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Pressure Ulcers: Reducing the Patient's and Your Risk

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Joyce Black
Joyce Black, RN, PhD, CWCN
Past President, NPUAP Associate Professor, University of Nebraska
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Lecture Transcription

Present e-learning systems


Pressure ulcers are a big problem in today’s healthcare system. A problem both for our patients and for our healthcare providers. I am Joyce Black. I am here to talk to you today about pressure ulcers including the present on admission rule by CMS and other things that your system can do to reduce the risk of pressure ulcers in your patients.


Production of this PRESENT lecture was made possible by a generous grant from Coloplast.


There are 3 objectives for this session. The first one we will cover is the changes in funding for hospitals related to pressure ulcers. Then I will describe the documentation to be paid for pressure ulcers that indeed are present on admission and the last one is to look pressure ulcer prevention programs to reduce risk both to the patient and to the hospital.


Well you might ask the question of why are we footing the bill for pressure ulcers? The history is fairly long. It actually started prior to 2005 but in 2005 Congress passed an act called the Federal Deficit Reduction Act and that was a mandate for Congress to put a lid on spending on healthcare. The figure that you see in the slide is the percentage of money that we are spending on healthcare in this country and as you can see we are not going to be able to sustain that rate of growth. We are simply not going to be able to afford healthcare if we don’t put some limits on it. In addition, back as far as 1999 the institutes of medicine came out with a document that detailed the number of errors that were happening in hospitals that were not being regulated, not being checked up on, and probably most seriously not being reduced. So those two together created the background for the rule that we saw in 2007 on present ulcers present on admission.


So why then were pressure ulcers chosen as one of the areas to target. Well there are several reasons you can see on the slide. Number one, on the slide but not necessarily in order of priority. The number of cases of pressure ulcers were actually rising. You can see that in just over a decade there was a 63% increase in pressure ulcers in hospitalized patients. The cases of ulcers were common. Patients over the age of 65 have 72% of hospitalizations during which pressure ulcers were found or noted or cared for in the medical record. Pressure ulcers according to the National Quality Form were classified as a never event. The price of taking care of patients with pressure ulcers was rising. Hospital treatment was around thirteen days at an average and the documentation by the hospitals on the presence of pressure ulcers was poor. The study was done several years ago in which they looked at records of patients with known pressure ulcers at the time of admission to the hospital and very, very few of the documents actually contained anything about the hospital being aware that the ulcer was there. So these are patients coming in from home care settings and long term care settings in which there was a known pressure ulcer at the time of admission to the hospital but the hospital failed to assess it and record it in the medical record.


In April of 2008, CMS produced a document that detailed the amount of money they had spent on 8 conditions that they were no longer going to pay for. You can see the top one was pressure ulcers, stages 3 and 4. CMS spent 11 billion on the treatment of pressure ulcers. Now they don’t believe and I don’t expect that they are going to recoup 11 billion dollars with the October 2007 rule on non-payment but you can see that pressure ulcers was a large part of the bill of what they considered to be never events. The other 7 items on the slide were the original 8 events that CMS was not going to pay for and you are sure that there are multiple programs in your facility that are dealing with reducing the risk of falls, reducing the risk of vascular access device infections, urinary tract infections, and we have several programs going on in the operating room today to reduce the risk of retained objects during surgery. I’m sure you have seen a lot of the processing already put in place to reduce the risk of the 7 problems that you see on the slide in front of you. Hopefully you have also seen something on pressure ulcers. If not stay tuned.


Well the big 8 became the big 12. The big 8 were the original ones that I showed you on the previous slide starting with pressure ulcers including other never events that CMS and the National Quality Forum were staring to look at with some detail. They added another four to that list and now we have the big 12 and you have probably seen these. They added deep venous thrombosis with pulmonary embolism after orthopedic surgery, surgical site infections, poor glycemic control and falls that led to injuries both from the fall or crush or burns or electrical shocks were added in October in 2007. To give CMS many more things to consider never events and therefore try to meet that 2005 Federal Deficit Reduction Act law that they were obligated to try to address.


