OASIS Alert

New stance shows your ulcer-prevention intent -- no matter the final outcome.

So says the National Pressure Ulcer Advisory Panel (NPUAP) after its February consensus conference that brought together agroup of 24 pressure ulcer experts to define and characterize "unavoidable" pressure ulcers.

"Unavoidable" Gets Expert Facelift

Though the experts agreed with the spirit of the federal government's definition of unavoidable for long-term care settings, they ultimately decided on a better, more comprehensive definition for the term.

New way: The advisory panel issued the following definition:

"The individual developed a pressure ulcer even though the provider had evaluated the individual's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with individual needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate," NPUAP announced on March 3.

This new definition, which suits all care settings, allows your agency to show how dedicated you were to avoiding pressure ulcers -- from evaluation and treatment to education and interventions -- even if an ulcer manages to develop, says Marianne Rone, director of clinical services at Healthcare Provider Solutions Inc. in Nashville.

Why it's so important: Traditionally, a patient developing a pressure ulcer under your agency's care would be a reputation killer, both with potential patients and industry quality rankings. However, the new definition allows you to explain that you did everything right, which could benefit your quality score.

Crucial: Your documentation is your only method of proving your due diligence.Nursing and other clinical notes must detail what work you performed, how you reacted to patients' response to their treatment, and whether you adjust the patient's plan of care.

This includes "identifying that a patient is at risk and educating the patient and family about turning and positioning, skin care, and nutritional support," as well as monitoring the skin for ulcer formation, points out Dorothy Doughty,director of the Wound, Ostomy, and Continence Nursing Education Center at Emory University in Atlanta.

NPUAP conference attendees agreed that there are two main reasons for the development of unavoidable ulcers:

Reason #1. Clinical situations make the development of pressure ulcers inevitable. "These are instances where the patient's medical condition takes priority over the preferred turning schedule for the patient," Rone says.

Examples: Often, inevitable pressure ulcers develop in the following situations:

• Hemodynamic instability which precludes turning patients.

• Severe hypotension related to multiorgan failure.

• Patient requires vasopressors which shunt blood away from skin.

• End of life situations.

Note: Despite the increased potential for a pressure ulcer, you must continue providing an integumentary assessment and proper skin care for the patient, as well as work with the patient's physician to figure out a compromise that could slow down or prohibit pressure ulcers, Rone notes.

Reason #2. Patients and their family members choose not to participate in their own pressure ulcer care plan. "Many patients and their families decide not to adhere to the elements of your agency's ulcer prevention plan," even though you've explained in detail the repercussions, Doughty says.

Examples: A few obvious reasons for their decisions include:

• A terminally ill patient elects for comfortover skin preservation.

• A depressed patient complains of exhaustion or pain to delay or limit turning.

• A stubborn patient refuses to comply with treatment orders.

Just because your patients opt not to comply with your plan of care doesn't mean you can throw your hands up and let the chips fall where they may.

Better: You must make sure patients understand the complications that will develop from their noncompliance. Education and reinforcement are your best weapons for convincing patients to follow the treatment plan, Rone points out.

And remember to alert physicians to their patients' decisions to go against your advice. Patients may be more willing to accept what they need to do if they hear it from the horse's mouth.