Pressure ulcer product selection
Current wound care expertise encompasses numerous dressing-related skills including:
• Treating the cause of the wound and addressing patient centered concerns to set the stage for local wound care
• Properly assessing the wound and identifying the dressing requirements
• Selecting dressings based on their form and function for an individual wound’s needs
• Meeting setting-specific requirements for dressing change frequency and maintenance
• Addressing formulary or healthcare system availability as well as reimbursement requirements

Wound care product selection today must be as sophisticated and as evidence-based as possible. Wound dressing product selection process is based on three principles:

• Holistic Perspectives
• Interprofessional Considerations
• Patient-Centered Concerns

Pressure ulcer products: the olden days
Many wound care clinicians remember the “good old days” when wound dressing product selection simply involved choosing between a handful of products that were essentially variations on the same theme. There was gauze, impregnated gauze and filled gauze pads. In the earlier 20th century, clinicians added antimicrobial solutions, creams and ointments (like Dakin’s solution developed during World War I and silver sulfadiazine developed in the 1960’s) and the wound care formulary was limited and simplistic.

Fast forward to the 21st century and wound care clinicians are confronted with a totally different situation: hundreds of products, scientific rationale for moist interactive dressings and an emerging evidence-base for product selection. Selecting appropriate wound dressing products and supportive care to maximize healing and patient outcomes is a complex process. Dressing and local wound care options based on science and best practices must be filtered by clinical experience and must be consistent with patient preferences, care- giver requirements and setting/access issues. Additionally, effective dressing selection and local wound care planning involve the perspectives of the entire interprofessional team.

Knowing the performance parameters of dressing categories/ individual products and matching these attributes to an individual’s wound can optimize the healing process. But dressings are only one piece of the puzzle. Dressings alone will not promote wound healing, unless the underlying cause(s) for the wound are also addressed (e.g. treatment of the wound cause, blood supply, nutrition, patient centered concerns, local wound care etc.). As the wound changes, the plan of care must change and dressing products may have to be changed.

Appropriate pressure ulcer dressing product selection:

• Optimizes the local wound healing environment
• Reduces local pain and suffering
• Improves activities of daily living and quality of life

Inappropriate presure ulcer dressing selection can:
• Cause the wound status to deteriorate (e.g. wound margin maceration, increased
risk of superficial critical colonization or deep infection, skin stripping).
• Increase local pressure or pain especially at dressing change (dressing removal
and cleansing).
• Increase costs with the need for frequent dressing changes or the selection
of an inappropriate advanced or active dressing.

National and international wound care guidelines and best practice documents mean that there is no longer a local standard of care. No matter where nurses and doctors practice, they will be held to national/international standards of wound care practice. Some experts have argued that the selection of the wrong dressing is just as problematic as the administration of the wrong drug and the clinician would be just as liable in a court of law. If dressings can be shown to delay the healing process (e.g. wet-to-dry gauze dressings in a wound that requires moist wound healing, pain from inappropriate adhesives, failure to treat critical colonization that can lead to deep infection), their use might be deemed negligent by a jury in a court case.

Modified with permission from Dr. Diane Krasner, coauthor of Wound Dressing Product Selection, 2010

Dr. Diane Krasner

When you register for the course, you will receive the full article quoted from here, plus 9 additional articles, the opportunity to participate in the course and receive the transcripts, plus a substantial discount off two programs: Take the Terror of out Testifying and Negative Pressure Wound Therapy. Receive an optional individualized critique of your report. Sign up for Pressure Sore Case Analysis and Reports here.

Early bird pricing ends on February 13.

Current numerical pressure ulcer classification systems (staging, grading, or categories) are problematic and misleading because they imply that pressure ulcers progress through defined stages (from I to IV).

