We here at ALN sometimes encounter a sense of “Am I making a difference and is it enough?” in our profession. And it’s interesting to hear that same thing from other nurses.  Diane M Goodman recently posted a piece that so compelled us, we just had to share.  Thank you, Diane.”

Sticks and Stones; The Power of a Nurse’s Words

By Diane M. Goodman, Originally appeared in MedScape, Jan 21, 2016

Many of us were raised in a generation by mothers who warned us of the old English adage about taunting others through the use of name-calling and words. We knew better. Words could either be unbelievably comforting or leave lasting scars on our memories.

As nurses, our words and our voices are no less profound. We can change the trajectory of a life by coaxing change from a desultory or despondent patient, and we can inspire peers to greatness when they feel they cannot work another moment or another busy day.

Sharing research with peers may allow them to comprehend the improbability of what we DO on a daily basis. By reading a quantitative time-study, for example, and sharing it with colleagues, they may have an improved understanding of why nurses need stress management techniques to perform their jobs. Nursing is extremely difficult work. Expecting substantive conversation or specific phrases to “just happen” at the bedside is like asking the typical pilot to land an airplane on the Hudson!

Nurses, on the average, complete >70 (!!) tasks per hour. Nurses change tasks approximately every 55 seconds. They are also interrupted approximately once every 32 minutes, with the highest amount of interruptions recorded during medication administration!*

Why is it important to know this? While this time/event study was conducted in Sydney, the research was rigorous enough to be utilized internationally as an example of why nurses may find it “difficult” to bond with patients. We may be groping to find the right words to instill initiative, hope, and change in our patients. We could even be struggling a bit.

Nina (not her real name) reminded me of this in ICU. I was struggling. She was paralyzed, intubated, ventilated, and so, so sick. I was sure she would not survive. She was only 19.

I was exhausted every night, hanging more blood, platelets and medications than I had ever hung in my life. She was septic and she had leukemia. “Sticks and stones”, I repeated in my head over and over, warning myself not to frown or sigh, or show tiredness EVER. Instead, I stroked her hair, and told her how much I loved my little sister, and my dogs. I played music for her when my voice got tired or I ran out of words. If nothing sweet or positive was left to be said, I smiled and hummed, night after exhausting night. OK, so I did a lot of humming.

Her bed was empty one night, as ICU beds often are. Rehab, they said. Long-term. Newer, sicker patients came and went.

Six months later, a young, attractive woman was wheeled in with a huge family circling her, including one very determined sister. It was Nina. She remembered nothing of her stay but a woman who stroked her hair and hummed and talked softly of dogs and family. I would have given her almost zero odds of surviving, and here she was!! Sitting tall, with very little residual effects. I couldn’t believe she remembered me! She remembered nothing else.

Medical malpractice claims in 2015 were on the rise for the second year in a row. In 2014, $3.8 billion in payouts were awarded to claimants and plaintiffs alleging malpractice, according to Diederich Healthcare. Malpractice claims exceeded $713 million for New York State alone. Altogether, the quantity of claims increased 4.4 percent compared to 2013 — the second increase in two years.

Many malpractice insurers are hemorrhaging money as a result of these claims. One method they can try to reduce the size of settlements is to consult a legal nurse to analyze the data and determine whether the damages are to the extent the claimant alleges.

A growing numbers of plaintiffs are already using this same tact to increase the size of their claims. Legal nurse consultants were able to analyze data and case histories in order to bolster the claimant’s argument for a larger settlement. Without a legal nurse consultant of their own, many defense attorneys representing insurance carriers were unable to counter the compelling evidence set forth by the plaintiff.

Now, insurance carriers are recognizing the need for a legal nurse consultant in order to ensure a more accurate and complete analysis of the case’s circumstances. Defense attorneys who do not keep pace with this trend will soon find themselves outmatched in a profession that concerns itself exclusively with persuasive matters of fact.

Legal Nurse Consultants Make Worthy Opposition

In the legal consulting world, each side does their best to examine the case in an objective manner while still singling out the details that can benefit the client they are helping represent. A single expert witness for the plaintiff can clinch the outcome in their favor.

