1. Salcido, Richard MD

Article Content

Many of the patients we care for will develop secondary complications of chronic illness, such as pressure ulcers (PrUs). Until now, these complications were generally considered acceptable comorbidities, especially in patients with advanced age and complex neurologic conditions. As of October 1, 2008, however, the quality and the methods of our PrU care will be monitored to conform to higher standards of clinical care, including striving to meet or surpass local, regional, and national benchmarks for PrU outcomes. Moreover, third party administrators for the Centers for Medicare & Medicaid Services (CMS) will monitor our outcomes, quality, and other pay-for-performance standards.

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Looming at the surface of these changes are elevated material regulatory obligations, which include no or reduction of reimbursement for ostensibly "hospital acquired conditions" or preventable conditions that were not present at admission, and are furthermore now and in the future labeled as medical errors and "never events." Under the new CMS payment plan, PrUs that are present on admission will qualify for a higher reimbursement, only if the presence of a Stage III or Stage IV ulcer is noted in the medical record by the attending physician within 2 days of inpatient admission.1 PrUs identified after day 2 will not be eligible for additional reimbursement. Although these changes are rooted in CMS policies and procedures, history tells us that third party payers are more than likely to follow suit. PrUs are among the most prevalent, costly, and difficult to detect, classify, and treat conditions. In addition to interfering with recovery, lengthening hospital stays, and causing pain and discomfort, PrUs can increase the risk of infection. Each year, nearly 60,000 deaths occur from hospital-acquired PrUs.1


A Clinical Vignette

By way of example, evidence demonstrates that the condition of tetraplegia (high-level paralysis) causes multiple secondary complications, such as pneumonia, urinary tract infections, and PrUs-all complications or conditions that may appear on the "reasonably preventable list" from the CMS ruling. Given this eventuality, we will require scrupulous documentation as to the source, probable cause, and the timing of onset of any secondary complication, especially in PrUs. In other words, patients who are paralyzed and immobile are at high risk for the development of these secondary complications including PrUs, preventable or not. Under these circumstances, if untoward complications arise from a given PrU that advances from a Stage I to the so-called "deep tissue injury" (DTI)2-5 or Stage IV, to a more advanced stage rapidly, regardless of our best efforts, we may not be reimbursed at a higher rate unless there is documentation the condition was present on admission. In other words, in the brave new regulatory environment there is not much room for misdiagnosing an impending Stage IV as a lesser lesion. Notwithstanding, some thought and content leaders would argue that a DTI should simply be classified as a Stage IV PrU.4 Thus, if a patient is admitted with a suspected DTI that progresses a few days after admission to a Stage IV, it might be subject to clarification by the third party administrator.


Suffice it to say, the irrefutable fact remains that some of the patients we care for will develop frank open PrUs and we must redouble our efforts to revert to basic principles, techniques, and practices centered in deterrence, detection, documentation, and diagnosis. I firmly believe that the recent climate and associated policy changes afford us new and greater opportunities to focus meticulously on the deterrence mode of the evaluation of our patients. We must take advantage of the clinical resources that will be brought to the bedside by innovative clinicians, organizations, and industry. To quote a military aphorism-we are definably in a "target-rich environment" and our resources should be accurately aimed at the 4 D's of PrUs.



Hospitals around the country have implemented innovative alert systems to prompt staff in 2-hour increments to turn or reposition patients at frequent intervals. There are many examples of workforce solutions employed to reposition patients on a frequent and regular basis, all targeted to reduce the risk for the development of PrUs.6 Some of these organizations have employed the Deming's model and Six Sigma strategies for advancing clinical effectiveness and quality improvement of risk and PrUs, with some reporting significant reductions in PrUs. Various research and technical innovations will emerge in this vein, producing novel technology and analytic devices, such as individual global positioning system monitors. Such monitors will track the patients' mobility and positioning, and calculate periodic movements on a remote computer terminal. This accessible data will be available as part of the patient's record and allow for a robust data-driven improvement process. Research has demonstrated that frail patients with decreased nocturnal periodic movements are at risk for PrUs.7 More sophisticated and less expensive support surfaces will compete with the currently available air flotation beds.


With the advent of such advancements, it seems that the "gold standard" for turning schedules sadly remains at 2-hour intervals, without much strength of evidence. For years, we have been advised to turn our patients at least every 2 hours to prevent tissue breakdown. This axiom is uncritically passed down through generations of wound care practitioners. It is time to look more closely at this practice. Is turning patients every 2 hours really enough?8 Or, should we be turning them more often? Where did the 2-hour time frame originate? How often is it being followed in practice? Kosiak, Husain, Dinsdale, and Salcido quantitatively verified this hyperbolic relationship in dogs, rats, and pigs. The concept of a critical interface pressure, then, is more specific to animal models.9 This early animal research led to the practice of turning patients every 2 hours, and was advanced in humans with the work of Reswick and Rogers10 in 1976.


