A new study published in the Journal of the American Geriatrics Society sheds light on hospital acquired pressure ulcers with data on epidemiology, mortality, and patient characteristics. Its results are certain to fuel the debate on avoidability of pressure ulcers.
The researchers analyzed 51,842 discharges of hospitalized Medicare patients in 2006 and 2007 for occurrence of hospital acquired pressure ulcers (HAPU). They found a nationwide HAPU prevalence rate of 4.5%. States with the lowest HAPU rate were Wisconsin (3.1%), Alabama (3.3%), Tennessee (3.7%), and North Carolina (3.8%). Highest rates were found in New York (5.2%), New Jersey (5.3%), Massachusetts (5.5%), and Pennsylvania (5.9%).
The majority of HAPU's were located on the coccyx or sacrum (41%) followed by hip and buttocks (23%) and heels (23%). Several patient characteristics were associated with HAPU including age, obesity and use of corticosteroids. Associated diagnoses included cancer, congestive heart failure, emphysema, stroke, and diabetes mellitus. Patients with HAPU had higher in-hospital mortality, increased mortality within 30 days of discharge, and higher readmission rates within 30 days. Patients with HAPU had significantly longer hospital length of stay (11.6 ± 10.1 days) compared to those without (4.9 ± 5.2 days).
This study is valuable because it provides the first reliable national benchmark rate for HAPU occurrence. But is this rate of 4.5% acceptable for an outcome known to be associated with deficits in quality of care? In their discussion, the authors suggest that the rate "might be acceptable" because of prevention programs currently implemented in hospitals across America. Such a view would support the theory that pressure ulcers can develop independent of good care, supporting the "unavoidable" theory. However this research does not supply any supportive date for the assumption that HAPU developed in the presence of preventive measures.
It is not surprising that HAPU were associated with higher in-hospital and post-discharge mortality, and the authors carefully note that their data do not infer a causal relationship between pressure ulcers and death. However, these findings might provide new support for the SCALE theory – or Skin Changes at Life's End – which states that pressure ulcers might be an unavoidable consequence of impending death.
The study does not offer explanation for the wide geographic variation in hospital acquired pressure ulcer rates. Why is the HAPU rate in Pennsylvania nearly twice the rate in Wisconsin? The answers could include quality of prevention measures, quality of documentation, array of co-morbidities, or other population characteristics of hospitalized patients. It would be interesting to follow HAPU rates to determine the effect of CMS policy changes which deny payment to hospitals for new stage 3 and 4 pressure ulcers, a rule which which went into effect October 2010 — after the study period for this article. Hopefully these questions will be addressed in future research.
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Download my article entitled: The Unavoidable Pressure Ulcer: A Retrospective Case Series.
Download the reference for Skin Changes at Life's End (SCALE).
Read about my book entitled Pocket Guide to Pressure Ulcers.
Related blog posts:
Determining the Avoidability of Pressure Ulcers.
How CMS Views Pressure Ulcers in Hospitals.
Pressure Ulcer Prevention for Patients in Wheelchairs
Caution Urged with Negative Pressure Wound Therapy
Straight Talk on Reverse Staging of Pressure Ulcers
Complete citation for the article discussed in this post is: Lyder et al. Hospital acquired pressure ulcers: Results from the National Medicare Patient Safety Monitoring System Study. Journal of the American Geriatrics Society 60: 1603-1608, September 2012.