Dr. Jeffrey Levine is a well known and respected geriatric doctor who specializes the prevention and treatment of pressure ulcers. He recently wrote an article on his blog about new research on hospital acquired pressure ulcers from the new study published in the Journal of the American Geriatrics Society. Below are excerpts from Dr. Levine’s article.
The study sheds light on hospital acquired pressure ulcers (HAPU) with data on epidemiology, mortality, and patient characteristics. Its results are certain to fuel the debate on avoidability of pressure ulcers.
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.
For further information, we encorage you to vist Dr. Levine’s blog which has many excellent articles on this issue.