WOUND BLOG by Matthew Livingston RN

As of October 2008, the Centers for Medicare and Medicaid Services (CMS) is enacting several strategies to reduce the rate of pressure ulcers in the acute hospital environment. CMS will stop paying for future treatments when stage three and stage four pressure ulcers are acquired in the hospital. Conversely, CMS will increase funding for hospitals treating stage three and stage four pressure ulcers that are present on admission. Because of these new changes Scottsdale Healthcare realized that: First, it is important to identify newly admitted patients with previously occurring pressure ulcers. Second, being reimbursed appropriately will be contingent on expedited and accurate skin and wound assessments. Scottsdale Healthcare then created a present on admission committee to consider ways to improve and expedite skin and wound assessments in their acute hospital setting.

Scottsdale Healthcare’s Present on Admission (POA) committee established a goal to correctly identify the type of skin problem within 48 hours of admission. The committee then identified the major point of entry for new patients. The committee considered the emergency department to be the priority entry point. Emergency department wound and skin documentation was then reviewed and modified to reduce complex and confusing wound terminology. Emergency room physician and nurse training was initiated. Since emergency department physicians are problem focused, emergency room nurses will be responsible for learning to identify wound problems and then referring those problems to the emergency room physician.

Emergency room staff training specifics include:
1. October 1st is the initiation of new CMS guidelines.
2. Trigger a wound care nurse or physician consultation as soon as a skin issue is noted. A wound care nurse or physician can insure that the wound is properly identified and that documentation is supported.
3. Refer to a skin issue as a “skin problem” in their charting and then immediately refer the patient to the wound care nurse for proper identification. This reduces the risk that untrained nurses will improperly document the skin issue.
4. Do not call skin problems a “decubitus ulcer,” unless certain of etiology. This is a commonly overused term that implies specific knowledge of how this skin problem occurred (i.e. by pressure only).
5. Do not check “skin intact” unless you have turned the patient and visualized all of the pressure points completely. Document if the patients condition has prevented turning.
6. Example picture sheets will be reviewed. Example picture sheets with explanations will then be placed in the patient’s charts (examples include staged wounds, shear, and deep tissue injury).
7. Nurses who request further training will be referred to (nursingquality.org) in order to complete a module on pressure ulcers.

The committee then established measurable outcomes. Including a report of facility acquired stage three and four staged pressure ulcers. Quality control will track and send this information to CMS. The Arizona Adult Protective Services (APS) will also be notified. A study will evaluate the example picture sheets to evaluate its effectiveness. The study will be conducted prior to the program’s initiation and at three months post initiation.

Post Script: Please note that these strategies should be considered as what one hospital system has considered prudent to initiate, but it does not suggest that this is a stand alone solution. Please refer to the ongoing series of strategies for dealing with new CMS pressure ulcer guidelines in the CMS POA Category of the wound blog website for more suggestions.