The slide you are looking at is one that was prepared by CMS when they introduced the October 2007 ruling that a hospital would not receive. So let’s just look at the basic idea. The MSDRG assignment is a numeric code that references the amount of money a hospital will get when caring for this patient under perspective payment. In this instance the principle diagnosis was inner cranial hemorrhage or stroke and CMS is saying that in the example they are giving you that this secondary diagnosis of a stage 3 pressure ulcer was indeed true. It was indeed present at the time this patient came in so in that instance the hospital can bill for and there the hospital bills around $8,000 per case. The next example down is the same basic diagnosis. This patient had and inner cranial hemorrhage, but this time developed the pressure ulcer during the hospital stay. This is now a hospital acquired pressure ulcer and CMS will now not pay for that. So this particular hospital on this individual patient would receive almost $2700 less money even though the patient would have had to gotten the care necessary for the ulcer during the stay.


A lot of people over the course of this event of CMS not paying have said well how do we get money for what we should get money for? Therefore what counts? According to the CMS rules, only full thickness ulcers count and they have a billable ICD9 code. That is just a numeric code and it just happens to be 707 for pressure ulcers but it is a billable code that the computer is set to recognize and therefore pay out on. Stage 3 and stage 4 only are the ones that if present on admission the hospital can list as a present on admission diagnosis and get money for it. Stage 2 and stage1 are not listed there. They will not be added to the list. On stagable ulcers are not something that can be recouped money for at the time of admission and deep tissue injury can be recouped if the physician reports that the pressure ulcer was evolving and you can see I have the word italicized for you, evolving pressure ulcer. The coders have been told that they can then stage that as a 3 or 4 and therefore make it a present on admission disease. So then the next question is what’s admission? What counts as admission? There were all sorts of ideas initially about admission was. At first, admission was thought to be a certain number of days or hours per the calendar and it became unclear in the end what admission was. So the final ruling was there is no clock running. It is not like the patient touches a time clock when they come in and you have a certain number of hours or days to record something as being present on admission. If the physician records in the notes or dictates in his record that the pressure ulcer was present on admission it will be counted that way. Now obviously if 17 days had passed at this hospitalization and there is a note in the chart that says this pressure ulcer was present on admission that is certainly going to be subject to scrutiny and I would not advise trying to fraudulently back prepare a set of records to get your money for it. The story was where does this admission take place? The admission is considered in-patient admission and therefore if the pressure ulcer started in the emergency department, outpatient areas, 23 hour observation areas, those ulcers that developed there can be considered present on admission when you get them admitted into the hospital properly.


A big piece of this story in present on admission is documentation counts. The final rule is that a physician or other professional with admitting privileges. So in your hospital that might be a nurse practitioner; it might a physician’s assistant. That is the person that has to document in the medical record either in hand writing or by dictation that a stage 3 or 4 pressure ulcer was present at admission. The wound nurse, the wound team could certainly assist and seeing these patients at the time of admission, but the provider is going to going to document the presence of admission. It is not within compliance to put a sticker in the chart that says I the wound nurse have seen this patient and this is a stage 3 pressure ulcer and have the physician simply sign off. That is not within the compliance guidelines. It is going to have to be hand written by the physician or dictated by the physician. The coders have been instructed and certainly have been for many years queried positions about discrepancies in the record when they see care provided to an ulcer by a wound nurse and that there is no documentation by the physician about that ulcer so they will help you quite a bit in getting the queries answered. The difficult piece of the story as all of you have come to realize is that nurses do a lot more diagnosing of pressure ulcers than physicians do. There was a study done in some geriatric residents back in 2003 and they gave them a description of a pressure ulcer and the tissue loss and I believe showed the photographs and only 52% of geriatric residents could actually accurately diagnosis and document a stage 3 or stage 4 pressure ulcer. So nurses certainly have a role in this present on admission rule but their role is to make sure the medical record contains the necessary information for the hospital to be paid when it is appropriate that the hospital is paid but not put down in the chart themselves. But coders have been instructed that if the person with admitting privileges does that recording.