The majority of what we know about pathomechanics associated with PrU development is based on incomplete information, with a strong influence from animal wound models. As technology advances and newer devices for analyzing tissue relief and turning frequency evolve, we must exploit the opportunity to enhance our best practices. The 2-hour turning rule needs to be challenged with new patient-oriented research. Turning frequency lacks the strength-of-evidence rating to draw scientific conclusions. For now, the best advice is to listen to expert opinion and realize that turning our patients more frequently than not is important for PrU prevention.



One of the most important interventions in PrU management is early detection. Aside from the time-honored clinical observation to evaluate PrUs at the bedside, we will need to employ advanced tools to specifically target detection. Currently available clinical detection tools need to achieve higher levels of sensitivity and specificity in the advanced detection of DTI and Stage I pressure ulcers earlier in their course or before they evolve.


In addition, we need more sophisticated methods of evaluating patients with darkly pigmented skin to help diagnose and prevent their chronic wounds. Researchers are working to provide us with those methods. Testing is currently under way on a variety of devices that could be used to detect and diagnose-regardless of skin color-alterations in blood flow and other changes that are specific to ischemia and reperfusion injury associated with the development of chronic wounds. These include visible and near-infrared spectroscopy, pulse oximetry, laser Doppler, and ultrasound.11 Each of these methods infers clinical parameters associated with hemoglobin concentration and blood flow. Combining such physiologic measures with other clinical information would allow skin and wound care professionals a high degree of sensitivity and specificity in preventing, diagnosing, and treating impending chronic wounds in patients with any skin color.11



The methodologies for measuring and documenting wound geometries are advancing. We now have multidimensional computerized wound documentation. For the effective management of a chronic wound, an accurate and objective assessment of the lesion is invaluable. A thorough assessment should include consideration of the geometric aspect of the wound; the physiological aspect of the wound, such as the pressure and degree of wound perfusion; and the biochemical aspects of the wound, including the concentrations of various enzymes involved in tissue degradation and healing. Of these aspects, an objective measurement and documentation of the geometry of the wound and its progression in time is essential in determining the severity of the lesion, developing a proper management plan, and monitoring the process of healing. This ensures the overall quality of wound care.


Documenting the progression of wound shape and size is important in patient-oriented research and in basic research that tests the effectiveness of new treatment strategies for chronic wounds. In addition, meticulous documentation of wound size and appearance serves as a written record in cases of litigation. Physical quantities that can be measured as part of wound documentation include length, width, depth, area, volume of the wound, and most recently, the exact geometry of the wound itself. Available methodologies of wound measurement range from manual methods, using rulers and transparency films, to computer systems of varying degrees of sophistication. Most commercial wound documentation systems report physical quantities calculated from 2-dimensional data, such as digital photographs. Recent progress in wound measurement technology, however, allows use of the full 3-dimensional shape of the lesion, and gives information about both global and local changes in wound surface that accompanies wound healing.



Use what taxonomy you like: PrUs are significant insults to the integrity of the skin, subcutaneous tissues, fascia, muscle, and often bone, with a significant impact on the homeostasis of a given patient. Given our current lack of evidence for the precise classifications between stages that are not distinct, such as the differences between Stage I and DTI, we must rely on precise documentation. In February 2007, the National Pressure Ulcer Advisory Panel updated its definition of the original 4 "stages" used to diagnose pressure ulcers, and added 2 new stages on DTI and unstageable pressure ulcers.2 Advisory panels in both the United States and Europe are updating guidelines in several languages through a joint project ( A number of quality groups, including the nonprofit Institute for Healthcare Improvement, and VHA Inc, an alliance of 2400 not-for-profit hospitals in the United States, are working with hospitals on the new prevention programs.6


Despite eloquent descriptions of Stage I PrUs and DTIs, some contend that clinically they may be difficult to distinguish and possibly co-exist in a visual and anatomical sense. For example, some thought and content leaders believe that a DTI is an evolving Stage IV PrU.4 Therefore, it is possible that a DTI could evolve rapidly to a Stage III or IV PrU just a few hours after admission. Under the new CMS rules, this leaves significant room for conflict, controversy, and nonpayment for services rendered in good faith.


A Change for the Better

I think our efforts in this target-rich environment are ample, given the new and exciting tools, policies, and procedures that are now available. This affords us a wonderful and exciting period in which we can advance our field and the care we provide to our patients. Although we must remain rooted in the basic principles of wound care, we must apply the 4 D's of wound care to facilitate the embracement of regulatory change for the betterment of patient care and the health of our organizations.


Richard "Sal" Salcido, MD

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