Pressure Ulcers and the Law - Critical Care · South African Context ... medical malpractice claims totalling R573 million. ... rather than to the degree of negligence

Pressure Ulcers and the Law

Cheryl Carter - Durban

South African Context

In 2009/2010, the Gauteng Department of Health and Social Development reportedly faced medical malpractice claims totalling R573 million.

Media reports of high damages awarded for malpractice in public health institutions are

commonplace and becoming more frequent. SAMJ 2013; 103(2) 83-84

• There have been large pay-outs to patients related to the harm suffered rather than to the degree of negligence

• The lawyers know where to lookSAMJ 2013; 103(7) 433

• Assumption PU’s are a result of improper care

• Skin not viewed as an organ do not understand “skin failure”

• Seek justice or answers and compensation for lack of quality care

S

• Litigation is personal Traumatic experience; leave profession

• Financial exposure• Potential loss of

registration

• Vicariously liable for conduct of employees

• Financial loss • Loss of reputation

Legal Perspective

• The healthcare provider owed a duty of care to the patient

• The healthcare provider breached or violated the duty owed to the patient i.e. negligent

• The patient suffered injury

• The injury was caused by the provider

Williamson and Lavecchia – Mid Atlantic Wound Care Conference “Pressure Sores and the Law”

Pressure Ulcer Perspectives

• Why are lawsuits on increase?

• Unlike other medical complications they never go unnoticed by patient and their family

• Visually disturbing

www.medlineuniversity.com

Concept: Preventative Legal Care

Preventative Legal Care

• Utilise preventative medicine to reduce medical costs and minimize health related risks

• Fail to apply same principle of preventive care to our own legal risks

• Implementing preventative legal care reduces healthcare practitioners legal risks and potential costs

Preventability

• Pressure Ulcers considered “Hospital Acquired Condition”

• Long-term care settings

– Avoidable

– Unavoidable

• Acute care setting

– Reasonably preventable

Judgement is based on assessment of compliance to requirements

Preventative Legal Care

• Policies & Procedures

• Documentation

• Communication

Policies and Procedure• Policies & Procedures must be drafted not

only with an eye towards improving care, but also with careful consideration of their potential use by adversaries in future litigation.

Fife & Yankowsky. Legal Implications of Pressure Ulcers www.medlineuniversity.com

Consensus paper –International Expert Wound Care Advisory Panel: 2009

Policies and Procedure


Policies and Procedures

Policies that fail contain:

• Absolute words

– “must be done”

• Inflexible deadlines

– “immediately”

• Unnecessary mandates


Policies and Procedures

Policies designed to succeed contain:

• Clear guidelines

• Flexible deadlines

• Discretionary judgment


Documentation

• Documentation the first thing a plaintiff’s lawyer looks at when evaluating a case

• Used in ways you don’t intend when building a case


PreventabilityCriteria for assessment of preventability

1. Patients clinical condition and pressure risk factors

2. Defining and implementing interventions that are consistent with the patient’s needs, goals and recognised standards of practice

3. Monitoring and evaluation of the impact of interventions or revision of interventions as appropriate

• If the facility failed to do one or more of these the pressure ulcer is “reasonably

preventable” Litigation Risk;• If a patient developed a pressure ulcer

despite all the criteria being met the pressure ulcer would be “unavoidable”

Consensus paper –International Expert Wound Care Advisory Panel: 2009

Preventative Legal Care – In practice

Prevention• Know your numbers

• Policy and Procedure– Remember judgement against compliance

• Preventative strategy– Education

– Risk Assessment

– Skin Care

– Nutrition

– Mechanical Loading and Support Surfaces

– Effective Communication

Prevention: Education• Single most important factor in preventing hospital

acquired pressure ulcers• Poor knowledge and understanding• Focus on: -

Etiology of and risk factors for pressure ulcers Risk assessment tools and their application Skin assessment Selection and use of support surfaces Nutritional support Bowel and bladder management Development and implement individualized programs of

skin care Positioning to decrease risk of tissue breakdown Accurate documentation of pertinent data

Prevention: Risk Assessment

• Scoring Tools– Norton Score

– Braden

– Waterlow

• None validated for use in ICU

• All have limitations

• Ensures systematic evaluation of individual risk factors preventative strategies