Well what about unstageable ulcers? Where do they fit in the present on admission ruling? Unstageable ulcers are not covered in the present at admission rule. They need to be debrided if possible and if appropriate because most unstageable ulcers are going to be full thickness ulcers when we debride them and you will then be able to appropriately label them as a stage 3-stage 4 present on admission. Now obviously it’s important not to violate the standard of care. So you don’t want to debride stable? Or ischemia limbs simply to have a stage 3-stage 4 that you can bill on.


So what about deep tissue injury in the new present on admission ruling? Deep tissue injury has its own ICD-9 code but that code is not one of the payable codes. The CDC provided some advice on this and said that if the ulcer was present on admission and at 48 hours you are starting to see purple tissue, you can record in the medical record that the ulcer was evolving at the time of admission and therefore you couldn’t see it. The damage actually started before the patient came in so evolving is the key word. We know that deep tissue injury evolves within the first 48 hours after the event and you should see purple tissue at 48 hours so that will give you a sense of when it started. Now here again, unfair to use this system of using the word evolving to document deep tissue injury in your facility. If they did not happen in your facility this is a perfect example of how you can use the coding system as it is today to recoup the money that you will need for the care of that patient.


And then what about unavoidable pressure ulcers? At this point in time the only place that unavoidable occurs in the guidance documents or the regulations are in long term care. There has been no provision put into place for avoidable or unavoidable in acute care and there is no appeal option for avoidable- unavoidable pressure ulcers in acute care. This rule and this interpretation has very large impact on hospitals that are carrying for patients that have catastrophic illness when there is no preexisting medical problems to bill. The way the billing works today is that states are allowed to choose from the medical diagnoses a patient has which one gives them the best payment and so if the patient and you can imagine some of these patients, they have end stage lung disease, and heart failure and diabetes and all sorts of medical problems. And each of those medical problems can be rolled up into this bill and the hospital will receive money for it. So in patients that are young and previously healthy and now have a catastrophic illness, there may not be enough other conditions to bill upon and the pressure ulcer piece of that bill will be very important. Just like the slide we looked at from CMS which the patient had a hemorrhage, a cerebral hemorrhage that patient had no other medical conditions to bill upon so it has a big impact so if you are working in a hospital with chronically ill patients you may not see the financial impact that you will see in a trauma center because the patient will have all sorts of other conditions to bill upon. This issue of avoidable and unavoidable was the top public policy concern in the February 2009 NPUAP meeting. NPUAP is addressing the issue.


I do think it is important though to think about other unavoidable ulcers in other patients there are lots of groups of patients besides the catastrophically ill that could develop an unavoidable pressure ulcer. Certainly the patient who refuses to eat or be tube fed the ulcer that is there deteriorates or ulcers develop due to malnutrition. The patient who refuses to be turned or cannot be turned and then the patient that is terminally ill, all of those situations have been known to clinically lead to unavoidable pressure ulcers. The current ruling however they are not billable to CMS.


I want to make you aware of some of the impact of the CMS rule beyond the hospital. There are some hospitals that have decided if they are not going to be paid for the pressure ulcers they are not going to list it on the list of medical diagnoses. That creates a problem downstream when homecare and long term care need to procure equipment for this patient because they need to be able to link to an existing medical diagnosis so be sure that even if you are not getting paid for you, you continue to list it on the record if indeed it is still true or is true for that patient because it will help somebody else downstream in the care of your patient.


Some of the future considerations for the present on admission ruling is to look at some sort of risk adjustment in the data analysis so that individuals at high risk and groups at high risk can be examined differently. There is some question about how public reporting is going to be done for present on admission data. The ICE 10 which is again that numeric list of codes for various medical conditions will have 125 codes for pressure ulcers along. In the current coding system there is only enough numbers to code either the stage or the location and in the new system they will have both the stage and the location so there will be multiple nuances of all the different locations and different stages and multiple numbers of ulcers on different anatomical parts. Of course there has all been concern by people who currently work in rehabilitation centers and long term acute care centers and other centers that this none payment ruling with extend to them and that is the plan I believe CMS is looking at that as a way to consider those never events beyond just an acute care setting.


