Examining End of Life Ulcers: Balancing the SCALE

Patient Safety Indicator 3 protects the patient from harm. It drives quality care and prevents hospital acquired pressure ulcers (HAPUs) whose development has been identified as a sign of poor care. In an effort to ensure that quality care is being provided and patients are protected, institutions are surveying more often and being held more accountable than ever. Failure to recognize unavoidable skin injury related to end of life both clinically and in the regulatory forum has tipped the scale for institutions responding to this challenge. One urban safety net hospital decided to examine this impact.

Two years of data that included 129 cases were reviewed via electronic and coding records to match qualifications for Kennedy Terminal Ulcer (KTU) and/or Skin Changes at Life’s End (SCALE). Patients qualified for KTU when a sacral wound had the correct shape, progressed rapidly to necrosis and the patient died within 6 weeks. Patients qualified for SCALE when they died within one year of developing a sacral wound, and experienced sustained hypotension, hypoxia and Multisystem Organ Failure (MOF/MODS) when the ulcer declared. Of our 129 reported HAPU cases, 34 or 26% died. Of these, 35% met KTU criterion and 23% met SCALE criterion. A total of 12.4% of our reportable pressure ulcers were evidence of the progression of the disease process and therefore not negligence.

Zero harm remains the ideal and the mission in our institution from the board room to the patient room. In these 34 cases the best practice interventions were implemented and the ulcer was a symptom of failure of the patient, not the care. Increasing unavoidable skin injury awareness will help drive regulatory bodies, bring back balance, and protect both patients and institutions.