Meghan D’Angelo was one such clincher. She was once called in to provide an objective confirmation on whether or not a hospital followed protocol. Her plaintiff, who was tragically deceased, had died as a result of complications from falling out of bed. The plaintiff’s family and representing lawyer simply wanted to know if the hospital had breached protocol by allowing the patient’s bed rails to be left down.

What she found went far deeper than bed rails. As D’Angelo analyzed the case report and medical records, she discovered that the patient was given the wrong dose of a medication that had sedating side effects — twice. She also noticed that the nursing staff did not exercise their full diligence when performing the patient’s assessment.

This discovery transformed D’Angelo’s role from a one-note confirmation to a full-blown consultant who worked with the case for two months. “We’re looking from a high level down to a detailed level,” D’Angelo told the Daily Record. “I’ll say, ‘Look, let’s not only focus on what happened at the bedside, but also, were the hospital policies and procedures followed?’”

Countering Knowledge with Knowledge

No one can say for certain, but it is likely that the defense attorney was dumbfounded upon D’Angelo’s discovery. Without a legal nurse consultant of their own, they could have easily been blindsided by the information and not in a strong enough position to dispute the findings.

Having a legal nurse at your side allows your case to respond in a tit-for-tat manner with the plaintiff’s own expert consultant. Many nuances and complex details surrounding patient medical records could make the typical paralegal’s head spin. A legal nurse, though, can respond in kind and work to bring a full spectrum of opinions and findings to the defense.

In fact, a legal nurse consultant can come into play countless times during a discovery and case-building period. The American Association of Legal Nurse Consultants outlines an entire process that can be extremely difficult for someone without a medical background to handle.

Even if your case is not going to litigation or your claimant has not consulted a legal nurse of their own, relying on a legal nurse could potentially save insurers thousands or more. Many insurers are already recommending that attorneys hire legal nurse consultants in order to view the claim from a professional standpoint.

To make sure that your legal team does not get out of their depth and can keep settlements as low as possible, strongly consider the increasingly-common recommendation of insurers and hire a legal nurse to bolster your case. Your client just might not be able to afford for you not to.

To learn more about ALN Consulting’s process, click here.

As part of ALN Consulting’s commitment to our legal partners, we introduce the second installment of our CMS Interpretive Guidelines series by diving into the revisions on the use of restraints. The guidelines include an explanation of the intent of the law, definitions of terms, and instruction on determining compliance with the law. The most important update to the Interpretive Guidelines regarding restraints prohibits their use in fall prevention. This update significantly impacts the defense of long term care facilities. These revisions must be studied thoroughly in order to build a firm case for the use or non-use of restraints. Continue reading for a thorough explanation of these revisions in the Interpretive Guidelines.

42 C.F.R. §483.13(a).

The CFR Regulation states, “The resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms.” Relevant definitions in the Interpretive Guideline include:

Chemical Restraint: any drug that is used for discipline or convenience and not required to treat medical symptoms.

Convenience: any action taken by the facility to control a resident’s behavior or manage a resident’s behavior with a lesser amount of effort by the facility and not in the resident’s best interest.

Discipline: any action taken by the facility for the purpose of punishing or penalizing residents.

Freedom of movement: any change in place or position for the body or any part of the body that the person is physically able to control.

Medical Symptom: an indication or characteristic of a physical or psychological condition.

Physical Restraints: any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body.

Removes easily: means that the manual method, device, material, or equipment can be removed intentionally by the resident in the same manner as it was applied by the staff (e.g., side rails are put down, not climbed over) considering the resident’s physical condition and ability to accomplish objective (e.g., transfer to a chair, get to the bathroom in time).

Regulation Tag F222 Guidance on Restraints

The main principal in the Interpretive Guideline is that restraints may not be used for staff convenience, and the only acceptable use of a restraint is to treat a medical symptom, with a physician order. The order itself is not justification to use a restraint, but must be “viewed in the context of the resident’s condition, circumstances, and environment.”  In addition, as a measure of last resort restraints can be used to protect the safety of the resident or others for a brief period of time. The facility may not use restraints in violation of the regulation solely based on a legal surrogate or representative’s request or approval.