Ok. So now what do we do? I think it is important to look at a multi-tiered approach to reducing ulcers and to control the cost. Obviously this is a great example of spending money preventively to prevent diseases down the road. So the stitch in time kind of analog works well here for us.


When you start thinking about how can you reduce your risk. Well number 1 look at where your areas of risk are. Determine in your hospital where your high risk areas are. I think it important when you do that to look at incidence or hospital acquired pressure ulcers not prevalence. Incidence are the number of new cases of pressure ulcers that you may want to examine closely because they are ulcers that happened on patients that came in with intact skin. Prevalence includes the ulcers that started on intact skin during your hospital stay. But they also include patients who had ulcers when they came into your hospital. So if you are looking at prevalence you are counting ulcers that you had nothing to do with. Not important not to deal with them. I don’t disagree that we still need to do something about them but when you are trying to figure out where you are going to make your biggest impact. You want to make your biggest impact on your incidence numbers. The other thing that you can do then from that data is look to see where your prevention program could be improved. If the greatest number of ulcers in your facility are in critical care then what can you do in critical care to improve the process of providing care in the ICU. Maybe you need to look at the support service of critical care. Maybe you need to look at the turning and repositioning programs. Maybe its skin care and nutrition. Start where you have some numbers that you can work on because the first change is going to be most easily seen for example if you want to do your numbers, find your numbers that are high in your trauma ICU, it’s going to make a huge impact in your hospital’s bottom line if you can prevent those ulcers because these are patients that were previously healthy. May not have insurance to bill on and may default into a Medicaid or Medicare program, and you are going to lose the most money on these patients because if they are previously healthy you don’t have any comorbid conditions to bill on and you are going to take a big hit on the fact that you can’t bill on the pressure ulcer. So use that as your starting point to make your big impact and look at your prevention program there first.


There are probably some other groups if you don’t happen to have a trauma ICU that you could look at. You need to look at malnutrition in your facility and this time you should look at prevalence because patients are probably coming in with malnutrition. Work with your nutritionist and dieticians and figure out if you are really meeting the nutrient needs of that patient and then if you have patients who are refusing to be fed and refusing to be tube fed, you probably need to get your Ethics Committee involved. You need to decide if nutrition is needed for healing these wounds or whatever the basic condition is then is refusal to eat or to be tube fed, a non-compliance or non-adherence and how do you deal with those patients. Because not only is it important for us to cause no further harm to the patient but to understand what the true wishes of that patient are. If it is something that have decided long ago not to be tube fed, they may not understand that today it would be important to jump start their healing and to get them on a trajectory of healing to get them out of the hospital. All of that needs to be considered when you are looking at this pressure ulcer story.


A caution on the word non-complaint. I want you to think about the fact that by definition a non-compliant patient understands the risk that they are taking on to themselves by not doing what was advised or ordered. This is a person who has to be mentally competent to understand that. If I to refuse to turn or I refuse to eat it can impact my skin and it can create an ulcer that is going to take weeks or months to heal even though I chose to do that only a couple hours one day or did not understand the impact of the decision they may seem to be lucid at the time they are saying I won’t do that to you, but they don’t remember that they also won’t do it two hours before or they wouldn’t do it yesterday or the day before. So be cautious when you label demented patients as non-compliant. Be sure that you reproach them to ensure that when you are thinking how can we reduce their harm that you are talking to the family, you are trying to figure out what do you do with these patients when they simply refuse. It is their right to refuse but the rub comes in when you try to make sure that they understand the full implication of their refusal.


