Cath Lab Digest

D espite advances in preventive interventions such as pressure-reduction surfaces, risk assessment scales, and improved knowledge of prevention techniques, pressure ulcers continue to occur in healthcare facilities. Pressure ulcer prevalence and incidence studies show that overall rates in the last decade have remained essentially the same, averaging between 8% and 15% from 1989 to 1999.^1,2 Wound care specialists do not agree on whether the majority of pressure ulcers are preventable.³ The concept of skin failure in relation to pressure ulcer development has been suggested.⁴ The Centers for Medicare and Medicaid Services, whose directives are the foundation for the majority of state healthcare regulations, include the determination of avoidable versus unavoidable pressure ulcers in their surveyor guidelines.⁵ Nevertheless, the occurrence of a pressure ulcer continues to stigmatize caregivers - whether medical/nursing professionals, healthcare facilities, or patient family members - with an aura of negligence. This can result in guilt on the part of the caregiver for "letting" the ulcer occur or the pursuit of legal action by aggrieved family members.

Less publicized in the debate surrounding pressure ulcer risk assessment, prevention, and treatment are follow-up studies on outcomes of patients with pressure ulcers. Berlowitz⁶ demonstrated in a study of 19,981 nursing home residents that while patients with pressure ulcers are more likely to die, the increased risk is largely related to the frailty and high disease burden of the resident and is not a direct result of the ulcer. Thomas,⁷ in a study of 286 hospital patients, determined that 59.5% of residents who developed a pressure ulcer died within 1 year of developing the ulcer. It appeared that the development of new pressure ulcers was a marker of coexisting illnesses, impaired nutrition, and functional status and not an independent risk factor for increased mortality. Berlowitz,⁸ studying a group of 301 nursing home admissions, also discovered that the presence of a pressure ulcer on admission, the development of a new ulcer, and failure of the ulcer to heal were all associated with a two- to threefold increase in the risk of dying during a 6-week period following admission. The results of this study also suggested that the pressure ulcer itself did not cause the observed increased mortality. Other research has shown that 1) death occurs in acute hospitalizations in 67% of patients who develop pressure ulcers,^{9 2}) 55.7% of nursing home residents who die with a pressure ulcer do so within 6 weeks of the onset of the pressure ulcer,¹⁰ and 3) nursing home residents with pressure ulcers experience a 6-month mortality rate of 77.3%.¹¹

Data on pressure ulcer healing and mortality outcomes are difficult to acquire in many healthcare settings. A comprehensive patient chart often lacks information due to the common practice of transferring patients to multiple facilities based on the level of care. Acquisition of a complete chart from several facilities is, therefore, a time-consuming and expensive undertaking for any researcher. The Veterans Affairs Health Care System is unique among healthcare systems and since 1999, virtually all patient data for any admission at the facility where this study was conducted are available through the Computerized Patient Record System (CPRS). This allows broad, efficient access to a variety of data from history, physical assessments, and discharge summaries to laboratory tests and progress notes.