ARE ALL PRESSURE ULCERS AVOIDABLE?

Abstract

The debate on whether pressure ulcers are preventable has been fraught with emotional and political agendas. In his article “Are all pressure ulcers avoidable?” 1 Thomas DR Are all pressure ulcers avoidable?. J Am Med Dir Assoc. 2001; 2: 297-301 Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar in the November/December 2001 issue of JAMDA, Dr. Thomas provides us with an evidence-based, objective, and unemotional review and analysis of the available literature, making the correct conclusion that the development of a pressure ulcer is not always preventable, that is, its development is not always the fault of a person or a process of care. This is congruent with the emerging understanding that factors causing the development of pressure ulcers include not only external physical forces such as pressure, shear, or friction, but an interaction between these forces and a multitude of host characteristics and risk factors. The more risk factors, the higher the likelihood of a patient developing an ulcer. 2 Berlowitz D Brandeis GH Morris J et al. Deriving a risk-adjustment model for pressure ulcer development using the Minimum Data Set. J Am Ger Soc. 2001; 49: 866-871 Crossref PubMed Scopus (75) Google Scholar , 3 Berlowitz D Brandeis GH Anderson JJ et al. Evaluation of a risk-adjustment model for pressure ulcer development using the Minimum Data Set. J Am Ger Soc. 2001; 49: 872-876 Crossref PubMed Scopus (45) Google Scholar Thomas is absolutely correct in stating that “An effective strategy. is lacking” and that the currently available clinical strategy for prevention does not work despite being applied. The assumption some make that we have a good preventive strategy that always works, and therefore conclude that when an ulcer develops it must mean that the strategy was not applied or that there was some other problem with the care process, is incorrect based on the evidence. It should be noted that current recommendations and guidelines for the prevention of pressure ulcers are based on weak evidence or on “expert” opinion and consensus. 4 Agency for Health Care Policy, and Research. Pressure Ulcers in Adults: Prediction and Prevention. U.S. Department of Health and Human Services, Public Health Service Rockville, MD 1992. Google Scholar , 5 American Medical Directors Association. Pressure Ulcers Clinical Practice Guideline. Columbia, MD, 1996. Google Scholar , 6 Rijswijk LV Braden B Pressure ulcer patient and wound assessment: an AHCPR clinical practice guideline update. Ostomy/Wound Management. 1999; 44: 56S-67S Google Scholar , 7 Bates-Jensen BM Quality indicators for prevention and management of pressure ulcers in vulnerable adults. Ann Int Med. 2001; 135: 744-751 Crossref PubMed Google Scholar The best we can do at the present time is for facilities and clinicians to provide care that incorporates an appropriate process (assessment, cause finding, care planning, management of problems and risks and monitoring) with the currently available knowledge and concepts of pressure ulcer prevention. In fact, CMS is correct in defining an “unavoidable” pressure ulcer as an ulcer that developed despite the facility and care team having provided an appropriate process of care. 8 Department of Health, and Human Services, Health Care Financing Administration. State Operations Manual, Provider Certification. Transmittal No. 10, July. Appendix P Part I: Survey Procedures for Long Term Care Facilities. Investigative Protocol, Pressure Sore/Ulcer. P-38–40, 1999. Google Scholar In addition, based on current evidence, it is clear that the use of pressure ulcer prevalence as a quality indicator is not an appropriate measure of quality and probably should be replaced with an appropriate process measurement.