So what the new role from CMS we certainly have an opportunity to move prevention up to the front and center. It’s going to be very important in our hospital programs, long term care programs, ambulatory programs, where ever we are working to get these pressure ulcers prevention programs that are targeted to the specific population of patients that we are talking about. We need to triage the same way the ER does. Pressure ulcer risk on high risk patients before they are right. We need to think about what is that package of patients that we care for. If you are admitting patients to an emergency rooms and there is no beds for admission to the hospital is there a way to put these patients into standard hospital beds, get them off the carts, get them out of their street clothes and get them into a standard hospital bed. If this is a morbid EOB patient we need to get the obese bed, the bariatric bed into place before the patient has been admitted to their room. We need to be sure that the nurses that are caring for patients are not relying on the beds to turn the patient. The bed may assist in turning patient but the bed may give them a longer time frame between turns but they do not replace turning. I think we need to consider an ICU as a high risk patient and put all of the ICU beds into very high profile, high classifications special beds for these patients. We should not have to change out beds all the time in critical care. These patients are high enough risk that it actually becomes dangerous to move them from one bed sometimes to another. We need to think about what can we do in the operating room. We know that coronary artery bypass surgery and patients who have anesthesia times every three hours are at the highest risk of developing a pressure ulcers in the operating room so if your OR nurses look at the lifting indication of the probable OR time based on the fact that they have seen this patient before, they need to go on special bedding for the operating room.


Part of our prevention program should be increasing awareness of the staff. Frain wrote an article on Optimal Wound Management where a comprehensive program was developed in long term care was described. This program described training the staff and producing job aids. There were pencils labeled with the words “float heels” and there were kites on the doors that indicated the stage of the pressure ulcer that was present in this patient so that the staff knew what was going on in that patients room. Then there was a daily assessment of the heel of all the residence in that study. They had both a mixture of low and moderate risk indications in the study. The offloading method was actually chosen by a CNA which is a novel approach for any institution. The premise by Frain and her colleagues was that the CNAs are at the bedside and they know that this patient is not going to stay in these boots or is not going to stay on these pillows and it was the CNA that actually made the decision on what to do and the results were pretty spectacular at the beginning they had 11 residents with 15 ulcers and by the end of the program they had no new ulcers, 17 residents remained in the program. None of them had new ulcers and all the other ulcers had healed so tremendous program using a combination of multiple people involved in the decision making, clear communication with them about the patients risk and the tremendous outcome.


Another important aspect of the prevention package is that we have to get complete skin assessment done. We need to expect that complete skin assessments are done at time of admission to hospital and that may involve a team of people going into to see this patient because you’ve got to see all their skin. You have got to remove devices that are removable. You have to move tubes such as endotrachial tubes from one side of the mouth to the other. You have got to be able to look underneath stockings and sequential devices that are in place on those patients. Then the other thing we must do within our documentation system is have a way to record the skin assessment. It is unacceptable to have only 2 options in your skin assessment document that says intact and non-intact. You need much more detail than that to give the nurse to accurately describe what is being seen. Then we need training for nurses to accurately describe the wounds that are seen. Nurses tend to default to any time there is an open wound to state it’s a stage 2 pressure ulcer and that is not going to work for us. We need differential diagnoses. We need the nurses to help with that. We need to have clear descriptions of the wounds so that the physician can appropriately diagnoses the skin condition and then I would strongly suggest that you have skin assessments at the time of discharge so that you close that loop and make sure that you know what happened to those patients while they were your hospitalized patients. And you can drive and turn your skin care program based on that.


Of course one of the pieces of prevention is the use of a risk assessment and the risk assessment should indicate to you the type of risk that the patient has so clearly needs to be valid. I think that some patient areas are simply high risk. When you think about the ICUs and cardiac surgery, those patients are very, very ill and probably should just be considered high risk. We need to upgrade the beds in the entire unit rather than just waiting for the patient to ulcerate to qualify for a bed. You also need to teach the staff if the patient has an ischemia non-moving limb, have had orthopedic surgery, they are diabetic or have leg bypass, those legs are very high risk for pressure ulcers on the heels. You need to develop a heel prevention program that looks at the risk for if you are using grades for example the grades score and then combining it with other factors that increase the risk of heel ulcers. A risk assessment should be done daily and you should target intervention based on the level of risk the patient has. It is much more cost effective than to target to the total risk score because you are targeting exactly where the patient’s particular problem is. And then I think the last piece to make sure quality assurance is where it is supposed to be sure that the preventative program is actually being carried out. You could do a unit by unit review. You could do the CQI program. It’s a good place to use your student nurses that are looking for management projects on your units.


