Never Say Never: Debunking the myth of pressure ulcer "never events"

Purpose: The study seeks to investigate the association between co morbidity burden and the development of hospital acquired stage II, stage III or IV pressure ulcers (HAPUs) among inpatients in an urban trauma center.

Background: In 2006 CMS designated Stage III and Stage IV HAPU’s as “never events”.  The term implies that the HAPU occurrence is secondary to the absence of nursing care, surveillance, prevention and/or treatment strategies regardless of a patient’s risk and other co morbidities. Skin Failure literature suggests that all skin injuries of this type are not preventable; and data suggests that HAPUs occur at consistent rates and can be the result of complex underlying metabolic and mechanical factors. Labeling of HAPU’s  as “never events”  place nurses and institutions at litigation risk for negligence; fixing blame  rather than advancing study of the true cause of PU’s- the confluence of metabolic and mechanical risk.  

Methods:  Research questions will be answered using retrospective and prospective medical chart review.  Wound Nurse Consultants will  review of 100% of all HAPUs stage II and above.   Case review will be guided by a data extraction tool designed for the proposed study. In addition to demographic data, co morbidity, Braden risk and utilization of prevention strategies will be collected.

Statistical Methods: Inferential statistics will be used to describe the characteristics of the sample and correlations will be used to summarize the associations between co morbidity burden and HAPU incidence. 

Study Implications: This study will quantify co morbidity burden associated with the development of    HA PUs. It is hoped that this study helps refute the assumption that all HA PUs are preventable events that directly reflect the quality of nursing care delivered.   

Findings: Seven months of date indicate the presence of heavy co morbid burden in all HAPU (mean 7.3 co morbid conditions per case)