissues that may extend down to, but not through, underlying fascia
Stage IV full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures
Coverage and Payment Rules
An air fluidized bed is covered only if all of the following criteria are met:
The patient has a Stage III (full thickness tissue loss) or Stage IV (deep tissue destruction) pressure sore.
The patient is bedridden or chair bound as a result of severely limited mobility.....
The air fluidized bed is ordered in writing by the patient's attending physician based upon a comprehensive assessment after conservative treatment has been tried without success...
The patient must generally have been on the conservative treatment program for at least one month prior to use of the air fluidized bed with worsening or no improvement of the ulcer."
It does not seem possible to imagine a greater insult than to have the hospital you depended on for care deliver you a bedsore, then to insist that you suffer with it until it develops into an horrendous wound before the treatment that would have prevented the ulcer in the first place is provided.