Perhaps you haven’t looked at the support surfaces yet that you have in your standard patient beds. A good time is now to take a look at the beds that you get good baseline beds with good pressure redistribution properties in them. It is an important part of all hospital patients stay. I think it is also helpful if you can purchase a few frequently used beds. Get a sense of how many beds you are using house wide. I certainly wouldn’t advise you to purchase the high maintenance beds. Certainly low maintenance beds. Bariatric overlay for example would be a helpful one to have around and not have to wait for it to be delivered. Then I think you need to come up with criteria that are specific for your patient population. Obviously every hospital patient population is slightly different, if they are a center of excellence, the nature of the community of where they are involved. You need to be able to match the surface to the patient’s needs, so not all patient’s need the high end beds but some patient’s do and we need to get them on those beds when it is appropriate for them. We need to create in our nurses an understanding of overdependence on beds. They should not be beds. Patients must be turned on any surface that they are on. There is no bed that completely prevents pressure ulcers.


Chair and chair cushions are another aspect of pressure ulcer prevention programs. I want you to think for a minute about how good is that bedside chair that you are using. Was it really designed that nobody is comfortable in it or is it really designed so that people don’t sit in it? Does the cushion have padding or is it simply nagahide over a spring base? Then who in your system gets additional padding on those chairs? If it takes four people to transfer this patient to the chair they are not going to be moving in the chair. So are you using 4 inches of foam? If you are using 4 inches of foam you have to limit it to people that are not going into long term care because it is not cleanable. It cannot go into long term care. Air cell cushions are transferable because they are cleanable and then we’ve got ROHO cushions and gel cushions in persons who have long term problems, long term sheathing problems, like parasaquads? And those kind of patients. The standard of care requires that patients be repositioned hourly when they are in the chair. Is that done routinely in your facility or is it assumed that if the patient is up in the chair it is good for them to be up and the fact that they cannot move off of their ischial tuberosities doesn’t rise to an importance the patients are slumped over to the side. You need to get into your care package for this patient or visit by your staff hourly to make sure that they are seated properly in the chair and that they have been repositioned so that their skin has a chance to get a little blood flow.


Pressure ulcers are a system issue. This is not just a nursing issue. It is important in your system to develop and use an interdisciplinary. The team should include nurses, physicians, physical therapists, occupational therapists, dieticians, all of the people in your system that interface and can help with the prevention of pressure ulcers. It is certainly important to gain administrative support. There are very few teams that make any progress when they don’t have assistance or support from the administrator. The administrator is going to want to know data so it’s important to start looking at your numbers. What are your incidence numbers? Can you look at the care that was provided to a patient and equate it to the outcome that you are seeing? What kind of monitor system to you have in place? Are pressure ulcers part of your CQI package or do they only come up every once in a while because you are looking at other things? Decide in your system how many ulcers you have and how important this process should be. We need to educate folks house wide. Important I think house wide pressure ulcers prevention. Competencies- prevention is a very big piece of the story. You may or may not decide to have house wide competencies on pressure ulcers treatment. That will depend on how many patients you have in your system but that education has to be on going. It has to be mentored; it has to be followed through. It’s easy to listen to something for an hour and then go back to whatever you were doing. Part of making it stick is going to be to have a rewards system and there are great examples of this out in the literature where facilities started to reward CNAs and nurses’ aides and care providers when they found stage one pressure ulcers and when they reported it they got rewarded for that rather than chastised, I can’t believe you didn’t turn this patient until they got a stage one they were rewarded for finding it because the presumption is if we found it at stage one, we can prevent it from becoming a stage 2.


