Pressure Ulcers and the Law. Cheryl Carter - Durban

Transcription

1 Pressure Ulcers and the Law Cheryl Carter - Durban

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5 South African Context In 2009/2010, the Gauteng Department of Health and Social Development reportedly faced medical malpracice claims totalling R573 million. Media reports of high damages awarded for malpracice in public health insituions are commonplace and becoming more frequent. SAMJ 2013; 103(2) There have been large pay-outs to paients related to the harm suffered rather than to the degree of negligence The lawyers know where to look SAMJ 2013; 103(7) 433

6 S Vicariously liable for conduct of employees Financial loss Loss of reputaion LiIgaIon is personal à TraumaIc experience; leave profession Financial exposure PotenIal loss of registraion AssumpIon PU s are a result of improper care Skin not viewed as an organ à do not understand skin failure Seek jus(ce or answers and compensa(on for lack of quality care

7 Legal PerspecIve The healthcare provider owed a duty of care to the paient The paient suffered injury The injury was caused by the provider The healthcare provider breached or violated the duty owed to the paient i.e. negligent Williamson and Lavecchia Mid AtlanIc Wound Care Conference Pressure Sores and the Law

8 Pressure Ulcer PerspecIves Why are lawsuits on increase? Unlike other medical complicaions they never go unnoiced by paient and their family Visually disturbing

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10 Concept: PreventaIve Legal Care

11 PreventaIve Legal Care UIlise preventaive medicine to reduce medical costs and minimize health related risks Fail to apply same principle of prevenive care to our own legal risks ImplemenIng preventaive legal care reduces healthcare praciioners legal risks and potenial costs

12 Preventability Pressure Ulcers considered Hospital Acquired CondiIon Judgement is based on assessment of Long-term care seengs Avoidable compliance to requirements Unavoidable Acute care seeng Reasonably preventable

13 PreventaIve Legal Care Policies & Procedures DocumentaIon CommunicaIon

14 Policies and Procedure Policies & Procedures must be draged not only with an eye towards improving care, but also with careful consideraion of their potenial use by adversaries in future liigaion. Fife & Yankowsky. Legal ImplicaIons of Pressure Ulcers Consensus paper InternaIonal Expert Wound Care Advisory Panel: 2009

15 Policies and Procedure Fife & Yankowsky. Legal ImplicaIons of Pressure Ulcers

16 Policies and Procedures Policies that fail contain: Absolute words must be done Inflexible deadlines immediately Unnecessary mandates Fife & Yankowsky. Legal ImplicaIons of Pressure Ulcers

17 Policies and Procedures Policies designed to succeed contain: Clear guidelines Flexible deadlines DiscreIonary judgment Fife & Yankowsky. Legal ImplicaIons of Pressure Ulcers

18 DocumentaIon DocumentaIon the first thing a plainiff s lawyer looks at when evaluaing a case Used in ways you don t intend when building a case Fife & Yankowsky. Legal ImplicaIons of Pressure Ulcers

19 Preventability Criteria for assessment of preventability 1. PaIents clinical condiion and pressure risk factors If the facility failed to do one or more of these the pressure ulcer is reasonably 2. Defining and implemening intervenions that are preventable à consistent with the LiIgaIon paient s Risk; needs, goals and recognised standards of pracice If a paient developed a pressure ulcer despite all the criteria being met the 3. Monitoring and evaluaion of the impact of intervenions or revision of intervenions as appropriate pressure ulcer would be unavoidable Consensus paper InternaIonal Expert Wound Care Advisory Panel: 2009

20 PreventaIve Legal Care In pracice

21 PrevenIon Know your numbers Policy and Procedure Remember judgement against compliance PreventaIve strategy Risk Assessment Plan to miigate risks à Implement Monitor and evaluate efficacy

22 PrevenIon: EducaIon Single most important factor in prevening hospital acquired pressure ulcers Poor knowledge and understanding Focus on: - ü EIology of and risk factors for pressure ulcers ü Risk assessment tools and their applicaion ü Skin assessment ü SelecIon and use of support surfaces ü NutriIonal support ü Bowel and bladder management ü Development and implement individualized programs of skin care ü PosiIoning to decrease risk of Issue breakdown ü Accurate documentaion of perinent data

