Ulceras Por Preison

Pressure Ulcers: What Clinicians Need to Know
William T Wake, MD, FAAFP
William T Wake, MD, FAAFP, is a Physician in the Department of Family Medicine and Department of Continuing Care at the Baldwin Park Medical Center in CA. E-mail: william.t.wake@kp.org.
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Copyright © 2010 The Permanente Journal
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Introduction
Pressure ulcertreatment is one of many aspects of patient care in which nursing care interfaces directly with clinician-provided medical services. Traditionally, the treatment of pressure ulcers has been left to nurses. No less an authority than Florence Nightingale said in 1859, “If he has a bedsore, it's generally not the fault of the disease, but of the nursing.”1 Physicians have tended to be passiveparticipants, routinely cosigning orders written by hospital-based wound-care nurses or home health nurses. Realization of the costs associated with the treatment of pressure ulcers and recent requirements by third-party payers have prompted physicians to become more actively engaged in the prevention, identification, and treatment of pressure ulcers.
Pressure ulcers are localized areas of tissue damageor necrosis that develop because of pressure over a bony prominence. They have previously been called pressure sores, bedsores, and decubitus ulcers, terms that imply that only bed-bound, nonambulatory patients develop pressure ulcers. It is important to recognize that patients who are ambulatory can also develop pressure ulcers, although reduced mobility is still a major risk factor.
The purposeof this article is to familiarize physicians and other clinicians who provide care to hospitalized patients, such as physician assistants, certified nurse midwives, and nurse practitioners, with some of the terminology associated with pressure ulcers, so that they can better assess patients at risk for the development of pressure ulcers and properly identify and describe pressure ulcers.
Go to:Costs
For a sense of the total costs of the treatment of pressure ulcers, data from the 1990s, although old, can shed a light on current costs. In 1996, $6.4 billion was spent on pressure ulcers, which was 1.2% of total health care costs in the US.2 In 2006, excluding neonatal and maternal conditions, almost $11 billion was paid out for hospital stays in which pressure ulcer was either a primaryor secondary diagnosis.3 For the individual patient, the current costs of providing care for one pressure ulcer can range from $3500 to over $60,000, depending on the stage of the ulcer.4
Pressure ulcers have also attracted the attention of the medicolegal community. Some courts regard pressure ulcers as evidence of elder abuse, and some lawsuits have awarded judgments of more than $10 million.5If the presence of pressure ulcers is considered to indicate elder abuse, such legal judgments are not covered by conventional medical malpractice insurance policies, nor are such awards limited by the caps imposed by many US states in medical malpractice lawsuits.
In November 2008, the Center for Medicare and Medicaid Services instituted a policy to withhold reimbursement due to be made toacute-care hospitals for the costs of treating hospital-acquired conditions,6 such as pressure ulcers. Although hospitals will be paid for the care of pressure ulcers that originated before admission, hospital-acquired pressure ulcers would be the responsibility of the admitting hospital. Because of this change in policy, there is now an incentive for hospitals to accurately assess for skin problems inall patients being admitted and to identify all patients at risk for developing pressure ulcers so that preventive measures can be put in place. Increasingly physicians are being called on to identify at-risk patients and accurately classify skin conditions present at admission.
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Identification and Risk Assessment
On admission to an acute-care hospital, all patients should undergo a...