In December 2011, a panel of experts rocked the pressure ulcer world by attacking some of the underpinnings of the current pressure ulcer classification systems (Staging, Grading, Categories). They said that some of the language creates problems from clinical, regulatory, legal and economic perspectives. The advisory panel is proposing the new Superficial Changes & Deep Pressure Ulcer Theory©. Here is one piece of what they asserted:

The current numerical pressure ulcer classification systems are intended to describe the anatomic depth of tissue damage. Stage 1 is characterized by non-blanchable erythema of intact skin that may be coupled with alterations in skin temperature and tissue consistency. Stage 2 is a superficial lesion involving the erosion of epidermis with epidermal base or an ulcer with loss of epidermis and a dermal base. Full thickness tissue damage may extend to subcutaneous tissue as in stage 3 pressure ulcers and to deeper supporting structures such as muscle, fascia, joint capsule and bone that are classified as stage 4 pressure ulcers. Evolution of pressure ulcers does not necessarily follow a predictable linear pattern from superficial to deep; from Stage 1 ulcers to Stage 2, then to Stage 3 and finally Stage 4 ulcers.

Deep tissue injury
Accumulating evidence suggests that a number of pressure ulcers (most Stage 3 and 4 ulcers) may initially originate in the deep tissue compartment and progress outward to the dermis and epidermis (inside out theory). Deep tissue injury may not be visible to naked eyes but may take hours to days before any clinical signs are evident. Once observed, deep tissue injury can deteriorate rapidly into deep craters despite stringent and optimal treatment that meets the standard of care. Deep tissue injury has the appearance of a purple or maroon bruise under intact skin that resembles and is often mistaken for a stage 1 pressure ulcer. Donnelly documented that 10% of pressure ulcers were initially diagnosed as stage 1 by visual inspection and evolved to stage 3/4 within days. It is possible that a proportion of the stage 1 ulcers in this study were misclassified and that they were really deep tissue injuries given how quickly these ulcers evolved over time. Other skin lesions with color change may reflect different dermatological diagnoses including; moisture associated dermatitis, fungal or yeast intertrigo or other dermatological conditions.

By eliminating the current numerical classification system and documenting the partial thickness and full thickness depth along with the appropriate physical findings (location, size, base, exudate, and margins), healthcare providers may prevent misleading communication.

Modified with permission from Dr. Diane Krasner, one of the authors of the Shifting the Original Paradigm article published in Advances in Skin and Wound Care December 2011.

This is only one of the controversial areas covered by this article. Get in on the shifting thinking about pressure sores by learning from one of the authors of this landmark statement. Dr. Krasner explores these and other controversies in an all new multimedia course that will take place on February 27 and March 5. Set aside the day of February 27 to join us for an interactive course, and complete the course the evening of March 5. Reserve your spot today. Can’t join us on either date? Get the on demand recordings of Pressure Sore Case Analysis and Reports here.

When you register for the course, you will receive 10 articles loaded with essential information about pressure ulcers, the opportunity to participate in the course and receive the transcripts, plus a substantial discount off two programs: Take the Terror of out Testifying and Negative Pressure Wound Therapy. Receive an individualized optional critique of your report. Sign up for Pressure Sore Case Analysis and Reports here. Early bird pricing ends February 13.

The second category, a maintenance wound, is when the patient refuses the treatment of the cause (eg, will not wear compression) or a health system error or barrier (no plantar pressure redistribution is provided in the form of footwear or the patient cannot afford the device). These may change, and periodic re-evaluation may be indicated.

Expected healing time for wounds
Chronic wounds are often recalcitrant to healing, and they may not follow the expected pathway that estimates a wound should be 30% smaller (surface area) at week 4 to heal in 12 weeks.

Impact of nonhealing wounds
Chronic, nonhealing wounds are disabling and constitute a significant burden on patients’ activities of daily living (ADLS) and the healthcare system. Of persons with diabetes, 2% to 3% develop a foot ulcer annually, whereas the lifetime risk of a person with diabetes developing a foot ulcer is as high as 25%.8 It is estimated that venous leg ulcers affect 1% of the adult population and 3.6% of people older than 65 years. As our society continues to age, the problem of pressure ulcers is growing. Each of these common types of chronic wounds will require accurate and concise diagnosis and appropriate treatment.

Chronic wounds: Medical legal assumptions
In the medical legal world there may be an assumption that most if not all wounds can be healed with proper care. In the medical world, what percentage of wounds are considered nonhealable? In a study of 173 wounds, 70% were considered healable, 25% were considered maintenance, and 5% were considered nonhealable including skin changes at life’s end.

Dr. Diane Krasner

Dr. Diane Krasner provides an intimate and detailed look at pressure ulcer causes and cures in a multimedia course that will take place on February 27 and March 5. Set aside the day of February 27 to join us for an interactive course, and complete the course the evening of March 5. Reserve your spot today. Can’t join us on either date? Get the on demand recordings of Pressure Sore Case Analysis and Reports.

