CDPH Changes Mandatory Reporting of Pressure Ulcers

CDPH is the California Department of Public Health

Though this posting contains facts and attachments to support these facts, please be advised that the final paragraphs are only this authors opinion and commentary, meant to initiate the conversation we all should be interested in having right about now.

When the National Pressure Ulcer Advisory Panel (NPUAP) collectively determined revised definitions of pressure ulcers in 2007 to include the new categories of Unstageable and Deep Tissue Injury (DTI), it wasn't long before the Centers for Medicare & Medicaid Services (CMS) followed suit with reimbursement regulations for Pressure Ulcers diagnosed after admit to the hospital. Ulcers that were Stage 3, Stage 4, or Unstageable, were designated as adverse, and classified as one of the 27 (at that time) "Never Events" -- events that are preventable and therefore should never happen after someone is admitted to a hospital facility.

The California Department of Public Health (CDPH) sent out a mandated reporting clarification letter in May of 2008, indicating per statute that "hospitals are mandated to report all Stage 3 and 4 pressure ulcers acquired after admission to the health facility..." The reporting of DTI pressure ulcers was left unclear, as it was not discussed in this letter.

Many wound care clinicians and experts were clear on one fact: the DTI pressure ulcer was a full thickness injury to the tissues, reaching degradation at the bone, muscle, or subcutaneous levels, without an opening at the surface of the skin. There was no clear directive to report DTIs acquired after admit though, so many went unreported.

The 2008 letter from CDPH addressed the Unstageable pressure ulcer by stating, "Unstageable ulcers are either Stage 3 or Stage 4 ulcers that cannot be definitively placed in either category because of the eschar that is obstructing the clear observation of the wound. Unstageable ulcers are not stage 2 or stage 1. Thus all unstageable ulcers are reportable by hospitals as adverse events if acquired after admission, excluding progression from Stage 2 to Stage 3 if Stage 2 was recognized and noted upon admission."

After many inquiries into the nature of the Deep Tissue Injury pressure ulcer, CDPH sent out another clarification letter to acute care facilities in February of 2010. The letter stated, "Based upon the NPUAP’s definition of a DTI, the tissue involvement of a DTI does not support a Stage 3 or 4 pressure ulcer. Thus, CDPH [Licensing & Certification] does not require the reporting of a DTI as an adverse event." Though they went on to state, "However, should the DTI progress to a Stage 3 or 4 ulcer after admission to the hospital, the hospital would then be required to report the ulcer as an adverse event..."

Only 2 days ago, on February 9, 2015, CDPH sent out another letter to the acute care facilities. In this letter, we come to learn that there is no longer a mandate to report Unstageable or DTI pressure ulcers as adverse events. In the letter it clearly states, "CDPH recommends the careful documentation of skin conditions and instances of suspected deep tissue injuries or unstageable/unclassified wound conditions in the patient’s medical record. If the unstageable ulcer or suspected deep tissue injury progresses and is classified as a Stage 3 or 4 pressure ulcer, it becomes an adverse event reportable to CDPH." So basically, find the DTI or Unstageable, document it clearly in the medical record, but don't worry about reporting it to any authority, because we don't really care about them, we only care about Stage 3 and Stage 4 ulcers.

Wow! I suppose this should be a celebration, a deep sigh of relief, and a "thank God" moment, but I am deeply disturbed to hear this, knowing what I do about the characteristics of DTI and Unstageable ulcers. These are full thickness assaults on the integrity of the skin and underlying tissues. If there is negligible care given that results in the formation of either of these conditions, apparently there is no longer accountability to the State. Ok I guess. Right? NO!! This is not right.

Hospital Administration is thrilled, Quality Assurance is relieved, and Risk Management is cautiously optimistic--as families may still pursue legal action for this, but hey! "the State is off our back now" right? Well, I hope that facilities strengthen their own internal reporting practices, to maintain some sort of care and practice standard. It must be understood that these ulcerations create potential for severe detriment to the patient, with risks that include scarring, pain, blood loss, infection, and even death due to sepsis from a wound infection.

