Over the past several months, my team and I have been asked to review multiple cases involving pressure injuries. We analyze events surrounding pressure injuries occurring in both long-term care and hospital settings and help attorneys determine whether the injuries were avoidable or unavoidable.
For our hospital cases, we frequently refer to a landmark, 2019 study by Pittman et al which studied hospital-acquired pressure injuries (HAPIs) in critical and progressive care.
Pittman et al found that close to 60% of HAPIs are avoidable and 41% are unavoidable. They identified several risk factors that help differentiate avoidable from unavoidable. These include:
· A congestive heart failure diagnosis (CHF)
· Multi-organ failure
· Mechanical ventilation
· Chemical sedation
· Systolic blood pressure less than 90 mm Hg
· Malnourishment
· Incontinence
· Prolonged hospitalization
· Vasopressors (medication to support blood pressure).
· Old age
So, what if a patient with many or all risk factors develops a pressure injury? That is an unavoidable injury, correct?
Not necessarily.
Pittman et al writes, “Unavoidable pressure injuries may occur when the magnitude and severity of the risk factors are extremely high AND preventive measures are either contraindicated or inadequate given the risk. In this study, unavoidable HAPIs were defined as those that developed in spite of consistent documentation of evidence-based preventive interventions.”
In other words, ultimate determination rests heavily on whether preventive interventions were documented and implemented appropriately.
For example, 90-year-old Ed has CHF and is sedated and intubated in the ICU. His blood pressure is very unstable, and he is on high doses of pressors. In fact, Ed’s hemodynamic status is so unstable that even turning and repositioning will precipitate a drop in blood pressure.
Even in Ed’s precarious situation, best practice would require that efforts are made to safely shift his position periodically.
Pittman et al notes that “the critical care unit’s culture and clinicians’ perceptions about hemodynamic instability may lead to staff members’ not repositioning patients.” However,
best practice recommends that slow, gradual turning allows sufficient time for stabilization of blood pressure and oxygen saturation and should be attempted.
The path to determining avoidable vs. unavoidable pressure injuries always involves careful and comprehensive review.
Source: https://lnkd.in/gXAWF2nz