When a restraint has been used, the surveyor must determine if the facility followed a systematic process of evaluation and care planning prior to using restraints, and if the plan of care was consistently implemented.

Surveyor “Probes” in facility use of Restraints

The defense team can use the “probes” or questions posed by the Interpretive Guidelines for surveyors in cases which involve restraints:

• What are the medical symptoms that led to the consideration of the use of restraints?
• Are these symptoms caused by failure to:
  • Meet individual needs in accordance with the resident assessments
  • Use rehabilitative/restorative care?
  • Provide meaningful activities?
  • Manipulate the resident’s environment, including seating?
• Can the causes of medical symptoms be eliminated or reduced?
• If the causes cannot be eliminated or reduced, then has the facility attempted to use any alternatives in order to avoid a decline in physical functioning associated with the restraint use?
• If alternatives have been tried and deemed unsuccessful, does the facility use the least restrictive restraint for the least amount of time? Does the facility monitor and adjust care to reduce the potential for negative outcomes while continually trying to find and use less restrictive alternatives?
• Did the resident or legal surrogate make an informed choice about the use of restraints? Were the risks, benefits, and alternatives explained?
• Does the facility use the CAA’s to evaluate the appropriateness of restraint use?
• Has the facility reevaluated the need for the restraint, made efforts to eliminate its use and maintained residents’ strength and mobility?

Updates to the Interpretive Guidelines

The most recent update to the Interpretive Guidelines for restraints was published in November 2014. The examples of facility practices that met the definition of restraint was noted to be “not limited to” the list. Also, in discussion of side rails, the addition of “assist with physical functioning” was added as an acceptable use.

The most important update to the Interpretive Guideline stated, “Falls do not constitute self-injurious behavior or a medical symptom that warrants the use of a physical restraint. Although restraints have been traditionally used as a falls prevention approach, they have major, serious drawbacks and can contribute to serious injuries. There is no evidence that the use of physical restraints, including but not limited to side rails, will prevent or reduce falls. Additionally, falls that occur while a person is physically restrained often result in more severe injuries (e.g., strangulation, entrapment).”

This update has implications in the defense both of the use or non-use of restraints, as well as in matters involving falls. When understood and implemented, these interpretive guidelines can be crucial in the defense of long term care facilities.

In conclusion, the successful defense of long term care facilities relies on a thorough understanding of the CMS Interpretive Guidelines. With our expertise, ALN Consulting can advise your legal team on how to best navigate the complicated CMS Interpretive Guidelines to support your legal team’s defense. Let us help you decipher the latest revisions of the Interpretive Guidelines and strengthen your long term care case.

References

1. Harris, Rick E. (2015). How to Use the CMS Surveyor Guidance to Craft a Winning Defense [Presentation at the DRI LTC/SNF Seminar].
2. Centers for Medicare & Medicaid Services. (2015). State Operations Manual – Appendix PP – Guidance to Surveyors for Long Term Care Facilities. Retrieved 01/04/16.

2016

In April 2016, the National Pressure Ulcer Advisory Panel or NPUAP announced a change in the terminology and the stages of pressure injuries. Though these stages continue to include both unstageable pressure injuries and deep tissue pressure injuries the new definitions do not specifically mention the Kennedy Terminal Ulcer. Over the years, however, multiple panels and advisory groups have documented the Kennedy Ulcer as an end of life phenomenon.

The unavoidable skin breakdown that occurs as part of the dying process, known as a Kennedy Ulcer, has been recognized by Ostomy Wound Management since a 2009 journal article. Also in 2009, an expert panel released a consensus statement known as SCALE or Skin Changes At Life’s End which identified skin organ compromise occurring at the end of life. The panel recognized that the ulcer is usually seen on the coccyx or sacrum but has been reported in other anatomical areas and is usually associated with imminent death.

This special classification was also mentioned by the Center for Medicare and Medicaid Services (CMS) in 2014 within its Quality Reporting Program Manual and its Continuity Assessment Record and Evaluations Data Set (CARE) for long-term care hospitals. The “Coding Tips” of the publication noted if an ulcer was part of the dying process, developing from six weeks to two to three days before death, it should not be coded as a pressure ulcer.

