Pressure Ulcers in Hospitals: Ethics, Law, and Patient Care

Background: Understanding Pressure Ulcers

Bedsores, also known as pressure ulcers, are lesions primarily caused when soft tissues are pressed against bone for a prolonged period of time, restricting blood flow to the affected area. These injuries commonly occur when a patient is immobile or confined to a recovery bed for an extended period. They are most frequently found on the hips, elbows, knees, ankles, and even the back of the head. Current research shows that pressure ulcers are exacerbated by other conditions such as diabetes, perspiration, incontinence, infection, and medications that impair the circulatory system.

Pressure ulcers are particularly serious in older patients — especially those who use a wheelchair or who do not move or exercise regularly. Bedsores are often fatal even when treated aggressively and are one of the leading causes of death from complications in many developed countries, second only to adverse drug reactions (Preventing and Treating Pressure Ulcers, 2009).

Pressure ulcers are best addressed through preventive care: turning the patient regularly so blood flow is not compromised, using catheters or impermeable dressings to keep bed sheets dry, and shifting paralyzed patients on a regular schedule or using pressure-distributing mattresses. Additionally, higher levels of Vitamin C appear to have a beneficial effect on both the prevention and healing of bedsores (Preventing Pressure, 2011; Meschino, 2011).

Ironically, even though Medicare and Medicaid do not reimburse — or do not reimburse fully — for the treatment of pressure ulcers, more than 2.5 million people in the United States develop them each year. Within acute care, the incidence is as high as 38%, and in long-term care it is 24%. The rate is considerably higher within intensive care units, likely due to immunocompromised patients, with 8–40% of patients developing sores (Pressure Ulcers in America, 2001).

The Centers for Medicare and Medicaid Services announced as far back as 2008 that it would no longer reimburse hospitals for treating pressure ulcers because, in the agency's view, they are preventable. Several academic papers and professional medical societies have refuted this position, arguing that there are clinical circumstances in which pressure ulcers are unavoidable even with excellent multidisciplinary care. Because the skin is the body's largest organ, many diseases overwhelm it, and even best practices cannot prevent pressure ulcers 100 percent of the time (WOCN Society, 2009).

Scenario: A Disputed Pressure Ulcer Case

The situation involves a patient admitted to a hospital from a skilled nursing facility because of severe dehydration. Both facilities frequently cross-refer patients and maintain a close working relationship. Within a few days of admission, hospital staff noticed a pressure ulcer and claimed it was caused by the nursing facility. The nursing facility countered that there was no documentation of any skin issues prior to the patient's discharge and that the hospital was to blame. Beyond the clear moral and ethical dimensions, there is also the matter of payment from Medicare, which classifies bedsores as "never events." Several arguments therefore surround this type of case.

Practical Issues: Medicare Coverage and Ulcer Timing

The core of the argument extends beyond healthcare management into medical ethics and the bureaucracy of healthcare financing. Medicare Part A is hospital insurance that helps cover care in hospitals and skilled nursing facilities, generally covering inpatient care and inpatient rehabilitation costs. Medicare Part B covers medically necessary services: physicians, medical equipment, home health care, and services or supplies that treat a medical condition. Medicare Part D is specifically for prescription drug coverage and, once enrolled, covers costs based on co-payments, a yearly deductible, medication costs, and the pharmacy used; in any case, pharmaceuticals are less expensive than they would be without coverage (Medicare.gov).

There is not a great deal of research available on the timing of pressure ulcer development. A number of factors affect this, including predisposition, actual health status, nutrition, severity of injury or surgery, pharmacological profile, and the patient's weight, size, and body dimensions. Based on available research, findings indicate that pressure ulcers are likely to develop between the first hour and 4–6 hours after sustained loading onto the tissues (Gefen, 2008). In this case, it is therefore more probable that the pressure ulcers developed after the patient was transferred to the hospital — though it is possible that the final day of care at the nursing facility contributed to the event. Based on the charting showing that the skin sores were not noticeable for 24–48 hours, there is a higher probability that the patient did not receive sufficient preventive care at the hospital.

References

Coverage information retrieved from http://www.medicare.gov

Medicare Nonpayment for Hospital Acquired Conditions. (2012). National Conference of State Legislatures. Retrieved from:

Medicare Will Not Pay for Hospital Mistakes and Infections. (2007, August 20). Medical News Today. Retrieved from:

Pressure Ulcers in America: Prevalence, Incidence, and Implications for the Future. (2001). Advanced Skin and Wound Care, 14(4), 208–15.

Preventing and Treating Pressure Ulcers. (2009). UCan Health. Retrieved from: http://ucanhealth.com/topics/?T=pressureulceramyotrophiclateralsclerosisALS

Preventing Pressure Ulcers in Hospitals. (2011). Agency for Healthcare Research and Quality. Retrieved from:

Benjamin, M., & Curtis, J. (2010). Ethics in Nursing: Cases, Principles, Reasoning. New York: Oxford University Press.

Gefen, A. (2008). How much time does it take to get a pressure ulcer? Ostomy Wound Management, 54(10), 26–35. Retrieved from:

Meschino, J. (2011). Vitamin C — Ascorbic Acid. Meschino Health. Retrieved from: http://www.meschinohealth.com/books/vitamincascorbicacid

Wound Ostomy and Continence Nurses Society. (2009, March 24). Position Paper: Avoidable versus Unavoidable Pressure Ulcers. Retrieved from: