One of the biggest challenges in caring for patients with pressure ulcers from a risk-management  standpoint is determining whether the ulcer was avoidable.  The National Pressure Ulcer Advisory Panel has recently come out with a statement that “Not all pressure ulcers are avoidable.”  As a reference point, we can look at the Interpretive Guidelines for F-Tag 314 issued by the Department of Health & Human Services, which was used by the NPUAP as a basis for their consensus statement.  Although these regulations apply only to Medicare certified long-term care facilities, the wording regarding avoidable versus unavoidable pressure ulcers is instructive and well thought out.
Dr. Jeffrey M Levine

“Avoidable” means that the resident developed a pressure ulcer and that the facility did not do one or more of the following: evaluate the resident’s clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate.

“Unavoidable” means that the resident developed a pressure ulcer even though the facility had evaluated the resident’s clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate.

In any setting – hospital, nursing home, or home care – unavoidable pressure ulcers certainly occur.  Based upon the above definitions, this occurs when all preventives are in place, yet the patient’s underlying illness and debility exceeds what is technologically possible by standard evidence-based guidelines.

To help define when pressure ulcers are unavoidable, I performed a research study on unavoidable pressure ulcers looking retrospectively at a group of hospitalized patients.  We identified 20 individuals who developed pressure ulcers when all preventives were in place, then studied the cluster of clinical characteristics that were present in those patients.  The top 10 conditions were as follows:

► Hypoalbuminemia (Alb < 3.0)
► Respiratory failure with intubation
► Severe anemia (Hb < 10)
► Hypoxemia
► Sedation
► Hypotension
► Sepsis
► Malignancy
► Diabetes mellitus
► Renal failure (acute or chronic)

Persons with malignancy had a variety of cancer types that were often metastatic, or occurred in patients with multiple primaries.  Cancers included ovarian, lung, bladder, colon, and hematologic sources (multiple myeloma, chronic lymphatic leukemia).

The bottom line is that damage and death of the skin and deeper tissues can indeed occur when the patient’s medical, physiological, and functional status is so impaired that the effectiveness of preventive measures is limited.  To remedy this situation from a risk-management standpoint demands proactive documentation of physiological risk factors, as well as a quality oriented system of risk factor assessment, implementation, and documentation of all necessary pressure relief modalities.

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Download my research article entitled: The Unavoidable Pressure Ulcer: A Retrospective Case Series.

Related posts:

Pocket Guide to Pressure Ulcers.
Revised F-Tag 314: Pressure Ulcers.
How CMS Views Pressure Ulcers in Hospitals.
New Research Sheds Light on Hospital Acquired Pressure Ulcers

Read the NPUAP statement on Unavoidable Pressure Ulcers.

Read the Wound Ostomy & Incontinence Nurses Society (WOCN) position on Unavoidable Pressure Ulcers

 

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