Click here for the full detailed staging guidelines.

ALN Consulting will continue to stay on top of these and other developments. Contact ALN Consulting if you have questions about a case and would like an initial consultation.

A thorough understanding of the development and treatment of pressure ulcers is critical when defending against these medical malpractice cases. Attorneys must stay up-to-date with the latest definitions, risk factors, and stages of pressure ulcers to help address the complicated claims in these cases. Studying the prevention and treatment of pressure ulcers allows for the strongest defense to be made. Pressure ulcer cases are rarely straightforward. Growing debate around the avoidability of pressure ulcers gives more room for defense teams to make defensible claims.

This portion originally published on November 18, 2015:

What is a Decubitus or Pressure Ulcer?

The term decubitus ulcer (from Latin decumbere, “to lie down”), pressure sore, bed sore, and pressure ulcer are often used interchangeably among patients, family, and medical staff. As the root of the name suggests, these ulcers occur at sites overlying bony structures that sustain more pressure when the person is recumbent. The National Pressure Ulcer Advisory Panel (NPUAP) and the most up to date literature refer to these type of ulcers as pressure ulcers, or an area of unrelieved pressure over a defined area, usually over a bony prominence, resulting in ischemia, cell death, and tissue necrosis.

Risk Factors for Pressure Ulcers

In a Long Term Care (LTC) setting surveyors follow the guidelines of F-tag #F314 which states that an admission assessment must be performed, along with an identification of patients who are at risk for pressure ulcers. There is no one formal risk assessment tool recommended, but many facilities use the Norton or Braden scales. Risk factors mentioned in #F314 include, but are not limited to:

• Impaired/decreased mobility and decreased functional ability;
• Co-morbid conditions, such as end stage renal disease, thyroid disease or diabetes;
• Drugs such as steroids that may affect wound healing;
• Impaired diffuse or localized blood flow;
• Resident refusal of some aspects of care and treatment;
• Cognitive impairment;
• Exposure of skin to urinary and fecal incontinence;
• Under nutrition, malnutrition, and hydration deficits;
• A healed ulcer. The history of a healed pressure ulcer and its stage (if known) is important since areas of healed Stage III and IV pressure ulcers are more likely to have recurrent skin breakdown; and
• Diabetic neuropathy, frailty, cognitive impairment.

Regardless of any individual’s risk score, the nursing staff is responsible for the creation of a resident specific care plan that addresses each risk factor and the extent to which the factors can be modified, stabilized or removed.

Staging of Pressure Ulcers

An important facet of caring for a patient with pressure ulcers is assessment and re-assessment of the stage, size, and appearance. If a pressure ulcer exists upon admission, or develops during residency, the stage of the ulcer should be documented. Nursing staff should not use the following staging system for ulcers that are not a result of pressure, such as ulcers and wounds called arterial ulcers (the result of blockage in the arteries with inadequate blood flow to the limbs), venous insufficiency ulcers (known as “stasis ulcers”), and diabetic ulcers. These ulcers should be documented, reported to the physician, and monitored, but not staged using the NPUAP International Classification System. For use along with the below NPUAP definitions of each stage, artistic renditions of the skin layers of these stages, as well as pictures for reference can be found at: http://www.npuap.org/wp-content/uploads/2014/08/Updated-10-16-14-Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-16Oct2014.pdf

Stage I: Nonblanchable Erythema: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin many not have visible blanching; its color may differ from the surrounding area.

The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” individuals (a heralding sign of risk).

Stage II: Partial Thickness Skin Loss: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

Presents as a shiny or dry shallow ulcer without slough or bruising. ⃰ Stage II should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.

Stage III: Full Thickness Skin Loss: Full thickness loss of tissue. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

The depth of a Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and a Stage III can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

Stage IV: Full Thickness Tissue Loss: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

The depth of a Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g. fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.

Unstageable: Depth Unknown: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as ‘the body’s natural (biological) cover’ and should not be removed.