23 PrevenIon: Risk Assessment Scoring Tools Norton Score Braden Waterlow None validated for use in ICU All have limitaions Ensures systemaic evaluaion of individual risk factors à preventaive strategies All paients admiped in ICU should be considered at risk à assess every 24hrs Consensus Paper InternaIonal Expert Wound Care Advisory Commipee: 2009

24 PrevenIon Strategies 1. ConInuous assessment 2. Skin Care 3. NutriIon 4. Mechanical Loading and Support Surfaces 5. EffecIve CommunicaIon

25 1. ConInuous Assessment Head to toe skin assessment daily à Document Focus on potenial pressure areas Dependent of paient posiioning Risk factors Devices 10% pressure ulcers in ICU

26 Choose correct size device to fit individual Cushion and protect skin with dressings in high-risk areas e.g. nasal bridge Inspect skin in contact with device at least daily Avoid placement over sites of previous or exising ulcer. Avoid tracion on tubing Educate staff on correct use of devices and prevenion of pressure ulcers Be Aware of oedema under devices and potenial for skin breakdown Confirm devices not placed under paient

27 2. PrevenIon: Skin Care Individualize bathing frequency. Ø Mild cleansing agent. Ø Avoid massage over bony prominences Establish a bowel and bladder program for inconinence. Ø Cleanse skin at Ime of soiling Ø Use a topical barrier to protect the skin. Ø Pads/ Nappies absorbent and provide a quick drying surface to the skin Ø? collecion device to contain stool and to protect the skin. Prevent / manage dry Skin Flexi-Sheath

28 3. PrevenIon: NutriIon Early feeding Meet paients nutriional requirements PrevenIon of diahorrea

29 4. Mechanical Loading and Support Surfaces Aim to limit Amount of Ime and pressure FricIon and shear forces

30 PreventaIve Strategies: Time + Pressure RecommendaIons AcIvely mobilize if possible Turning Remains mainstay of pressure ulcer prevenion à paient dependant PosiIon use of pillows / devices to prevent pressure knees, ankles Adjuncts Foam dressings Best Practice Guidelines (2005) hpp:// Cooper, L. (2013) Critical Care Nurse 23(6) 57-66

31 4. Mechanical Loading and Support Surfaces Mapresses 10cm deep solid foam à reduces pressure by 30% Dynamic mapresses relieve pressure à 15cm tubes Air fluidized beds + Low-air-loss CombinaIon of turning + mapress 1. Gunningberg (2005) International Journal of Nursing Practice. 11: 58-67; 2. Jastreski (2002) Journal of Critical Care 17(2); Best : Practice Guidelines 2005 hpp://

32 4. Mechanical Loading and Support Surfaces Shear and FricIon Forces Head at lowest elevaion consistent with medical condiion Slidy sheets Skin moisturizers for dry skin Use of polyurethrane dressing to prevent further fricion Permeable to water vapour, O 2 Impermeable to water, bacteria Maintain moist interface for healing Best : PracIce Guidelines 2005 hpp://

33 5. EffecIve CommunicaIon Handover IdenIfied risks CondiIon of the skin Assessment and staging of wounds /pressure ulcers PreventaIve strategies uilised Efficacy of preventaive strategies NB! DocumentaIon of everything Skin Bundle

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35 Conclusion Hospital acquired pressure ulcer have potenial for liigaion Need to pracice preventaive legal care Document Policies and procedures DocumentaIon CommunicaIon Everything PrevenIon - 3 Guiding Principles IdenIficaIon of the paient at risk Use of preventaive measures appropriate to paient specific risk factors Close follow-up of high risk paients i.e. coninuous assessment

36 SANC PerspecIve The principle of something not being done, if it cannot be proven in the records of the paient, is a worldwide known principle in the nursing profession and is accepted. There is no reason why the commipee should change its view on this principle especially if paients suffer harm Extract from SANC Disciplinary Hearing Transcript