Jeffrey M. Levine

New opportunities to improve pressure ulcer prevention and treatment: implications of the CMS inpatient hospital care present on admission indicators/hospital-acquired conditions policy: a consensus paper from the International Expert Wound Care Advisory Panel.

INTRODUCTION As part of the Deficit Reduction Act of 2005, the Centers for Medicare & Medicaid Services (CMS) initially identified eight preventable adverse events on August 1, 2007, with nine more conditions proposed on April 14, 2008. They have introduced a plan to help contain costs by rejecting payment of the higher diagnostic category when such events occur as a secondary diagnosis in acute care facilities. This policy, which began a phased rollout in the acute-care setting in October 2007 (culminating in October 2008), has created some logistical and implementation concerns in the clinical community. The financial implications for pressure ulcers will be determined by the Present on Admission Indicator (POA). The POA Indicator identifies if a patient has a pressure ulcer at the time the order for admission occurs. Now there is a renewed urgency and heightened focus on prevention because beginning in October of 2008, the hospital will not receive additional reimbursement to care for a patient who has acquired the pressure ulcer while under the hospital’s care. Like any groundbreaking policy, this provides impetus for change. We view this payment provision as challenging, but one that provides all clinicians and particularly wound care specialists with an opportunity to assume leadership in important preventive healthcare strategies. Pressure ulcers represent the possibility to implement best practices to improve outcomes. In FY 2007, CMS reported 257,412 cases of preventable pressure ulcers as secondary diagnoses. The average cost per case in which pressure ulcers were listed as a secondary diagnosis is estimated to be

New opportunities to improve pressure ulcer prevention and treatment: implications of the CMS inpatient hospital care Present on Admission (POA) indicators/hospital-acquired conditions (HAC) policy. A consensus paper from the International Expert Wound Care Advisory Panel.

43,180 per hospital stay. The incidence of new pressure ulcers in acute-care patients is around 7 percent, with wide variability among institutions. The Medicare program’s hospital inpatient prospective payment system (PPS), as currently set forth, will no longer assign a higher DRG for facility-acquired pressure ulcers effective October 1, 2008. Physician/provider* determination and documentation during the hospitalization that the pressure ulcer was present at the time of admission is critical. Since this

Dakin's solution: past, present, and future.

As part of the Deficit Reduction Act of 2005, the Centers for Medicare & Medicaid Services (CMS) initially identified eight preventable adverse events on August 1, 2007, with nine more conditions proposed on April 14, 2008.1,2 They have introduced a plan to help contain costs by rejecting payment of the higher diagnostic category when such events occur as a secondary diagnosis in acute care facilities. This policy, which began a phased rollout in the acute-care setting in October 2007 (culminating in October 2008), has created some logistical and implementation concerns in the clinical community. The financial implications for pressure ulcers will be determined by the Present on Admission Indicator (POA). The POA Indicator identifies if a patient has a pressure ulcer at the time the order for admission occurs. Now there is a renewed urgency and heightened focus on prevention because beginning in October of 2008, the hospital will not receive additional reimbursement to care for a patient who has acquired the pressure ulcer while under the hospital’s care. Like any groundbreaking policy, this provides impetus for change. We view this payment provision as challenging, but one that provides all clinicians and particularly wound care specialists with an opportunity to assume leadership in important preventive healthcare strategies. Pressure ulcers represent the possibility to implement best practices to improve outcomes. In FY 2007, CMS reported 257,412 cases of preventable pressure ulcers as secondary diagnoses.2,3 The average cost per case in which pressure ulcers were listed as a secondary diagnosis is estimated to be

Essentials of MDS 3.0 section M: skin conditions.

43,180 per hospital stay.2,3 The incidence of new pressure ulcers in acute-care patients is around 7 percent, with wide variability among institutions.4 The Medicare program’s hospital inpatient prospective payment system (PPS), as currently set forth, will no longer assign a higher DRG for facility-acquired pressure ulcers effective October 1, 2008.5 Physician/provider* determination and documentation during the hospitalization that J Wound Ostomy Continence Nurs. 2008;35(5):485-492. Published by Lippincott Williams & Wilkins

Secondary analysis of office of inspector general's pressure ulcer data: incidence, avoidability, and level of harm.

Dakins solution has been used for almost a century. It is a dilute solution of sodium hypochlorite, which is commonly known as household bleach. When properly applied, it can kill pathogenic microorganisms with minimum cytotoxicity. This article reviews its history and discusses how evolving technology might pave the way for a new role for this antiseptic.