Suspected Deep Tissue Injury (SDTI): Depth Unknown: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

On April 8, 2016, the NPUAP will hold the 2016 Staging Consensus Conference at the Hilton Rosemont/Chicago O’Hare Hotel. Attendees will have the unique opportunity to provide input on the future of the staging system as it is now, including the possibility of doing away with the staging system altogether. Find out more here: http://www.npuap.org/events/2016-staging-consensus-conference/

Prevention Strategies

For prevention of pressure ulcer development, the 2014 NPUAP Quick Reference Guide recommends the following interventions (not an all-inclusive listing):

• Avoid positioning the individual on an area of erythema whenever possible.
• Keep the skin clean and dry.
• Do not massage or vigorously rub skin that is at risk of pressure ulcers.
• Develop and implement an individualized continence management plan.
• Protect the skin from exposure to excessive moisture with a barrier product.
• Consider using a skin moisturizer to hydrate dry skin in order to reduce risk of skin damage.
• Consider the need to control moisture and temperature when selecting a support surface.
• Do not apply heating devices directly on skin surfaces or pressure ulcers.
• Consider applying a polyurethane foam dressing to bony prominences.
• Assess the skin for signs of pressure ulcer development at each dressing change or at least daily. Use a finger or disc method to assess whether the skin is blanchable. A transparent disc is used to apply pressure equally over an area or erythema can help the nurse observe for blanching.
• Screen, assess and care plan for nutritional issues. Follow dietary requirements for offering or providing the correct amount of hydration, calories and protein. Keep in mind that “offer” or “provide” does not mean “consume” and no individual can be forced to eat or drink. If there is a risk of malnutrition or dehydration, alternatives should be provided to the individual and decision makers in the family (e.g. IV fluids, tube feedings).
• Reposition all individuals at risk of, or with existing pressure ulcers, unless contra-indicated. Consider a pressure redistribution support surface when determining the frequency of repositioning. (Other considerations when determining frequency are tissue tolerance, level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort).
• Document frequency, position, and outcome of repositioning plan.
• Teach individuals ‘pressure relief lifts’ or other pressure relieving maneuvers as appropriate.
• Add assessments of skin folds in obese individuals.

Most nurses are familiar with a standard of turning patients “Q2” or every 2 hours to prevent pressure ulcers. The current recommendations in the 2014 NPUAP Reference Guide do not prescribe a frequency that applies to every patient, but instead recommends that the staff take into account the above considerations and develop an individual plan based on the risk factors and patient condition.

Treatment Plans and Wound Healing

NPUAP treatment recommendations are based on scientific principles and the opinion of experts in the field. These recommendations include (but are not limited to):

• Complete comprehensive initial assessment and reassessment. Wound assessments should be documented, and deterioration should be addressed immediately. Existing pressure ulcers should be reassessed at least weekly.
• There should be some pressure ulcer healing within two weeks, with adjustment of expectations for healing in the presence of multiple factors that impair wound healing.
• Reevaluate the plan if the pressure ulcer does not show signs of healing within two weeks.
• Assess and treat pain.
• Cleanse the pressure ulcer and surrounding skin at the time of each dressing change. Cleanse with potable water or normal saline, or aseptic technique when the wound healing is compromised. Consider cleansing solutions with suspected or confirmed infection.
• Debride devitalized tissue within the wound bed or edge of pressure ulcers when appropriate, and when the presence of biofilm is confirmed or suspected. Do not debride stable, hard, dry eschar in ischemic limbs.
• Assess for and treat infection.
• Select a wound dressing based on the ability to keep the wound bed moist, need to address bacterial bioburden, nature and volume of wound exudate, condition of the tissue in the ulcer bed, condition of periulcer skin, ulcer size, depth, and location, presence of tunnelling and/or undermining, and goals of the individual with the ulcer.
• Use hydrocolloid dressings for clean Stage II pressure ulcers in body areas where they will not roll or melt.
• Use care in removing film dressings on fragile skin.
• Consider hydrogel dressings on shallow, minimally exuding pressure ulcers.
• Consider alginate dressings for the treatment of moderately and heavily exuding ulcers.
• Consider foam dressings on exuding Stage II and shallow Stage III ulcers.
• Consider silver-impregnated dressings for pressure ulcers that are clinically infected or heavily colonized but avoid prolonged use.
• Avoid gauze dressings for open pressure ulcers.

