As pressure injuries climb, debate arises over whether some are avoidable

While hospitals have succeeded in the last few years in reducing the incidence of most healthcare-acquired conditions tracked by the federal government there is one persistent problem: pressure injuries.

Instead of decreasing, the most recent data from the Agency for Healthcare Research and Quality show they are actually increasing. The preliminary national rate of pressure injuries, previously called pressure sores or ulcers, was 23 per 1,000 discharges in 2017, which represents a 6% increase from 2014 when the national rate was 21.7. That’s compared with other conditions like adverse drug events, which saw a 26% decrease over the same time period, or central line-associated blood stream infections, which saw a 6% drop.

“Pressure ulcers are the only (hospital-acquired condition) pointing up in the wrong direction, so while we have managed to stabilize or reduce these other conditions, pressure ulcers are still harming patients,” said William Padula, assistant professor of health economics at the University of Southern California who has done extensive research on pressure injuries.

There are tough financial consequences for hospitals that do report these painful skin sores. Since 2008, the CMS stopped paying for care related to treating a pressure injury that develops during a hospital stay along with other conditions like some infections, determining they were “reasonably preventable based on the application of published, evidence-based guidelines.” Research shows treating a single pressure injury can cost a hospital anywhere from $500 to more than $70,000.

But wound-care specialists claim that unlike other hospital-acquired conditions followed by the CMS, not all pressure injuries can be prevented even when all guidelines are followed. Patients admitted to the hospital for long stays are much sicker than a decade ago because of longer life-expectancies. Most pressure injuries—painful lesions on the skin that develop due to pressure from lying in bed or being attached to medical devices—occur among patients in intensive-care units who are elderly, frail, have comorbidities and are experiencing organ failure. The severity of their conditions makes pressure injuries impossible to prevent even when the nursing staff does its due diligence, wound-care nurses argue. Given the challenges, they question the fairness of the regulation as it stands.

“If we had an incentive that we wouldn’t be financially penalized for unavoidable pressure injuries, across the country everyone would do better. Everyone’s game would step up,” said Sue Creehan, the former program manager of the inpatient wound-care team at the Virginia Commonwealth University Health System. “We get dinged for things that we can’t prevent, and it’s discouraging from a nurse’s point of view.”

This question of how to determine when a pressure injury is preventable or not will be addressed at a conference held in February by the National Pressure Ulcer Advisory Panel, which creates guidelines for the prevention and treatment of pressure injuries used widely across settings. The panel is coming out with new guidelines in mid-November. Janet Cuddigan, president of the panel, said she couldn’t offer any details about the new guidelines. They were last updated in 2014.

The science to determine if a pressure injury is avoidable is still in its infancy. “We are trying to get a better handle on which ones are avoidable and unavoidable,” Cuddigan said.

The CMS is unlikely to change its policy until there is better evidence supporting the notion that some injuries are unavoidable, Padula said in an email. He added that there aren’t any clinical studies yet on this subject and most of the literature is “commentary and qualitative work rather than data driven, grade-A trial evidence.”

The CMS did not respond for comment.

Even as some in the industry question the fairness of the CMS regulation, it did wake hospitals up to the problem of pressure injuries, which up until then was largely being ignored, Creehan said.

Before the regulation “taking care of patients with pressure injuries was taking care of them after the injury had already occurred,” she said. “It was after that move by the CMS that hospitals got serious about developing pressure injury prevention programs.”

Preventing pressure injuries is incredibly resource-intensive. Every patient must be given a comprehensive skin assessment regularly to determine if they are at risk of developing a pressure injury throughout their stay. Even if they aren’t at risk initially, the assessments must continue because the sores can develop at any point. For patients who are at risk, a host of interventions are recommended such as rotating the patient in their bed or a chair, applying dressings to bony areas of the body and changing their meals to enhance nutrition.

Some organizations, like Johns Hopkins Hospital, have invested in expensive pressure-reducing mattresses. “Everything about (preventing pressure injuries) is expensive,” said Amanda Owen, a wound nurse specialist at Johns Hopkins Hospital.

Training staff is another key component. At the University of Chicago Medical Center, since 2014 the focus has been educating nurses on appropriately identifying pressure injuries. Sometimes what looks on the surface like a pressure injury is actually another kind of skin lesion, said Susan Solmos, manager of nursing clinical services at the hospital.

The training is part of orientation and all nurses are re-trained each year. Additionally, each unit has at least two nurses, called champions, who ensure pressure injury prevention stays top of mind. The University of Chicago’s pressure injury rate has declined by 94% since 2014.

Despite the high cost of treating injuries, Padula questioned how much most hospitals are actually focusing on prevention, which takes more upfront planning.

“Hospitals have limited financial bandwidth,” he said. “They say to themselves, ‘We spend $1 million on pressure ulcers every year.’ But they only have to spend the $1 million once they happen … If they need half a million dollars in new prevention technology and labor to support it, then they would have to budget for it from the beginning of the year.”

But having an effective prevention program is one of the most important elements in figuring out if an injury was avoidable, Solmos said. “High-performing organizations that are able to demonstrate that practices were implemented and a pressure injury still occurred, that would be unavoidable.”

Executive buy-in is key to effectively prevent pressure injuries, Creehan added. She forged relationships back in 2006 with the C-suite at VCU Health to get the resources to begin a prevention program.

“You need CEO support,” she said. “A group of nurses aren’t able to really orchestrate organizationwide culture change. You need the help of senior leadership to set the expectations, monitor the data and allocate resources. I can’t stress that enough.”

Federal regulations also do little to provide an incentive to focus on prevention, Padula argued, saying the CMS “shot themselves in the foot” with the PSI-90 measure, which is used in the Hospital-Acquired Condition Reduction Program.

PSI-90 is a composite measure that includes pressure injuries and nine other measures. Under the program, the score a hospital gets on PSI-90 is evenly weighted along with the scores it gets for five infection measures to determine if they get a penalty. Those who score greater than the 75th percentile compared with their peers are hit with a 1% penalty on their Medicare payments.

Padula said the composite approach of the PSI-90 measure encourages hospitals to focus less on pressure injuries because it’s just one of many events that are part of the measure and therefore doesn’t have as much influence. “(It) led to hospitals prioritizing the things they could do well at low financial investment,” he said.

While the PSI-90 measure didn’t affect VCU Health’s work on pressure injuries, Creehan said composite measures do make it challenging for hospitals to track their improvement.

Padula said the CMS should consider weighing pressure injuries individually in the program so hospitals pay attention to it more. “If you don’t treat each (infection or injury) as important, it gives hospitals the opportunity to game the system,” he said.