When you register for the course, you will receive the full article quoted from here, plus 9 additional articles, the opportunity to participate in the course and receive the transcripts, plus a substantial discount off two programs: Take the Terror of out Testifying and Negative Pressure Wound Therapy. Receive an individualized critique of your report. Sign up for Pressure Sore Case Analysis and Reports.

Physiologic changes that occur as a result of the dying process (days to weeks) may affect the skin and soft tissues. These changes may manifest as observable (objective) changes in skin color, turgor, or integrity, or as subjective symptoms such as localized pain. Here is the medical legal issue: clinicians assert that these changes can be unavoidable and may occur with the application of appropriate interventions that meet or exceed the standard of care.

Dr. Alois Alzheimer was on call in 1901 when a 51-year-old woman, Frau August D, was admitted to his asylum for the insane in Frankfort. Dr. Alzheimer followed this patient, studied her symptoms and presented her case to his colleagues as what came to be known as Alzheimer’s Disease. When Frau Auguste D died on April 8, 1906, her medical record listed the cause of death as “septicemia due to decubitus.” Alzheimer noted, “at the end, she was confined to bed in a fetal position, was incontinent and in spite of all the care and attention given to her, she suffered from decubitus.” So, here we have the first identified patient with Alzheimer’s Disease having developed immobility and two pressure ulcers with end stage Alzheimer’s. In our modern times, end stage Alzheimer’s Disease has become an all-too-frequent scenario with multiple complications including SCALE (Skin Changes at Life’s End).

Causes of skin changes at the end of life
When the dying process compromises the homeostatic mechanisms of the body, a number of vital organs may become compromised. The body may react by shunting blood away from the skin to these vital organs, resulting in decreased skin and soft tissue perfusion and a reduction of the normal cutaneous metabolic processes. Minor insults can lead to major complications such as skin hemorrhage, gangrene, infection, skin tears and pressure ulcers that may be markers of SCALE.

Are skin changes at the end of life preventable?
Skin changes at life’s end are a reflection of compromised skin (reduced soft tissue perfusion, decreased tolerance to external insults, and impaired removal of metabolic wastes). When a patient experiences SCALE, tolerance to external insults (such as pressure) decreases to such an extent that it may become clinically and logistically impossible to prevent skin breakdown and the possible invasion of the skin by microorganisms. Compromised immune response may also play an important role, especially with advanced cancer patients and with the administration of corticosteroids and other immunosuppressant agents.

Skin changes may develop at life’s end despite optimal care, as it may be impossible to protect the skin from environmental insults in its compromised state. These changes are often related to other cofactors including aging, co-existing diseases and drug adverse events. SCALE, by definition occurs at life’s end, but skin compromise may not be limited to end of life situations; it may also occur with acute or chronic illnesses, and in the context of multiple organ failure that is not limited to the end of life.

Dr. Diane Krasner

Legal perspective on skin changes at end of life
What you’ve read is the medical perspective. There are attorneys who dispute the existence of SCALE and see it as a handy way for a facility to defend the development of a pressure sore. Join the controversy on February 27 and March 5, 2012. Dr. Diane Krasner provides an intimate and detailed look at pressure ulcer causes and cures in a multimedia course that will take place on February 27 and March 5. Set aside the day of February 27 to join us for an interactive course, and complete the course the evening of March 5. Reserve your spot today. Can’t join us on either date? Get the on demand recordings of Pressure Sore Case Analysis and Reports here.

When you register for the course, you will receive 10 articles loaded with essential information about pressure ulcers, the opportunity to participate in the course and receive the transcripts, plus a substantial discount off two programs: Take the Terror of out Testifying and Negative Pressure Wound Therapy. Receive an individualized optional critique of your report. Sign up for Pressure Sore Case Analysis and Reports here. Early bird pricing ends February 13.