Avoidable vs. Unavoidable, and Defense of Pressure Ulcers

In the defense of pressure ulcer claims, a legal nurse consultant (LNC) can be the most important member of your defense team in sorting through the many and varied recommendations regarding pressure ulcers, especially in light of so many of the recommendations being suited to individualized care plans and the many factors of each individual patient. There are few “cut and dry” recommendations which apply universally.

In certain populations, the NPUAP and CMS have acknowledged that not all pressure ulcers are avoidable. The NPUAP defines an unavoidable pressure ulcer as “one that develops even though the provider has evaluated the patient’s clinical condition and pressure ulcer risk factors; defined and implemented preventive interventions consistent with the patient’s need and goals, and formulated with recognized standards of practice; monitored and evaluated the impact of the interventions; and revised care as appropriate.” F-tag #F314 describes an avoidable pressure ulcer as one that developed after the facility did not do one or more of the above interventions. Of particular interest to many in defense, is the growing literature and research backing the existence of unavoidable tissue injury or organ failure such as skin failure associated with the natural dying process. There are many terms which address such skin failure, such as SCALE (skin changes at life’s end), the Kennedy Terminal Ulcer (KTU), and Trombley-Brennan Terminal Tissue Injury. The VCU Pressure Ulcer Summit was held in March 2014 to redefine pressure ulcer prevention. The group agreed that most of these unavoidable ulcers at the end of life were not caused by pressure/shearing forces alone, and hypothesized they had underlying etiologies related to insufficient perfusion.

Important takeaways when defending a pressure ulcer case are:

• There are no “black and white” preventative and treatment measures. If the nursing staff regularly documents assessment and re-assessment, and tailors a plan which is implemented for each individual, as well as non-compliance by the patient in the treatment plan, this documentation can be the cornerstone of your defense.
• The patient may have diabetes which leads to “non-modifiable fixed deficits that can lead to non-preventable pressure ulcers.”
• Non-reversible peripheral neuropathy is a significant causative factor in development of pressure ulcers of the feet.
• Malnutrition present on admission can be a very high risk factor for pressure ulcer development.
• Incontinence of bowel and bladder requires dedication by nursing staff and can be complicated by medical problems such as C. diff and urinary tract infections.
• Obesity upon admission is a hurdle for facilities in many facets of health maintenance, especially in skin health. The barrier of noncompliance with nutritional dietary items, and the moisture involved in skin folds makes the obese patient a high risk for skin alteration.
• Arterial insufficiency can lead to amputations, but the misdiagnosis of an arterial ulcer for a pressure ulcer places an impossible preventative and treatment burden on the nursing staff. Without adequate blood flow to the limbs, and considering the treatments of elevation compression wraps adding to the pressure risk, this patient population is at high risk of unavoidable ulcers. Venous insufficiency can be clearly seen in most cases by lack of hair on lower extremities, with more darkly pigmented skin and edema. It complicates the management of pressure ulcers to a degree that is unrelated to the intervention given by nursing staff.

References

1. Iyer, Patricia W. (2006). Nursing Home Liability and Its Consequences. In Nursing Home Litigation: Investigation and Case Preparation, 2^nd (pp. 270-279). Tucson, AZ: Lawyers and Judges Publishing Co, Inc.
2. Brindle, Creehan, Black, & Zimmerman. (2015). The VCU Pressure Ulcer Summit: Collaboration to Operationalize Hospital-Acquired Pressure Ulcer Prevention Best Practice Recommendations. J Wound Ostomy Continence Nursing, 2015:00(0):1-7.
3. Haesler, Emily. (2014). National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Cambridge Media: Perth, Australia. Retrieved October 8, 2015
4. Kirman, C., Geibel, J. (2015). Pressure Ulcers and Wound Care. Retrieved October 8, 2015 from Medscape web site.
5. Lee, K. (2015). All the World’s a “Stage”: Pressure Ulcers – Prediction, Prevention and Treatment: A Review of the NPUAP 2014 Guidelines. [Presentation].
6. Sharpe, J. N. (2015). Preventable vs. Non-Preventable Pressure Ulcers – Evaluation and Defense. [Presentation].

