Pressure ulcers (bed sores) can cause severe pain and decrease quality of life. They are common among the very ill, the elderly, and immobile or neurologically compromised patients. In Canada, approximately 1 in 8 patients in acute care hospitals, 1 in 11 nursing home residents, and 1 in 50 home care clients experience pressure ulcers. Patients with hospital-acquired pressure ulcers tend to stay 4 days longer in hospitals, are 7% more likely to die, and, on average, cost the health care system an additional $13,500. Although its financial burden to the health systems is not as well known as those of other diseases, pressure ulcers are expensive, costing the health care system as much as diabetes and about a third as much as cardiovascular disease.
There has been recent interest in proactive approaches to pressure ulcer prevention around the world. In the United States, there is an emerging belief that hospitals should not be reimbursed for serious complications that should never occur in a safe hospital. Pressure ulcers have been designated as one of the “never events”: medical errors that are identifiable and reasonably preventable through the use of evidence-based guidelines. As a result, hospitals are no longer reimbursed for additional care for hospital-acquired pressure ulcers. This move by the Centres for Medicare and Medicaid Services aligns financial incentives with patient safety and quality of care.
In Japan, recent policies reimburse hospitals approximately 50 yen (~ $0.50) per patient per day if they establish a pressure ulcer team including both physicians and nurses, introduce a standardized clinical protocol for pressure ulcer management, and provide adequate preventive support surfaces to at-risk patients. Hospitals also receive an incentive reimbursement of 5,000 yen (~ $50) per patient if they employ a government-certified wound care specialist, develop a comprehensive pressure ulcer management program, and conduct on-the-job training for their staff in pressure ulcer management. Preliminary results suggest that the proposed structure (i.e. staffing, guidelines, and equipment), and processes (i.e. risk assessment, wound documentation, team collaboration, and training) improve healing rates and reduce hospital-related costs.
Like the United States and Japan, Canada has an aging population. By 2026, when many of the baby boom generation will be retired, the proportion of elderly will increase from 13.2% today to 21.2%. Elderly patients are at risk of developing pressure ulcers because of immobility, poor nutritional status, impaired mental status, and incontinence. Over a 15 year period, the percentage of hospital patients reporting these morbidity conditions increased from 9% in 1994 to 17% in 2008.
In Canada, it is challenging to prevent pressure ulcers, especially in acute care hospitals. A high proportion (approximately 38% as of 2010) of hospitals reported a financial deficit. To cope with a high demand for hospital services from an aging population, hospitals strive to discharge patients as early as they can. As a result, discharged patients with hospital-acquired pressure ulcers are managed in the community. This arrangement of transferring care for pressure ulcers from acute to community care does not incentivize hospitals to improve prevention. This arrangement also subjects pressure ulcer care to variation in the quality of care transition, including problems with care coordination and documentation. Consequently, the lack of emphasis on prevention in acute care, coupled with an aging population, could lead to a gradual increase in the burden of pressure ulcers over time.
Prevention policies in Canada are generally formulated based upon their supporting evidence. For example, the Ontario Health Technology Assessment Committee recommends that high quality foam mattresses should be provided to all persons in an acute care setting, high quality support surfaces should be used during surgical procedures lasting longer than 90 minutes, and high quality foam mattresses should be used for all persons accessing emergency room care. While these recommendations are grounded in evidence, there is little data about how widely they have been implemented in practice.
The Canadian approach to pressure ulcer prevention is different from the accountability approach used in the United States or the incentive approach used in Japan. Given the impact of preventable pressure ulcers on patients and the healthcare system, we think it is time for Canada to proactively consider accountability or incentive measures to improve uptake of evidence-based guidelines. What do you think?
NP, CH, LT are panel members of the Registered Nurses’ Association of Ontario Best Practice Guideline for risk assessment and prevention of pressure ulcers.