What is an Unavoidable Pressure Ulcer?

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by Karen Zulkowski DNS, RN, CWS

There are several issues in pressure ulcer definitions. For example, exactly what is the definition for eschar? What is an unavoidable pressure ulcer? How can you decide it really was unavoidable?

Defining Unavoidable Pressure Ulcers

One of the best sources for definitions is surprisingly the Centers for Medicare & Medicaid Services (CMS). In the Minimum Data Set (MDS) instructions and surveyor guidelines there are very specific definitions for everything from wound types and stages to exudate. Definitions are also available for other categories as well, such as nutrition and incontinence. Other information is included on treatments. However, the manuals themselves are difficult to use. One is available on how to complete the MDS and another is for surveyors to use during their site visits. Both guides are long in length and challenging to navigate.

As many of you know, I am a World Council of Enterstomal Therapists (WCET) board member and in that capacity I represent the organization on the National Pressure Ulcer Advisory Panel (NPUAP) board. One initiative I have been involved in has been combining the items used for survey results (Tags) into an easy to follow format. This will be available soon on the NPUAP website and will be very helpful regardless of where you work. It provides definitions and steps of the survey process.

Conducting a Root Cause Analysis for Pressure Ulcers

A second item that is being finalized is on how to do a root cause analysis for pressure ulcers. A root cause analysis looks at when the pressure ulcer was found and what the care was prior to development. Any pressure ulcer that is found should be used as a learning experience. In other words, was it present on admission or was it facility-acquired? If it was facility-acquired, was it unavoidable? CMS defines both avoidable and unavoidable:

"Avoidable means that the resident developed a pressure ulcer and that the facility did not do one or more of the following: evaluate the resident's clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate.

Unavoidable means that the resident developed a pressure ulcer even though the facility had evaluated the resident's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate."

So basically unavoidable is: did you do everything correctly and did the individual still developed a pressure ulcer? Some populations are more likely to develop an unavoidable pressure ulcer. For example, someone in ICU for a prolonged time, especially if they are hemodynamically unstable. Unfortunately, the people who do develop an unavoidable pressure ulcer may bring a lawsuit. The public views any pressure as unavoidable and the result of poor care. It is important for staff to educate the patient and family about the quality of care they are providing and if the person is at high risk of developing a pressure ulcer.

In February, NPUAP had a consensus conference on unavoidable pressure ulcers. The results of this meeting will also be available soon on the NPUAP website. The results will be important for staff to understand what patients the "experts" agree are most likely to develop an unavoidable pressure ulcer. However, it will also be important to staff to keep the definition of unavoidable in mind and remember that the care plan has to be appropriate and actually carried out.

Finally, pressure ulcers can and do occur way too often. To treat any wound, we first have to identify its cause and what is the best evidence-based treatment available. To do that we have to be consistent in our documentation, assessment and care planning both within and between facilities.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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