Pain Scales Use with Pressure Ulcers
Pain from pressure sores can sometimes be measured. A variety of pain scales are used to measure that which is subjective. The universally accepted measurement techniques are the utilization of visual analog scales (10-cm line with no pain at one end and worst possible pain at the other end, and the patient places an ‘‘x’’ at the appropriate point), Faces Pain Scale (various levels of happy and sad faces), or the numerical rating scale. The numerical rating scale asks if the patient has any pain on a 0- to 10-point scale with the anchors that 0 is no pain, 5 is the pain associated with a bee sting, and 10 would be the amount of pain experienced by slamming the car door on your thumb. Even in patients who cannot respond verbally, such as those with dementia, pain still needs to be assessed. There are pain scales for these patients that rely on nonverbal clues such as facial grimaces and pupil dilatation. (Assessment of pain for people with dementia can be found at www. hartfordign.org.)

A patient with a pressure sore
Bill is a 70 year-old-man who developed paraplegia. During his prolonged hospitalization, a stage IV pressure sore formed. One year later, it is still present and it dominates his life at home. Pressure sores may have a huge impact on the quality of a patient’s life. There is a financial impact of prolonged treatment – dressing changes, supplies, debridements, and flap surgeries. There is a medical impact of complications and risk of death from sepsis. There is a personal impact of physical restrictions, social isolation, loss of independence, and emotional problems. There is dealing with odors and limitations on the length of time one can sit. But pain is one of the biggest factors that affects the quality of the patient’s life.

Causes of Painful Pressure Ulcers
Pain levels should be recorded before dressing change, during dressing change, and after dressing reapplication. Krasner has defined wound associated pain at dressing change (intermittent and recurrent) versus incident pain from debridement or the persistent pain between dressing changes. Woo carried the Krasner concept further and demonstrated that anxiety and other patient-related factors could intensify the pain experience.
The Wound Associated Pain Model of Woo and Sibbald defines pain from the cause of the wound as often being persistent or present between dressing changes and distinguishes this pain from the pain associated with local wound care components (dressing change, debridement, infection, lack of moisture balance). All of these factors can be modified by patient-centered concerns, including previous pain experience, anxiety, depression, mobility and awareness or lack of comfort with the setting, and the procedure or treatment plan. Pain is an under-recognized and undertreated component of chronic wound care that has been demonstrated to be more important to patients than healthcare professionals. Causes of pain at dressing change include the dressing material adhering to wound base, skin stripping from strong adhesives, and aggressive trauma from cleansing technique (eg, scrubbing with gauze).

Many patients also express chronic persistent pain between dressing changes even at rest. A systematized approach should examine other systemic and disease factors that may play a role in precipitating and sustaining persistent wound-related pain. Common systemic factors are bacterial damage from superficial critical colonization or deep and surrounding compartment infections, deep structural damage (eg, acute Charcot foot in patients with diabetes), abnormal inflammatory conditions (eg, vasculitis, pyoderma gangrenosum), or periwound contact irritant skin damage from enzyme-rich wound exudate.

Impact of Pressure Ulcer Related Pain
Bill has a Morphine pump in his abdomen to deal with his pain. He takes supplemental Morphine by mouth. There are times he sleeps all day and is awake all night. The impact of chronic unrelenting pain can be devastating, eroding the individual’s quality of life and constituting a significant amount of stress. Increased levels of stress have been demonstrated to lower pain threshold and decrease tolerance. The result is a vicious cycle of pain, stress/anxiety, anticipation of pain, and worsening of pain. Increased stress also activates the hypothalamus-pituitary-adrenal axis, producing hormones that modulate the immune system compromising normal wound healing. Medications including nonnarcotic for moderate pain and narcotic analgesics for moderate to severe pain are required to treat severe pain as outlined below. A consult from a pain and symptom management team may be considered. Comprehensive management should also include careful selection of atraumatic dressing, prevention of local trauma, treatment of infection, patient empowerment, stress reduction, and patient education.

Modified by Pat Iyer with permission from Dr. Diane Krasner, coauthor of Special Considerations in Wound Bed Preparation 2011, an Update, Advances in Skin and Wound Care, September 2011

Dr. Diane Krasner

When you register for the course, you will receive 10 articles loaded with essential information about pressure ulcers, the opportunity to participate in the course and receive the transcripts, plus a substantial discount off two programs: Take the Terror of out Testifying and Negative Pressure Wound Therapy. Receive an individualized optional critique of your report. Sign up here for Pressure Sore Case Analysis and Reports.

This is a great explanation of how the overload that occurs in a nurse’s job can result in distraction and medical errors.

