A Regular Series that Looks at Some of the Most Common Forms of Medical Injury
#1 | PRESSURE ULCERS
Pressure ulcers are generally considered avoidable. So why do they still account for the largest category of hospital harm? And one of the most expensive to treat?
Since the days of Florence Nightingale, pressure ulcers, commonly referred to as bed sores, have been seen as preventable with proper care. The problem is that more than a century after this revered icon of the healing professions made that observation, proper care is still not present in too many cases.
As the U.S.-based Institute for Healthcare Improvement put it,
Pressure ulcers cause considerable harm to patients, hindering functional recovery, frequently causing pain and the development of serious infections. Pressure ulcers have also been associated with an extended length of stay, sepsis, and mortality. In fact, nearly 60,000 US hospital patients are estimated to die each year from complications due to pressure ulcers. The estimated cost of managing a single full thickness pressure ulcer is as high as $70,000, and the total cost for treatment of pressure ulcers in the US is estimated at $11 billion per year.
Pressure ulcers are the most frequently occurring form of hospital harm from medical errors, and the most expensive to treat. Significantly, it is widely accepted that the cost to treat pressure ulcers is much greater than the cost of preventing them.
The numbers speak for themselves:
- Estimated number of cases of pressure ulcers in U.S. hospitals each year: 2.5 million
- Estimated number of U.S. deaths from pressure ulcers each year: 60,000
- Additional cost to care for a U.S. hospital patient who develops a pressure ulcer: up to $70,000
- Total annual cost for treatment of pressure ulcers in U.S. hospitals: $ 11 billion.
The actual incidence of pressure ulcers among U.S. hospital patients may be significantly higher than these numbers indicate, however. In 2012, the Office of the Inspector General, U.S. Department of Health and Human Services, found that a staggering 86 percent of adverse incidents involving Medicare and Medicaid patients were not reported.
Canada has produced few comparable figures to those available in the United States. However, one study concluded that the prevalence of pressure ulcers in Canada is greater than in the U.S. on a per-patient basis. Canadian costs for the care of pressure ulcers are not available.
There is ample evidence-based knowledge within the healthcare community about the conditions that lead to pressure ulcers and how they can be avoided. The risk of developing skin breakdown is known to be greatest among elderly patients. Pressure ulcers are also more likely to occur in patients who are incontinent or who have Diabetes, mobility limitations, or compromised nutritional status (malnutrition). Any patient who is hospitalized longer than five days is at greater risk for developing pressure ulcers. But the greatest risk of all is the hospital that neglects to provide the care necessary to prevent pressure ulcers, or worse, that leaves them untreated when they develop.
Given the ability of healthcare providers to prevent pressure ulcers, the fact that they continue to occur with such frequency confirms what Ms. Nightingale observed more than a century ago: they are a reflection of the poor quality of care. If adverse events like these cannot be controlled when the knowledge and means to do so are easily available, what hope is there that more complex contributors to hospital harm will be eliminated?
Patients and families regularly report to The Center for Patient Protection experiences where evidence-based recommended practices to prevent pressure ulcers were not followed, resulting in debilitating pain and complications to the hospitalized victims of these errors.
These experiences are confirmed by The Center’s founder, Kathleen Finlay, whose elderly mother, Lorraine, developed Stage II pressure ulcers at two hospitals during a six-month admission. At one of the hospitals, required standards of practice, including mandatory steps to prevent pressure ulcers, were not followed even though she was known to have developed pressure ulcers at the previous hospital and was rated at the highest risk for developing new wounds.
After Lorraine developed painful skin tears and open wounds, the hospital failed to provide the proper treatment and concealed the condition from the family. While refusing to address the matter for more than four years, one of the hospitals recently admitted to nursing regulators that a Stage II pressure ulcer was apparent, but was still never documented in the chart, toward the end of her stay.
Discovering the severe wound only after Lorraine was discharged home, the family was required to reposition her in bed every two hours, day and night, for several months, as part of the treatment regimen that was ignored at the hospital. Her condition also required a special hospital pressure reducing mattress, which the family purchased at considerable cost. It was the kind of mattress Lorraine required at the hospital but which was never provided.
Pressure ulcers are agonizingly painful and frequently unleash a cascade of complications that can lead to increased hospitalization, higher healthcare costs and even death. Patients and families need to be alert to the signs and to the conditions that pre-dispose a patient to developing such wounds, especially in the face of sub-standard care.
What you can do
Learn how to identify the signs of pressure ulcers, and which patients are most at risk.
- Look for signs of severe pain, especially if the patient is elderly, incontinent or has had a hospital stay lasting more than five days. Watch the accompanying videos for other warning signs and for what parts of the body are most susceptible to pressure ulcers, skin tears and breakdowns.
- Ask nursing staff if the patient has been assessed for the risk of developing pressure ulcers with a recognized tool such as the Braden Scale. Find out what the results are, if they have been assessed.
- If the risk is rated high, ask what protocols for prevention and treatment are being followed, including frequent turning in bed, the use of pressure-reducing surfaces and other devices, and wound care. Don’t assume the required care measures will be taken. In many cases known to The Center, they are not.
- Realize that in patients who are incontinent or malnourished, skin breakdowns can occur quickly. Serious complications can follow. Don’t take anything for granted. Get the information you need to be assured that all steps are being taken to prevent the development of pressure ulcers and skin tears and that they are being fully treated if and when they occur.
- All it will take is one look at even an early-stage pressure ulcer for you to realize how painful and dangerous they can be. It will make you all the more determined to prevent them from occurring. But only when hospitals everywhere are required by law to report them, along with all other errors and adverse incidents, and to not cover them up as many do today, will the public be able to have confidence that the known steps to prevent pressure ulcers are actually being followed in the clinical setting.
Additional information is available at:
- Pressure Ulcers: Avoidable or Unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference
- Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care
A Primer on Pressure Ulcer Prevention