Recent studies show the number of patients with advanced PU/Is is higher in the community than in the hospital.6,11 This greater number of patients with PU/Is from home makes sense anecdotally, because more people are at home than in SNF and patients in a SNF have 24/7 caregiver support. Corbett et al6 found 76.1% of hospital admissions of patients with PU/Is came from home as compared to LTC facilities. The current study found 70.4% of patients were admitted from home as compared to 29.6% admitted from SNFs. Stevenson et al8 found the average age for CAPU/I in the community was 77.6 years; the current study population was younger (average age of admission from home and SNFs was 62.2 years and 61.5 years, respectively).
Current study results suggest PU/Is occur at home at higher rates than in SNFs or LTC facilities. Much of the literature10,12 suggests patients who develop PU/Is are disproportionately older, immobile, have impaired nutrition and incontinence issues, and may be at EOL. However, the current study results showed patients admitted from home were younger and had a higher rate of immobility (82 persons [24.4%] had paraplegia/tetraplegia) than persons admitted from a SNF (18 persons with paraplegia tetraplegia [12.8%]) and that these persons were less likely to have access to nursing care at home, problems perhaps related to insurance qualifiers (Medicaid/Medicare) for care.
Slightly more patients within the study sample with a cancer diagnosis were admitted from home versus a SNF (see Table 2). This finding was in alignment with research conducted by Brink et al13 who studied patients in the home care setting and found more patients diagnosed with terminal cancer stayed home rather than enter a SNF or LTC.
Chronic stage 4 PU/Is may not close over time, but this amount of time is poorly defined.14 Chronic PU/Is may start superficially as stage 1 or stage 2 then progress to a full-thickness or stage 3, stage 4, or unstageable PU/I. This trajectory may be avoided with early Braden-related interventions, including pressure redistribution, improved nutrition, and moisture control.10 Some stage 4 PUs take years to close or do not close at all and may require reconstructive surgery.10 The authors suspect the high percentage of these deeper ulcers documented in study are indicative of the fact they had been there for a prolonged period of time as opposed to having developed more recently. The current authors found the highest number of patients from home and SNFs admitted with a POA PU/I had stage 3, stage 4, and unstageable ulcers. Similar to current findings, retrospective cohort studies7,15 have found patients developed full-thickness ulcers while in a SNF or LTC, even with the best of care. However, patients at home typically do not have 24-hour access to skilled caregivers, specialty beds, turning equipment, and immediate incontinence care that would help them avoid developing a PU/I. This may explain why within this study, more than twice as many patients were admitted to the hospital from home than from a SNF with PU/Is at advanced stages (see Table 1).
Patients within the SNF group died during the study period at a more than 6% higher rate than those admitted from home; however, SNF patients were older and had a higher rate of neurological disease (eg, paraplegia or tetraplegia). A systematic review article16 on EOL PU/Is (ie, Kennedy Terminal Ulcer [KTU]) describes a type of skin breakdown signaling impending death, appearing suddenly (most often on the sacrum), and progressing rapidly, despite appropriate clinical interventions. In 1877, Dr. Jean-Martin Charcot17 described the same phenomena, naming the skin ulceration decubitus ominosis, noting skin breakdown occurred shortly before death, similar to the KTU. Several researchers have argued whether KTUs are related to skin failure rather than to a PU/I18 that occurs in concordance with the decreased perfusion,2 ischemia, and multiorgan failure19 of the dying process. One retrospective cohort study5 concluded LTC residents who had PU/Is were more likely to die due to “frailty and high disease burden, and death was not a direct result of the ulcer.”
As professionals, clinicians must ensure that CAPU/I are identified early and gather important data to help with education and support in preventing CAPU/I among persons at risk. Supportive data should include the origin of the patient when the CAPU/I developed. Once the origin is identified, educational support and opportunities for prevention and treatment could be targeted specifically to home caregivers or staff in facilities.
An additional and important study finding was that the documentation about source of admission and PU stage was incomplete in the vast majority of records.
Considerations for the care continuum. Although the general goal is to have a patient age in place (despite diagnosis), future policy should include wound clinics with access to specialty equipment for assessing and treating patients who are at risk for the development of PU/Is. As an alternative, nurse practitioners should be able to assess and order treatment for patients while conducting full assessments of the patient and the wound during home visits. Current Centers for Medicare and Medicaid Services (CMS) rulings suggest that if patients can leave their home, they do not qualify for home care.1 The results of this study suggest a need for PU/I preventative care and treatment to improve quality of life of patients with long-term limited mobility or for those at EOL. Identifying POA PU/Is lends itself as an educational opportunity for patient/family/CMS regarding the development of PU/Is in persons with acute and chronic diseases and persons at EOL, no matter their setting.
Discharge planning of hospitalized patients with a Braden score that suggests they are at risk of developing a PU/I must include measures to help prevent their development. Education at hospital discharge or in clinics should include a list of resources and basic pressure redistribution surfaces should be supplied at the time of discharge from the hospital or clinic.
In addition, the development and testing of a PU/I risk scale for home care is needed. Patient lift assistive devices should be available in all primary care clinics in order to evaluate the skin of patients with low mobility or at high risk.
Patients (and family caregivers) struggle to manage the care of advanced stage PUs but often want to remain in the home setting. Patients who do not or cannot change their lifestyles enough to prevent or close advanced PU/Is need access to chronic/palliative wound care. Palliative chronic wound care and clinical support in accordance with patient goals should be provided with nursing support as appropriate.