CMS updates on MDS 3.0 section M: Skin conditions-change in coding of blister pressure ulcers.

PURPOSE To provide information about the impending changes in the Minimum Data Set (MDS) Section M on skin conditions and its implications for practice. TARGET AUDIENCE This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES After participating in this educational activity, the participant should be better able to: 1. Compare section M of MDS version 2.0 to MDS version 3.0. 2. Apply the complexities of the MDS 3.0 section M for coding. 3. Demonstrate accurate and complete documentation of wounds as per MDS 3.0 section M.

Clarification of pressure ulcer staging in long-term care under MDS 2.0.

PURPOSE: To provide information about a secondary analysis of pressure ulcer data regarding incidence, avoidability, and level of harm. TARGET AUDIENCE: This continuing activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to: 1. Summarize the data provided in the Office of Inspector General (OIG) study regarding incidence of pressure ulcers (PrUs) found in hospitals and skilled nursing facilities (SNFs). 2. Identify the classification systems used that designate levels of harm to patients and the avoidability of PrUs. OBJECTIVE: To investigate in greater detail the government data on pressure ulcer (PrU) incidence, avoidability, and level of harm. DESIGN: The authors performed a secondary analysis of PrU data published in 2 studies by the Office of Inspector General (OIG) on adverse events in hospitals and skilled nursing facilities (SNFs). SETTING: Acute care hospitals and Medicare-certified SNFs across the United States. PATIENTS: The hospital sample included 780 Medicare beneficiaries randomly selected from 999,645 discharges during October 2008. The SNF population included 653 Medicare beneficiaries randomly selected from 100,771 patients whose stay began within 1 day of hospital discharge, who had a length of stay of 35 days or less, and whose stay ended in August 2011. MAIN OUTCOME MEASURES: Pressure ulcer incidence with stage, location, avoidability, and level of harm using the Modified National Coordinating Council for Medication Errors Reporting and Prevention Index. MAIN RESULTS: The PrU incidence in hospitals was 2.9%, and the incidence in SNFs was 3.4%. Most PrUs were Stages I and II, with 78.3% in hospitals and 54.5% in SNFs. The avoidability of PrUs was similar in both locations, with 39.1% unavoidable in hospitals and 40.9% unavoidable in SNFs. All hospital-acquired PrUs and 90.9% of SNF-acquired PrUs were designated level E on the National Coordinating Council for Medication Errors Reporting and Prevention Index, indicating a temporary harm event. CONCLUSIONS: The OIG studies captured few Stage III PrUs and no Stage IV PrUs, and they underestimate the level of harm generated from PrUs in hospitals and SNFs. The studies offer a structured algorithm for avoidability determination, but lack measures of reliability and validity. Nonetheless, the high rate of unavoidable ulcers leads to questions on the reliability of PrUs as a quality indicator. There are several weaknesses in OIG methodology with regard to PrUs; however, its structured algorithm can be viewed as a starting point for future studies of PrU avoidability.

Historical perspective: the impact of plaster-of-paris splints on pressure ulcer occurrence in World War II.

Editor’s Note: The article ‘‘Essentials of MDS 3.0 Section M: Skin Conditions’’ was published in the June 2010 issue of Advances in Skin & Wound Care. Since the article’s publication, the Centers for Medicare & Medicaid has announced additional updates to its guidelines affecting this section. This special report addresses those changes. Following the posting of the revised Minimum Data Set (MDS) 3.0 on its Web site in November 2009, the Centers for Medicare & Medicaid (CMS) has continued to update the guidelines and resources needed for its implementation. Earlier this year, the CMS held educational programs to train surveyors and stakeholders on MDS 3.0. Based on information that was current at that time, an interdisciplinary team of authors, including a nurse from the CMS, authored an article in this journal on the essentials of MDS 3.0 regarding Section M: Skin Conditions. Since the article was published, revisions to these guidelines were posted on the CMS Web site. These revisions were based on concerns of attendees at the training sessions and continued dialogue with clinical experts to provide the best evidencebased practices. As of June 2010, the MDS 3.0 RAI manual had instructed the clinician to code all ‘‘blisters’’ related to pressure as Stage 2 pressure ulcers (PrUs). However, since that time, it was decided after continued consultation with clinical experts in wound care to further clarify coding related to Stage 2 PrUs (M0300B) and suspected deep tissue injuries (sDTIs) (M0300G) to emphasize the assessment findings of the wound and the surrounding tissue areas, rather than the presence or absence of a pressure-related blister (eg, blood filled). Thus, the former instruction to code all pressure-related ‘‘blisters’’ was updated in July 2010 to code according to the surrounding tissue. The emphasis is on complete and comprehensive assessment of the resident and the type of skin injury rather than just solely on the type of fluid in the blister. The first step is to determine if the ulcer being assessed is primarily as a result of pressure, which requires the clinician to rule out other conditions. If pressure is not the primary cause, then the clinician should not stage it as a PrU and not code it in Section M under the 300 subsections. Examples of this include blistering diseases, such as bullous pemphigoid. It is believed that blood-filled blisters related primarily to pressure may show signs of sDTI. Therefore, examination of the area adjacent to or surrounding the blisters for evidence of tissue damage is needed. The clinician is instructed to look for signs of tissue damage, such as color change, tenderness, bogginess or firmness, and warmth or coolness. Hence, if a pressure-related ‘‘blister’’ is associated with signs and symptoms of an sDTI as described above, code this lesion as ‘‘unstageable, suspected deep tissue injury’’ under subsection M0300G. On the other hand, if a pressure-related