• All patients admitted in ICU should be considered at risk assess every 24hrs

Consensus Paper International Expert Wound Care Advisory Committee: 2009

1. Continuous assessment

2. Skin Care

3. Nutrition

4. Mechanical Loading and Support Surfaces

5. Effective Communication

Prevention Strategies

1. Continuous Assessment

• Head to toe skin assessment daily Document

• Focus on potential pressure areas

– Dependent of patient positioning

– Risk factors

– Devices – 10% pressure ulcers in ICU

• Choose correct size device to fit individual• Cushion and protect skin with dressings in high-risk

areas e.g. nasal bridge• Inspect skin in contact with device at least daily• Avoid placement over sites of previous or existing

ulcer. Avoid traction on tubing• Educate staff on correct use of devices and prevention

of pressure ulcers• Be Aware of oedema under devices and potential for

skin breakdown• Confirm devices not placed under patient

2. Prevention: Skin Care• Individualize bathing frequency.

Mild cleansing agent.

Avoid massage over bony prominences

• Establish a bowel and bladder program for incontinence. Cleanse skin at time of soiling

Use a topical barrier to protect the skin.

Pads/ Nappies absorbent and provide a quick dryingsurface to the skin

? collection device to contain stool and to protect the skin.

• Prevent / manage dry Skin

Flexi-Sheath

3. Prevention: Nutrition

• Early feeding

• Meet patients nutritional requirements

• Prevention of diahorrea


• Aim to limit

– Amount of time and pressure

– Friction and shear forces

Preventative Strategies: Time + Pressure

Recommendations

• Actively mobilize if possible

• Turning

– Remains mainstay of pressure ulcer prevention patient dependant

• Position– use of pillows / devices to prevent pressure

knees, ankles

• Adjuncts – Foam dressings

Best Practice Guidelines (2005) http://www.rnao.org/bestpractices/PDF/BPG_Pressure_Ulcers_v2.pdf; Cooper, L. (2013) Critical

Care Nurse 23(6) 57- 66

http://www.rnao.org/bestpractices/PDF/BPG_Pressure_Ulcers_v2.pdf


• Mattresses– 10cm deep solid foam reduces pressure by 30%

– Dynamic mattresses relieve pressure 15cm tubes

– Air fluidized beds + Low-air-loss

• Combination of turning + mattress

1. Gunningberg (2005) International Journal of Nursing Practice. 11: 58-67; 2. Jastreski (2002) Journal of Critical Care 17(2); 122-125 3.Best : Practice Guidelines 2005 http://www.rnao.org/bestpractices/PDF/BPG_Pressure_Ulcers_v2.pdf

Shear and Friction Forces

• Head at lowest elevation consistent with medical condition

• Slidy sheets

• Skin moisturizers for dry skin • Use of polyurethrane dressing to prevent

further friction– Permeable to water vapour, O2

– Impermeable to water, bacteria– Maintain moist interface for healing

Best : Practice Guidelines 2005 http://www.rnao.org/bestpractices/PDF/BPG_Pressure_Ulcers_v2.pdf


5. Effective Communication

• Handover

– Identified risks

– Condition of the skin

– Assessment and staging of wounds /pressure ulcers

– Preventative strategies utilised

– Efficacy of preventative strategies NB!

• Documentation of everything

– Skin Bundle

Conclusion• Hospital acquired pressure ulcer have potential

for litigation

• Need to practice preventative legal care– Policies and procedures

– Documentation

– Communication

• Prevention - 3 Guiding Principles– Identification of the patient at risk

– Use of preventative measures appropriate to patient specific risk factors

– Close follow-up of high risk patients i.e. continuous assessment

Document Everything

SANC Perspective

“The principle of something not being done, if it cannot be proven in the

records of the patient, is a worldwide known principle in the nursing

profession and is accepted. There is no reason why the committee should

change its view on this principle especially if patients suffer harm”

Extract from SANC Disciplinary Hearing Transcript

Documents

Pressure Ulcers and the Law - Critical Care · South African Context ... medical malpractice claims totalling R573 million. ... rather than to the degree of negligence