Obstruction or criminal investigation of health care offense

The False Claims Act requires the defendant to submit a claim or cause a claim to be submitted to the government that is false or fraudulent, knowing of its falsity and seeking payment from the Federal treasure. There may be damages. The penalties include a civil penalty from $5,500 to $11,000 per false claim and three times the amount of damages which the government sustained.

Here is how nursing homes have gotten in trouble:
The long term care provider makes payments for patient referrals. (In US ex rel Wall v. Vista Hospice Care, Inc, the court denied motion to dismiss the allegation that the hospice paid nursing home employees for patient referrals. March 2011).
The long term care provider receives payments for referrals. (Mariner Health Care and SavaSenior Care paid $14 million to settle allegations they took kickbacks in exchange for renewing contracts with Omnicare, settled February 2010)
Medical directors may be paid more than fair market value.

What does the government expect of nursing homes?
They want a partnership with Federal and State governments to detect and prevent misconduct.
They want an ethical corporate culture.
They expect an organization to ferret out wrongful conduct and non-compliant activity.
They expect cooperation during investigations of an organization’s wrong doing.

Based on handouts from Broad and Cassel, American Conference Institute, April 2011

A few weeks ago I met a physician who told me of a fraudulent scandal at his hospital. A cardiologist was caught for performing stents on patients who were not true candidates for the procedure. He obtained a lot of money for doing the unnecessary procedures. This cardiologist was well-respected until the fraud was uncovered, and he lost his license to practice. The scandal rocked the hospital, damaged its reputation, and caused several people to leave their positions. The hospital is now for sale.

The rippling effects of fraud and greed are far reaching. I know that as I prepare this blog post, someone is hatching a scheme to defraud or cheat or steal. If only the creativity associated with fraud was channeled into positive pathways.

One of the most mystifying parts of the nursing home chart is the Minimum Data Set (MDS). The MDS is a standardized instrument used to assess all nursing home patients. It is a comprehensive assessment of the resident’s physical and functional abilities and cognitive status and includes indicators of delirium, fall history, diagnoses, wounds, nutritional status, restraint use, continence status, and more. The nursing and therapy notes and other documentation should be reviewed to ensure the information in the MDS is accurate.

Depending on the timeframe for the care being reviewed, the chart may contain an MDS that may be either version 2.0 or 3.0. After extensive review, the Federal government released the 3.0 version on October 1, 2010. The Resident Assessment Instrument (RAI) now consists of the Minimum Data Set (MDS) 3.0, the Care Area Assessment (CAA) Process, and the RAI Utilization Guidelines. The MDS 3.0 was refined to include many changes including, but not limited to, a focus on pain assessment and discharge planning, when assessments should occur, some changes in coding, and the use of Care Area Triggers (CATs) rather than Resident Assessment Protocol (RAPs). The MDS 3.0 focuses on resident participation through multiple interviews. The “look back period”, the time frame the MDS assessment is based upon, is seven (7) days for all areas unless otherwise noted on the assessment.

There are 20 CAA’s that can be triggered by the MDS responses. The identified triggers are used as a guideline for development of the individualized plan of care. The staff may override the trigger or decide to proceed and create a plan of care. For example, nutritional status may be triggered due to recent weight loss. However, the staff may override the trigger by indicating a recent history of bilateral above the knee amputations, thus justifying the recent weight loss or less than ideal body weight status. The CAA’s should be reviewed to ensure that all potential risks have been appropriately triggered and addressed in the plan of care.

While the Plan of Care (POC) is not paperwork specific to long term care, it is a very critical document and must be closely reviewed to ensure every risk unique to that resident has been addressed and that the POC is individualized to the specific needs of that resident. The care plan is a dynamic tool that should be updated as the needs of the resident change. For example, if the resident is at risk for falls and the goal indicates the resident will have no falls with injury within the next 90 days and that resident does indeed fall and sustained injury, the plan of care must be updated. You should expect to see new interventions to prevent falls.

Therapy documentation is critical to long term care cases. When a resident is involved in PT, OT or ST you will find frequent documentation which can be crucial, especially when there are few nursing and physician notes. Therapy notes will usually describe the resident’s functional ability, level of pain, subjective statements, cognitive status, and safety recommendations. Always be sure to review the therapy records thoroughly and compare these assessments to the nursing notes, physician notes, MDS, and care plan. Likewise, important information may be found in the social services notes as documentation regarding discharge plans, family concerns, and social history is likely recorded in this section.