On August 04, 2015, the Centers for Disease Control and Prevention or CDC released a report published in their monthly Vital Signs[1] newsletter regarding the increasing number of germs that no longer respond to the drugs designed to kill them. The report notes that inappropriate prescribing of antibiotics and lack of infection control actions can contribute to drug resistance and put patients at risk. Despite diligent precautions which may be implemented by one facility, these germs can be spread between health care facilities when patients are transferred from one to another.

The most common and deadliest of these superbug infections include carbapenem-resistant Enterobacteriacae or CRE which can cause deadly infections and have become resistant to nearly all antibiotics that we currently have in use. Perhaps the most commonly known antibiotic resistant infection methicillin resistant staphylococcus aureus or MRSA often causes pneumonia and sepsis. Also infections caused by Pseudomonas aeruginosa which can result in healthcare associated infection include strains that are resistant to almost all antibiotics. Clostridium difficile also known as ‘C. diff’ is a germ commonly found in health care facilities and is not resistant to antibiotics but results from antibiotic use killing the bodies “good germs” and allowing this bacterium to take over putting patients at high risk for deadly diarrhea.

In order to reduce the number of antibiotic resistant infections the CDC recommends beginning with implementation of systems to alert receiving facilities when transferring patients who have drug resistant germs as well as sharing data with the public health department about antibiotic resistance and other healthcare associated infections.

The CDC released these statistics in relation to the growing problems of antibiotic resistant infections:

• Antibiotic-resistant germs cause more than 2 million illnesses and at least 23,000 deaths each year in the US.
• Up to 70% fewer patients will get CRE over 5 years if facilities coordinate to protect patients.
• Preventing infections and improving antibiotic prescribing could avert 610,000 infections and save 37,000 lives from drug-resistant infections over 5 years. This would save the health care system nearly 8 billion dollars for treatment.

Source: CDC Vital Signs, August 2015

A study cited by the CDC where researchers think a more coordinated approach may be working included the South Dakota public health department which requires health care facilities to report cases of CRE for tracking the spread of the bacteria. Infections caused by the deadly bacteria in that sparsely populated state dropped from 24 to 4 over two years. In Illinois, the state health department maintains a registry of all patients infected with drug-resistant bacteria. When a hospital or nursing home admits a patient, the facility can check the registry to see if the patient has an infection and take the appropriate precautions to prevent transmission.

At this point, infection reporting is done voluntarily and many facilities do not comply. The Centers for Medicare and Medicaid Services (CMS) has begun fining hospitals with high rates of infections and other incidents of patient harm, but those punishments are based on only a few types of bacteria.

Recommendations by the CDC for healthcare facilities to combat the spread of these antibiotic resistant infections include implementation of systems to alert receiving facilities when transferring patients who have drug-resistant germs, reviewing and improving infection control measures within their facilities, sharing data with the public health department about antibiotic resistance and other healthcare associated infections, and making sure that their clinical staff has access to prompt and accurate laboratory testing for these germs.

The agency went further making recommendations to prescribers and healthcare staff to prescribe antibiotics correctly, getting cultures then starting the right drug promptly at the right dose for the right duration, and knowing when to stop antibiotic therapy. They also recommended being aware of antibiotic resistance patterns in each facility, asking patients if they have recently received care in another facility, and most importantly following hand hygiene and other infection control measures with every patient. Patients and their families should be educated on what they can do to protect themselves and their family against these ever increasing infections including informing health care workers if they have been hospitalized in another facility and insisting that everyone wash their hands before touching them as well as washing their own hands often.

Dr. John Jernigan, an official with the CDC and senior author of the paper stated, “Facilities can’t do it alone. There are not many places where a coordinated effort is happening and we think we need to do a much better job.”

[1] http://www.cdc.gov/vitalsigns/stop-spread/

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm64e0804a1.htm?s_cid=mm64e0804a1_w