The other thing that I have seen happening around the nation is that there is some bundling going on for pressure ulcer issues. We know from some research done in Japan that foam dressings are very helpful in reducing shearing on the sacrum of the patients with the head of the bed up for example with ventilators. And I know that there are some hospital systems that bundle the foam dressing to the ventilator. When you get the ventilator you get the foam dressing, which is a queue for the nurse to put it on the back of the patient. I’ve also been encouraging people to start bundling skin care products for patients that are tube fed to prevent skin damage from diarrhea. That often follows tube feeding. The evidence based guidelines that EPUAP and NPUAP have been working on are going to be available to you in May of 2009. This new guideline is phenomenal in the amount of detail that it has that will really help you put together a really scientifically based pressure ulcers prevention and treatment program in your hospital. I do think the idea of enablers is helpful. As we saw in the study by Frain, they used pencils and door signs. Some facilities use music to queue the staff to turn the patients every 2 hours. I’ve heard “Turn, Turn, Turn” an old song from the ‘60s. I’ve heard other songs that play over the intercom system just a way to queue people that it’s time to do something for those bed bound and chair bound patients. The other thing that I’ve seen personally at Nebraska Medical Center is that we integrate the data about the patients’ risk of pressure ulcers into the computer and then we generate a computer based care plan from that so it makes it easier to just jump from the data you recorded in the medical record to what you are going to do for the patient based on that and then the last thing is if we can design some support decision making systems that will help us in choosing the right products for the right patients. There are algorithms for making decisions about beds and if you don’t have one I think it would be helpful for your staff nurses to know that if a patient comes in on Saturday how do they get a specialty bed for that patient when the wound nurse won’t be around until Monday. So an algorithm for the decision of beds would be extremely helpful to help your staff make good decisions to prevent pressure ulcers from the start.


There of course are some issues that remain. One of the issues is that the discharge summary by physicians’ seldome contains information on pressure ulcers and this is a great time to work as a team to make that happen. Certainly nurses do not always have the training to reliably differentiate or discern a pressure ulcers from another wound and it’s important for the two to work together that the nurse can describe to the patient what has been seen or assessed at the bedside and the physician can make diagnosis after seeing that wound also. Fraudulent claims to misclassified pressure ulcers will be investigated so try to be accurate of course assume that you are going to be honest in your statements to CMS. Not all MDs will examine skin. There are some MDs that it is not in their practice to examine skin and nurses will have to be willing then to work with those physicians to help them see the wounds that they need to see to make sure that the documentation is done appropriately and not all patients with full thickness ulcers will be caught in this time frame of admission. This is going to be difficult if this patient comes in and is very, very unstable and they are not able to be examined. They go to the operating room and have emergency surgery and its a few days before the patient is actually physically stable enough to get that patient moved for all the skin to be examined. Those patients you are just not going to be able to catch and document that the ulcers were indeed present on admission because too much time has lapsed. Be honest if you think there is good data that the chances are greater than not that pressure ulcers was present on admission it’s still allowable according to CMS rules to record it as such.


There are still some system decisions that need to be made. How do you engender the physicians commitment to documenting these ulcers at the time of admission. Some of these patients are direct admissions from a physician’s clinic to the hospital where the patient is not disrobed in the clinic so if the physician did not see the skin in the clinic how do you get it documented that it was present on admission? This is a great place to use a hospitalist to help you when the patient comes in because certainly the nurse will see the wound. The physician may not fully understand the importance of the documentation for the hospital to get paid or may not specialize in wound problems and therefore doesn’t see that he or she has the knowledge to make that decision. So then when can the wound nurses or other parts of a wound team consult to help with the decision of what the etiology and the stage of the pressure ulcers is? How do you communicate within the record? What is the best form of documentation in your hospital system if your wound nurses are documenting on one form and your physicians on another, it may be time for you to look at how can we communicate one to the other. And then how do you get the administration to understand that we need to make better beds available for patients in a preventive view when they are going to look at it as a loss of revenue when there’s no payment for pressure ulcers and simultaneously increased expense. This will only happen if you have numbers and you can show people in your numbers, how many pressure ulcers you have. How many 707 diagnoses did you get paid for last year? If those happened on your watch, how many of you are not going to get those numbers? Some nurses have gone to the billing coders and said can you just generate the number of 707s which is the pressure ulcers code. How many 707s did we bill out last year and what is your incidence so that would be your total, total number of ulcers per year? What percent of those were incident ulcers and how many dollars were actually not or will not be collected because they are inpatient acquired pressure ulcers.


