By Heidi Cross, MSN, RN, FNP-BC, CWON

Introduction

Since the advent of coronavirus disease 2019 (COVID-19), I haven’t done much flying, but I love travel and I love flying. One of my favorite experiences is a window seat at about 30,000 feet on a clear sunny day. The views can be spectacular – whether flying across the Rockies or the Plains or any of the stunning and varied scenery of this country or the world. A couple of my most memorable flights involved flying into New York City with views of the New York skyline with Lady Liberty in clear sight, or into Washington, DC with clear views of the Mall, the Jefferson Monument, and the Capitol.

The Alps and the Rockies are incredibly awe-inspiring, beautiful, and breathtaking. From there, you get a good overall picture of the landscape. Many times, in looking at lawsuits related to pressure injuries, I open the discussion with the attorney with something like this, “Let’s start with the 30,000-foot view.” So often it is easy to initially get bogged down in the minutiae and necessary details of care to determine whether standards of care are met. Determining standards of care answers the question: Did this facility or practitioner do what any reasonable practitioner would do under similar circumstances? These actions include assessments and interventions such as risk assessment, nutrition, support surfaces, regular wound assessments, wound treatments, mobilization, turning and positioning, dealing with pain, and physician and family notification. Those are all essential parts of the chart and are critical to determine whether the standards of care were met.

Where to Start With the “30,000-Foot” View?

It all starts with the same dictum as for any good wound care: looking for a thorough patient history with awareness of underlying etiologies. This helps determine the patient’s stage of life and is helpful in deciding first which pathway of wound care is realistic. There are three pathways of wound care: aggressive, maintenance, or palliative.

• Of course, most of the time we do not take wound healing off the table, and this implies aggressive wound management. This may involve expensive wound treatments with potentially invasive diagnostic and treatment interventions.
• However, is the patient at a point of life or a degree of wound chronicity where healing is an unrealistic expectation? At best, can we hope to maintain the wound and keep it from enlarging or becoming infected?
• Palliative wound care does not necessarily mean hospice, but it is an acknowledgement that healing is unrealistic, and if anything, deterioration becomes the expectation. Think emerging fungating tumors or large pressure injuries in very frail and old patients. Declaring wound care to be palliative does not necessarily mean withdrawing care. It does, however, shift the goal posts somewhat, building realistic expectations in our interventions and in our documentation.

So What Does It Look Like at “30,000 Feet” of Wound Care?

Generally, the question here is, was this wound avoidable or unavoidable? An unavoidable wound is one that occurs or when a wound deteriorates despite evidence-based interventions meeting all standards of care. It is when a facility can say, “Hey, we did everything we were supposed to, and the ulcer still occurred or deteriorated!” A lot of defendability depends on documentation of thorough patient and wound assessments and interventions. The following situations may be seen when unavoidability may be declared, and they make a case more defendable:

• End-of-life situations, with concomitant skin failure. Among hospice patients, 40% develop a pressure injury.
• Ischemic conditions such as arterial insufficiency that is not correctable.
• Acute skin failure such as in the intensive care unit with fluctuating vital signs such as hypotension, an inability to be moved, hypoxemia, vasopressor use, hypoventilation, and congestive heart failure.
• Patient non-adherence and refusal of care.
• Drastic immunocompromise that can lead to infections and severe sepsis.
• Body edema and anasarca, leading to compromised tissue perfusion and fragility.
• Spinal cord injury patients who spend a lot of time sitting in their wheelchair, thereby leading to unavoidable ischial injuries.
• End-of-life and end-stage dementia, leading to poor appetite and decreased fluid intake, with downward-spiraling nutrition and hydration.
• Lengthy operating room times, transport times, and emergency room times.
• Lengthy hospitalizations. One study found that 97% of all pressure injuries occurred among study participants whose length of stay was greater than seven days.¹
• Medical device–related injuries when the device cannot be removed or repositioned.
• Reluctance to seek care or hospitalization because of COVID-19.
• Non-compliance with diabetes.

Conclusion

The foregoing list is not meant to be exhaustive, and other conditions can lead to unavoidability. Hopefully, we can all soon start flying and enjoying those 30,000-foot views. In the meantime, consider applying them to your practice.

Reference

1. Eachempati SR, Hydo LJ, Barie PS. Factors influencing the development of decubitus ulcers in critically ill surgical patients. Crit Care Med. 2001;27(10):1599-1605.

About the Author

Heidi H. Cross, MSN, RN, FNP-BC, CWON, is a certified Wound and Ostomy Nurse in Syracuse, NY. She has extensive experience caring for wound and ostomy patients in acute care as well as in long term care facilities. Currently, she is employed by CNY Surgical Physicians consulting for nursing homes in the Syracuse area, and has served as an expert witness for plaintiff and defense attorneys.