Recent—and controversial—changes to pressure ulcer (now pressure injury) terminology and staging are accompanied by potentially significant legal implications for the healthcare field.
Injury versus Ulcer
For starters, the terminology itself has changed, trending toward using the term “injury,” rather than “ulcer.” Plaintiffs’ attorneys commonly try to blame pressure ulcers on a defendant provider’s care practices as a trial tactic, and the change in terminology may not be favorable to healthcare defense. The word “injury” connotes the concepts of safety and prevention, which may work in the plaintiff’s favor, particularly given the public’s (i.e., the jury’s) existing perceptions and beliefs about pressure ulcers. In essence, this change in terminology could further the plaintiff’s position while damaging the defense’s position—even in cases where ulcers were not preventable, and regardless of the quality of clinical care.
Controversial New Definition
Additionally, some healthcare providers have found changes to the staging definitions controversial. For example, the new staging description for “Deep Tissue Pressure Injury” states that such a wound “results from intense and/or prolonged pressure and shear forces at the bone-muscle interface.” This definition fails to support the pathophysiology of pressure injuries recently revealed by several ground-breaking scientific studies. And because damage is attributed to "intense" or "prolonged" pressure or shear, the new definition implies that residents may have been abused or neglected. Ultimately, it may help plaintiffs’ attorneys argue that the injury developed because a resident was not properly cared for or unattended, or was left in one position for too long.
Further, while the concept of “intense or prolonged pressure” was added to the definition, other verbiage that might have shifted some of the blame from providers was removed. Specifically, a previously-included statement that “evolution may be rapid, exposing additional layers of tissue even with optimal treatment” was removed. Eliminating the acknowledgment that bad outcomes sometimes occur even with good clinical care may have left plaintiffs’ attorneys with a clearer path for attacking the level of care provided to residents.
Incorporating the Changes into Your Defense Strategy
In the wake of these changes and the likelihood of increased plaintiff activity, pressure injury cases will remain on defense attorneys’ radar. As always, the crux of the case is whether or not the provider met the standard of care. Perhaps now more than ever it is crucial for providers to enact interdisciplinary, personalized plans of care for skin integrity. Even more importantly, documentation related to pressure injuries must be exacting, and reflect the following:
- Pressure injuries must be staged, measured, and documented appropriately and according to the new staging system.
- The approach to treatment must be interdisciplinary and include timely and appropriate referrals/follow-ups when necessary, all of which must be documented.
- Specific treatments must not only follow the standard of care; they must follow the individualized plan of care and must be documented accurately and completely, including response to treatments.
Plaintiffs’ attorneys will look for deviations from the standard of care to support their case that the pressure injury was avoidable and was due to facility or provider negligence. The defense will have the burden of proving that the injury was unavoidable. Successful defense will largely be achieved through accurate and complete documentation by the facility caregivers. This documentation will be presented in tandem with expert testimony reflecting the large body of evidence demonstrating that early development of pressure injuries is not as simple as the “intense or prolonged pressure or shear” explanation included in the staging description.
In conclusion, there is considerable opinion that the new terminology and staging system leaves providers and facilities open to new or worsening litigation risk. With the burden of proof placed upon the defense, the importance of patient-specific care planning, complete and consistent documentation, and cutting-edge expert testimony has never been greater.
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