The impact of Short Staffing and the development of pressure ulcers

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Introduction

Determining incidence and prevalence of pressure ulcers in acute-care hospitals, long-term care, and home health is an ongoing challenge for healthcare. Incidence refers to new cases of pressure ulcers that occur during a specified period and prevalence is a cross sectional count of the number of pressure ulcers at a specific point in time. There are multiple ways to assess the pressure ulcer rate within institutions the most common of which is by performing pressure ulcer prevalence. This consists of a one day snapshot where all patients hospitalized on the study day are examined for the presence of a pressure ulcer. The medical record is examined to determine if the pressure ulcer was present on admission as documented usually by nursing staff or hospital acquired (documented more than 24 hours after admission).

Pressure Ulcer Assessment and Staging Process

Consistent, valid and reliable pressure ulcer staging is vital in determining prevalence of pressure ulcers and has been an ongoing challenge for practitioners and researchers. In 1987 a small group of healthcare professionals established a national organization to address pressure ulcer prevention, care, education, and advocacy. The National Pressure Ulcers Advisory Panel is an independent, non-profit organization that has become the U.S. organization that develops research, public policy, and education to improve patient outcomes in pressure ulcer prevention and management. This organization's efforts resulted in the landmark AHCPR guidelines for pressure ulcer prevention and pressure ulcer treatment. In 1999, van Rijswijk reevaluated the evidence and provided an update that confirmed the strength or weakness of evidence presented in the original publications. One of the most important outcomes of the NPUAP is the pressure ulcer staging consensus that resulted in a classification system for pressure ulcers setting the standard for determining a reliable and valid nationwide pressure ulcer assessment for data collection (Allman, 1995).

Current Pressure Ulcer Trends

Pressure ulcers are frequently associated with poor nursing care in long term settings. In 2004, US Centers for Medicare and Medicaid services (CMS) implemented changes the in long term care surveyor guidelines adding Tag F-314 that describes whether a pressure ulcer that developed in the facility was avoidable or unavoidable. As a result, skilled nursing facilities have been held to the higher standards for pressure ulcer prevention that spell out specific aims for care of patients who are at risk of developing pressure ulcer and appropriate documentation. Historical changes in Medicare reimbursement and newly mandated reporting of all hospital acquired stage III and IV pressure ulcers in California challenge healthcare providers to capture and manage pressure ulcer occurrences or suffer the consequences of denied reimbursement. As part of the 2006 Deficit Reduction Act, the Center for Medicare & Medicaid Services (CMS) enacted Present on Admission (POA) Indicator Reporting for stage III & IV hospital acquired pressure ulcers. In the deficit reduction act of 2006, CMS identified high cost, high volume secondary diagnosis that was considered potentially preventable for non-payment. As of October 2008, stage III and IV hospital acquired ...