The present on admission ruling has not changed our legal risks. It is still important to document the presence of pressure ulcers on admission because of CMS rule; but also from a legal venerability. We need to make sure we have good documentation of skin ulcers at time of admission. This is by the nursing staff. Get the stage if it’s a pressure ulcers. Get its size dimension; get all of its characteristics of the ulcer. Then get a diagnosis of the etiology. The physician or a certified wound nurse can make the determination of the etiology of the wound, we need to make sure the risk assessment that was done is accurate that if an external reviewer looks at that record, he or she will see the same thing as is detailed in that risk assessment and that the care provided matches the risk level so if this patient is immobile and inactive there was a turning schedule put in place, there was a better support surface put on the bed. If this patient is malnourished or incontinent that dietary was notified that a diet was ordered that was appropriate for the patient, the skin care products were placed on the skin to protect the skin, there needs to be a careful plan in place that shows that risk was identified and that a plan of care was placed to litigate that risk including education of the patient and the family on what was done and then of course the last thing is to make sure we document all the care that you provide and to document the specific name of the beds in use, that you document what kind of nutrition the patient was getting, you document the kind of wound care that you are providing and you document the fact that you are turning the patient including the position you put the patient in and if the patient can’t be turned what the reason is. Checkmarks in the record go day after day after day will not suffice to indicate that the patient was indeed turned.


As of October of 2008 hospital will not be paid when pressure ulcers occur during the hospital stay. It is imperative that you improve your care and the care in your hospital to reduce both your financial exposure and your legal exposure on this very important problem of pressure ulcers. This program has presented to you the CMS rule about the payment of pressure ulcers, the payment for pressure ulcers at the time of admission and several ways for your hospital to look at system based changes to reduce your financial exposure your patients cause and of course your legal risk. Thank you for your attention.


Production of this PRESENT lecture was made possible by a generous grant from Coloplast.


I want to thank you for your attention today and especially want to thank the Coloplast Company for sponsoring this program of me talking to you. Hopefully I will get to meet you someday and hopefully more importantly than meeting me is that you take good care of your patients. Thanks a lot.

The goal of this educational offering is to explore the CMS rule on pressure ulcers as a nonpayable hospital acquired condition and the possible preventive approaches to skin care.
Goals and Objectives
After participating in this activity, the viewer should be better able to:
1. Discuss the changes in funding for hospitals related to pressure ulcers.
2. Describe the documentation needed to be paid for pressure ulcers present on admission.
3. Identify pressure ulcer prevention programs to reduce risk to both the patient and the hospital.

Estimated time to complete this activity is 56 minutes.
Target Audience
Physicians, diabetes educators, and other health care professionals who treat patients with diabetes.
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Pressure Ulcers: Reducing the Patient's and Your Risk
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Method of Participation
Pressure Ulcers: Reducing the Patient's and Your Risk
Complete the 4 steps to earn CE/CME credit:
  • Complete and submit the required pre-test
  • View Lecture
  • Complete and submit post-test and program evaluation. Credit will be issued with a passing score of 70% or better.
  • Click Print Certificate.
Disclosure Information
Pressure Ulcers: Reducing the Patient's and Your Risk
It is the policy of PRESENT e-Learning Systems and it's accreditors to insure balance, independence, objectivity and scientific rigor in all individually sponsored or jointly sponsored educational programs. All faculty participating in any PRESENT e-Learning Systems programs are expected to disclose to the program audience any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the continuing education program. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker with a potential conflict of interest from making a presentation. It is merely intended that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts.
Joyce Black, RN, PhD, CWCN has nothing to disclose
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