Don’t allow your lack of familiarity with long term care records hold you back from an interesting case review. Your knowledge of the records outlined above will provide you the ability to thoroughly understand the residents’ needs and determine whether they were met. This information is just a brief overview of a few of the records. However, part of being successful is self educating and knowing how to find the information you need. Identifying a long term care nurse that you can call with questions as needed might just provide you with the added confidence needed to say “Yes” when asked to review a nursing home case. To learn more about record reviews and how to WOW your clients check out this information on how to polish your writing skills.

Angie Duke-Haynes, RN is President of Premier Medical Legal Consulting, LLC, co-owner of Legal Nurse Consulting Institute, LLC and co-presenter of an all new webinar on polishing your writing skills.

Here’s something light today. These make me laugh. They are dangling and misplaced modifiers from this site:

http://writing.wisc.edu/Handbook/CommonErrors_BestMod.html

The best misplaced and dangling modifiers of all time
Oozing slowly across the floor, Marvin watched the salad dressing.
Waiting for the Moonpie, the candy machine began to hum loudly.
Coming out of the market, the bananas fell on the pavement.
She handed out brownies to the children stored in Tupperware.
I smelled the oysters coming down the stairs for dinner.
I brushed my teeth after eating with Crest Toothpaste.
Grocery shopping at Big Star, the lettuce was fresh.
Driving like a maniac, the deer was hit and killed.
With his tail held high, my father led his prize poodle around the arena.
I saw the dead dog driving down the interstate.
Holding a bag of groceries, the roach flew out of the cabinet.
Emitting thick black smoke from the midsection, I realized something was wrong.
The girl was consoled by the nurse who had just taken an overdose of sleeping pills.
I saw an accident walking down the street.
Drinking beer at a bar, the car would not start.
Playing pool in the living room, the radio was turned on by Jim.
Frustrated by diagonal movement, the set was turned off.
Mrs. Daniel sews evening gowns just for special customers with sequins stitched on them.
Although exhausted and weary, the coach kept yelling, “Another lap!”
She carefully studied the Picasso hanging in the art gallery with her friend.
Having an automatic stick shift, Nancy bought the car.
Freshly painted, Jim left the room to dry.
He held the umbrella over Janet’s head that he got from Delta Airlines.
He wore a straw hat on his head, which was obviously too small.
After drinking too much, the toilet kept moving.

(1) Franklin Covey Style Guide, Franklin Covey, 1999

1. Striking the wrong key
Relying on the computer to function as the only proof reader of your LNC report is sure to miss a few common typographical or grammatical errors. An example I frequently see is the wrong word being typed, i.e. “form” when “from” should appear. A lack of attention to detail is guaranteed to have your client second guessing his request to have you review the critical evidence in his case.

2. Blind side your client
Do not include any references: source document, Bates numbers, literature citations. You don’t want your client to easily find the critical document or the article that supports the case theory. Attorneys really do want to search through all those medical records themselves.

3. One and done
Just provide the facts and your conclusion. Don’t include recommendations for the next steps the client should take. After all, the report speaks for itself. Attorneys, being familiar with the provision of health care, can easily identify just the specialty needed for an expert review. All attorneys understand the difference between a diagnostic radiologist and an interventional radiologist, for example.

4. Missing the point
Make your conclusion hard to find. Place it anywhere but the beginning of your report. Attorneys love to read the whole report before they learn what your conclusions are. Placing your conclusion at the beginning of your report with emphasis formatting would make the attorney less inclined to read your entire report, something to be avoided at all times.

5. TMI*
When in doubt, include it. It is important the attorney is made aware of all potential breaches in the nursing standard of care regardless of the relevance to the allegations.

* too much information

Dana Jolly, BSN, RN, LNCC is president of Jolly Consulting, LLC, a national legal nurse consultancy. She is a published author and frequent lecturer on legal nurse and clinical topics. To learn more about what you can do to present a polished, accurate report, join Angie Duke-Haynes, Pat Iyer, and Dana Jolly on February 1 and 8, 2012 for a webinar course, Polish Your Writing Skills.