The Effect of Oral Medication on Wound Healing

BACKGROUND Clinicians in long-term care must follow the Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI)Manual for pressure ulcer (PrU) staging. The manual for Minimum Data Set (MDS) 2.0 directs clinicians to stage suspected deep tissue injury (sDTI) and unstageable PrUs in a way that is different from practice in other care settings. This has led to some confusion among caregivers across the continuumof healthcare settings. It is anticipated that these differences may be corrected when MDS 3.0 is released as anticipated in the fall of 2010. This article seeks to clarify the CMS RAI Manual 2.0 regulations for PrU staging in long-term care, which clinicians must follow until MDS 3.0 is released, as well as underscore the importance of PrU care planning based on ulcer assessment. PrUs continue to be an important healthcare concern in longterm care. TheNursingHomeReformAmendments (Omnibus Reconciliation Act of 1987) state that ‘‘Each resident must receive, and the facility must provide, the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being.’’ Furthermore, F-Tag 314 states that residents who enter a facility without PrUs will not develop PrUs unless the individual’s clinical condition demonstrates that they were unavoidable. Because Medicare desires quality care for its 36 million recipients older than 65 years, clarification of guidance for surveyors on F-Tag 314 was revised and issued on November 12, 2004. This 40-page document, whichwas based on a reviewof the evidence available at that time, provided a succinct summary of PrU prevention and treatment. Despite the CMS developed educational program that was available on its Web site, some confusion about how best to document staging of PrUs on MDS 2.0 exists. PrU staging definitions have undergone major revisions. In 2007, the National Pressure Ulcer Advisory Panel (NPUAP) added ‘‘sDTI’’ and ‘‘unstageable’’ as 2 additional stages to the original 4 stages. Most recently, on October 22, 2009, the NPUAP, in conjunction with the European Pressure Ulcer Advisory Panel (EPUAP), released new international clinical guidelines that include further revised definitions. Despite these updated definitions, clinicians in long-term care are bound by CMS regulations to follow the RAI Manual for MDS 2.0, which directs practitioners working in Medicarecertified skilled nursing facilities to document PrUs in some specific instances in a different way from these NPUAP-EPUAP international definitions. Survey compliance with MDS 2.0 requirements is mandatory. Noncompliance with MDS 2.0 requirements can result in citations of deficient practices by the regulatory agency. The penalty determination of this deficient practice depends on the scope and severity of the failure to meet the intent of the regulation, but can include monetary fines and/or closing of the long-term-care facility. The RAIManual is intended as an aid to gathering pertinent clinical information to be used in the development of an individualized and appropriate plan of care for the resident. Inaccurate staging of a PrU might also impact on the choice of interventions and may delay healing. Because the same PrU maybe staged differently in long-termcare as opposed to acute care (Figures 1 and 2), reliance on just the stage can lead to misunderstanding by clinicians and, perhaps in the case of litigation, the misinterpretation by attorney or jury that the clinician did not know how to properly stage because of the discrepancy in staging of the same ulcer in the 2 care settings. Therefore, description and documentation of the ulcer characteristics in a narrative note are essential for clinicians to be clear on what the ulcer looks like, as well as to communicate this information across care settings (Figure 3).

Pressure ulcer knowledge in medical residents: an opportunity for improvement.

The epidemiology of disease is frequently transformed with advances in medical science and social change. For example, once-common disorders, such as polio and tetanus, nearly disappeared with the advent of vaccination technology. This article illustrates how evolving medical technology for treating wounded soldiers in war affected the epidemiology of pressure ulcers in the mid-20th century and discusses the implications for today’s practitioner.