Well, imagine this scenario: A male 48 year old patient is admitted for cardiac issues, and is now in the Intensive Care Unit. He slowly recovers and is transferred to a Step Down unit. Because this guy seems so much better, the staff doesn't worry about him as much, and they only peek in here and there but never really perform a full skin assessment. You know, they don't want to cause any possible embarrassment to him by asking to inspect his genital or buttock areas...that's a good excuse right? Ok, now he's well enough to be discharged, but he will be sent to a Rehab facility for a few weeks before being allowed to return to his home. Upon arrival to the Rehab facility, they discover a thick leathery dried coat of dark brown eschar measuring 6 x 9 cm over his sacrum. This is a pressure ulcer, and it is full thickness. This massive wound was created IN THE HOSPITAL, but there will be no accountability, no penalty, and no hope for changing the culture of care at that hospital, because no one really cared enough to enforce the minimal standard of care expectation. And it won't do any good to tell on them for it, because now there is no one to tell.

I think this recent letter is a sad indication of how inundated CDPH really was, with too many reports of adverse pressure ulcer events, and not enough funding to support the necessary investigation of the event by a State reviewer. It is just sad, and likely to get a "whole lot" worse, before it gets better.

Read the letter at this link:
http://www.cdph.ca.gov/certlic/facilities/Documents/LNC-AFL-15-03.pdf

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Vote NO on Prop 46 #California

I am hoping that if you are voting in the upcoming election, you vote NO on prop 46. The reason, is that yes, on the surface it appears to be a drug testing requirement for physicians, however, the true underbelly of the proposition is to eliminate the MICRA cap on medical malpractice claims. The current cap is $250,000 and if prop 46 passes, the new liability potential goes to 1 million dollars.

Now, to any non-physician, that may seem like a fair deal, to lift the cap, but really one must look at the consequences of this. First consequence, the cost of liability insurance for physicians will also increase, putting a strain on providers in small clinics and outpatient programs.

Next, look at the reasons the cap was originally in place. It was appropriate then, and is still appropriate now.

Finally, any clinician providing care to a patient, only has a cap of $250,000 liability, but this changes for EVERYONE if the patient is a senior citizen, due to the Elder Abuse laws. If any negligence occurs on a senior, the liability is automatically increased to $1 million... so the cap of $250k doesn't apply here anyway.

Please vote NO on prop 46, and send a letter or note to your congressman and state representative, as well as your local council members and government reps, that we love the idea of drug testing for docs, but not when it is combined with a removal of the liability cap.

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Here is a link to my article, on the Abbott Nutrition education website. Read it and take the post test to get 1 free nursing CEU.

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From "the" to "a"

What in the world am I talking about? Do I have a lisp? What’s with that title? Wrong question. It isn’t what, but whom. Let me explain. We all know who I am talking about. In high school, he was “the” man... "the" star athlete, "the" remarkable scholar, "the" ladies’ man…"the" smartest girl, "the" most talented....whatever he or she was, he/she was ultimately “the” guy or "the" girl. Now, graduated from high school, and no longer “the” man or "the" girl.. but rather, one of many. He is “a” scholar, not “the” scholar, for example, and she is "a" smart girl not "the" smart girl. 

Now comes the challenge of accepting and succeeding through the transition from “the” to “a.” How to find resolve in that? How do we accept that? What is the process of rebuilding the ego, the recognition, and the accolades? How does one transition successfully from “the” to “a”?

It is simple! Make it a transition from working and succeeding alone, to working and succeeding as part of a team.
 

...alone...

TEAM!

This was my struggle...one of my #careercurveballs

For several years, I was “the” wound care nurse. I had the knowledge and I was assertive. I could speak to the problem and people looked to me for the solution. Because I was alone in my role, and somewhat overwhelmed, there was always a plan to have another wound care nurse or two, but for the first four years I was “the” wound care nurse.

Over that four year period, I trained nine employees to do what I do. Each one would learn and grow, but would then move on to another facility after only 2-10 months. This wasn’t the plan. The plan was to train and keep committed peers, not train them to leave. Of those people, some went on to work their own wound care programs in another facility. Some didn’t fit the mold I was looking for—motivated, inspired, driven, precise, honest, and transparent. Some just couldn’t stand to be around me after a while, likely because my expectations seemed too high and unattainable by anyone else’s standards. I may have over-expected I now realize. Strong and steady though, I worked through those pitfalls and remained “the” wound care nurse.

