Placing priority on pressure ulcers

For many years, proper attention was not devoted to prevention, recognition and treatment of pressure (decubitus) ulcers, which greatly increase the risks of morbidity and mortality in hospitalized patients. However, the current emphasis on public reporting of quality scores, as well as pay-for-performance and consumer awareness, has made accurate documentation and effective management of pressure ulcers a crucial health care consideration.

Medicare now provides a substantial revenue inducement to hospitals for identifying and treating stage 3 and 4 pressure ulcers. There are also penalties for failing to do so, or allowing them to develop during hospitalization. In addition, the rate of hospital-acquired pressure ulcers is publicly reported for all hospitals as a quality indicator on the Centers for Medicare and Medicaid Services website.

Photo by Comstock
Photo by Comstock.

Screening for and early documentation of pressure ulcers are essential. Every patient should be screened for pressure ulcers at the time of admission; when found, they must be documented, correctly staged (see sidebar) and treated. Included in the exam should be the patient's back, pre-sacral/gluteal areas and heels. If not identified upon admission, pressure ulcers are likely to be considered hospital-acquired and an indicator of inadequate care.

Pressure ulcers are classified by stage and location. They should be distinguished from other forms of cutaneous ulceration such as diabetic, ischemic, stasis (venous), varicose, malignant, traumatic, atrophic, infectious (as cause), and burns. They typically occur at pressure/contact-point locations: elbows, low back, sacrum/coccyx, buttocks, and heels.

If a patient is turned to one side for prolonged periods, decubiti may be found over the ischial tuberosities (lateral hip), ankles or even shoulders. Sheer forces and friction also contribute to decubitus formation. Risk factors include debilitation, inability to reposition oneself, malnutrition, bed or chair confinement, sensory deficits, fecal/urinary incontinence, and inability to feed oneself.

Once the protective dermal layer is lost, necrosis may easily and rapidly extend to subcutaneous tissue, muscle and bone. Ulcers beyond stage 1 almost invariably become colonized with bacteria (usually Staphylococcus, Streptococcus, and gram negatives); can easily become infected and produce cellulitis, gangrene or abscess; and often progress to systemic infection with sepsis.

In summary, check patients carefully for pressure ulcers at the first encounter and document accurately, including location and stage. Provide appropriate treatment and use preventive measures for all patients at risk.