This is a very timely and thought-provoking project and article. It is timely in that hospital-acquired pressure ulcers (HAPU) are one of the care management events being targeted by the Centers for Medicare & Medicaid Services (CMS) for increased scrutiny and reduced payment or nonpayment effective October 2008.1,2 It is thought-provoking because it highlights gaps in our knowledge base and areas where more research is needed: gaps related to risk assessment, optimal preventive care, and the incidence and characteristics of avoidable versus unavoidable pressure ulcers.

Issues Related to Risk Assessment

Prompt and accurate identification of at risk patients permits timely initiation of preventive care; it is therefore important for the wound/WOC nurse to critically evaluate the risk assessment program in her/his agency and to initiate process improvement when indicated. An interesting finding in this project was the tendency of staff nurses to underestimate risk. This is clinically relevant since underestimation of risk is expected to result in failure to implement appropriate preventive care. A strength of this project report was the follow-up provided on the effects of intensive education and mentoring, which did improve accuracy of risk assessment. This suggests that we may need to spend more time and more effort on assuring accurate use of risk assessment tools, eg, by including risk assessment in annual skills fair/competency evaluations.

The authors of this project report identified a number of risk factors that appeared to correlate to development of HAPU that are not included in the Braden Scale: (1) length of stay, (2) transfer from another facility, (3) mechanical ventilation, and (4) comorbidities such as diabetes mellitus. However, as the authors note, this was a small project involving only one intensive care unit and one medical-surgical unit; clearly more data are needed to determine whether these factors represent independent predictors that should be incorporated into currently accepted risk assessment tools.

The authors introduce an interesting concept related to risk assessment, that of presumed risk. The project report did not include specific guidelines as to how clinicians were to use their clinical judgment related to presumed risk to adjust the risk assessment score generated by the standard tool, nor did the report address the impact of these subjective adjustments on the accuracy of risk assessment. Hopefully the authors will address this approach to risk assessment in greater detail in future articles. One must consider the possibility that encouraging clinicians to consider presumed risk acted to heighten their focus and attention to risk factors already included in established risk assessment tools, which would enhance the accuracy of risk assessment. For example, the authors encouraged clinicians to consider the fact that a patient with diabetes may have sensory neuropathy that would increase the risk for pressure ulcers on the heels; this was an excellent approach to increasing focus on conditions other than altered mental status and major neurologic lesions that can compromise sensory function. Clearly more study is needed to determine whether the presumption of risk increases the accuracy of risk assessment; perhaps the take-home message at this point is to conduct risk assessment with a higher index of suspicion, and to err on the side of greater risk when there is any ambiguity.

Nutritional compromise is commonly considered to be a risk factor for PU development, and is included in most of the widely used risk assessment tools. However, clinicians and researchers lack agreement on the best indicator of nutritional status, since both weight and serum studies (albumin and prealbumin) are affected by a number of factors other than nutritional status. The authors suggest that prealbumin should be routinely used as a screening study for nutritional compromise. However, additional evidence is needed to determine the reliability and validity of prealbumin as a screening tool for nutritional compromise, as well as the appropriate cut score indicating the need for preventive intervention.3

Issues Related to Prevention

An encouraging finding in this project was the positive impact of intensive education on both nursing practice and documentation, as evidenced by a significant increase in preventive care postintervention. This certainly provides support for ongoing staff development programs focused on pressure ulcer prevention, and highlights the importance of the staff development hat to WOC nursing practice.

Avoidable Versus Unavoidable Pressure Ulcers

Perhaps the most significant finding in this study was the lack of any significant change in clinical outcomes (incidence of HAPU) despite marked improvement in preventive care and documentation. This strongly supports the belief of many clinicians that some pressure ulcers are unavoidable, especially among very high-risk patients. This project was clearly focused on preventive care and did not involve formal root cause analysis on HAPU; the authors were therefore unable to distinguish clearly between ulcers that were avoidable and those that were unavoidable. I believe this is the most important take-home message from this report; we must begin to routinely conduct formal root cause analysis for any HAPU, for 2 reasons: (1) this will allow us to clearly distinguish between avoidable and unavoidable ulcers, which will become increasingly important with the increased scrutiny of these lesions; (2) this will permit us to conduct proactive problem-solving to enhance clinical practice and to reduce avoidable HAPU, which is our ultimate goal.

What is the accepted definition of an unavoidable pressure ulcer, and how would a clinician use root cause analysis to determine that a HAPU in her/his facility was in fact unavoidable? An unavoidable pressure ulcer has been defined as an ulcer that occurred despite appropriate preventive care, including assessment of the patient's clinical status and risk status, definition and implementation of preventive measures that reflect current standards of practice and that are modified based on the patient's individual needs, ongoing monitoring and prompt identification of any deterioration in skin status, and revisions in the management plan when indicated (eg, when there is evidence of deterioration in skin status).4

In conducting root cause analysis, the Wound Care/WOC nurse should devise a simple form that addresses each of these factors and that is used to evaluate each HAPU according to the following criteria:

* Was the patient's skin status assessed on admission, and was there any documentation of skin breakdown? (If no breakdown was documented on admission, any subsequent breakdown would be considered hospital-acquired.)

* Was a risk assessment conducted upon admission and at least every 48 hours thereafter, and was the patient identified as being at risk? (If a risk assessment was conducted but the patient was found to be not at risk, the Wound Care/WOC nurse should do further assessment of the risk assessment to determine if it was accurate.)

* If the patient was determined to be at risk, were appropriate preventive measures implemented? Preventive measures should include all of the following: placement on a pressure redistribution surface, routine repositioning, nutritional consult if indicated, appropriate incontinence care, and at least daily skin assessment. (Gaps in preventive care mean that the ulcer would be considered hospital-acquired.)

* Was the ulcer detected promptly during routine skin assessment, and was the prevention protocol modified as indicated? An example is placement of a patient on a higher level support surface in response to deterioration in skin status, as well as physician notification and initiation of appropriate topical therapy.

Any ulcer found to be hospital-acquired according to these criteria should prompt modifications in the overall pressure ulcer prevention system, in order to minimize the risk of additional HAPU and to clearly reflect the agency's commitment to quality care.

Issues Related to Staging of Pressure Ulcers

The proposal by CMS will target full-thickness ulcers (Stage 3 and Stage 4), and the CMS currently plans to rely on physician documentation of a pressure ulcer within the first 48 hours following admission as evidence that the full-thickness wound was present on admission. Clearly this brings up issues related to accuracy of physician staging and documentation, as well as issues related to deep tissue injury that is present on admission and later deteriorates into a Stage 3 or 4 pressure ulcer. Wound care/WOC nurses will need to collaborate with physicians in their agencies to assure accurate documentation of any lesions present on admission, and must also continue to work with CMS on 2 related issues: (1) recognition of deep tissue injury as a precursor to a full-thickness (possibly unavoidable) ulcer, and (2) a clear definition of the criteria for an unavoidable pressure ulcer, and establishment of measures to protect agencies against punitive measures for unavoidable ulcers.

Summary

Clearly there is much to be done to assure that our risk assessment methodology and preventive care meets current guidelines and that we can clearly differentiate between avoidable and unavoidable ulcers; this is a challenging but exciting time for wound care/WOC nurses based in acute care, and I appreciate the many ways in which this project report contributes to our awareness of the issues and possible strategies.

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