Then, I found the right peers—both whom were just as committed to wound care and patient advocacy as I am. Hoorah! I thought, I don’t have to do this alone anymore! This should be the best time at work since starting here 5 years ago! How amazing to finally have some help, right? Right? Wrong. I was struggling more with the help, than I ever did when I was working alone. Why was it such a struggle for me?

It wasn’t until I recognized my ultimate problem with the situation...that I have succeeded in working through the issue. Now that I had two peers working with me, I was finding it very difficult to say that I was “a” wound care nurse. Somehow it felt like a demotion. It should have been a relief, but it just felt so… so less-than. 

Before the help arrived, when an answer was needed about wound care, I was the one people called. When a problem was identified, they looked to me for the solution. When I called the unit nurse, or the doctor’s office, or the staffing office, to clarify who I was I would say, “It’s Kristie, the wound care nurse.” People knew who I was just by me identifying myself as "the wound care nurse."

Transitioning from “the” to “a” was a challenge. It was one of the biggest #careercurveballs I had faced, because at first I resisted this change. I became disgruntled, arrogant, and entitled. My attitude was bitter and pungent. I had lost my title, and couldn’t realize success and could not reclaim my own vision, my focus.

No longer a solo player in the sport of my work, I learned to be a part of a group, a collective effort, a team. In order to continue with the zest and success I initially had on my own, I was forced to learn teamwork, collaboration, respect, conflict resolution, professionalism, and emotional intelligence.

I had more personal growth in one year, than in all the years I worked alone…and that enhanced my professional growth potential more than anything else to date.

  

Hospital Stays: College or Prison? Influencing the Patient's Choice

I have noticed that patients and health care workers have opportunities that may not be that obvious. How a hospital stay is viewed will have an impact on the outcome for everyone.

Is the hospital a prison or a college for the patient?

As a health care team member, do you think of your patients as inmates or college students? I encourage you to begin to treat your patients as if they were in college, by acknowledging the actions that landed them here, inspiring them to take an active role in their health, and educating them on how they can take action to prevent complications and the worsening of their condition. A successful health care team member is one that recognizes this as the primary goal, and practices this in their role.

As a patient, you are the number one player, the MVP actually, on any health care team. How do you view your hospital stay?

Some of the patients I see tend to view the experience as if it were a prison sentence. Choices they’ve made have now caught up to them. They are here to serve out their punishment as an inmate. Though rehabilitation is possible, reentry is inevitable without some serious changes in lifestyle, and happens more often than not. These patients are here for treatment and treatment alone. Treatment unfortunately, is a reactionary practice, and we all know how reactions can go—some have unexpected outcomes and reactions are more of a gamble.

There are also the patients who participate in their hospital stay as if they were going to college. Whether knowingly or unknowingly, they have made choices that impacted their health, and they have landed in the hospital. Now that they are here, they view it as a gift, a wake up call, a near-miss or a near-loss. While they are here, they work to sponge up all of the knowledge they can, in hopes of learning as much as possible to prevent their condition from getting worse, or to prevent themselves from another condition or disease. These patients want prevention.

Prevention is the action, treatment is the reaction. Everybody plays a part in prevention. Whether it is prevention of a particular disease or unhealthy end, or prevention of further deterioration of an existing disease process, prevention should be the goal of any healthcare facility. Health care workers need to teach prevention and inspire patients to take part in it; patients need to be taught prevention, and inspired to practice it.

Rehabilitation and cure are much harder to come by, much more expensive, and more of a challenge than any prevention will ever be. Prevention can be slow and thoughtful, specific and practiced. Treatment comes at a high price—financially, emotionally, mentally, physically, and spiritually—and is rapid, stressful, and a gamble.

As a health care worker, it is time to recognize and live up to our role. We need to focus on prevention and treat our patients as if they were college students and we were their professors. Their success or failure is directly related to our ability to teach them and to provide them with tools and resources.

As a patient, it is time to recognize that you are not punished, you are not an inmate—rather, you just got a wakeup call and are a college student, and now is the time to learn how to stay awake for your own health.