More than a decade ago I was in Washington, D.C. at the annual National Quality Forum (NQF) meeting when the winner of the prestigious John M. Eisenberg Patient Safety and Quality Award was announced. Named after the former administrator for the Agency of Healthcare Research and Quality (AHRQ), each year the NQF and the Joint Commission select a winner as the, “best example of individual, local, and national efforts to improve patient safety and health care quality…” Lo and behold, the chief executive officer of my own hospital system was the winner. In his gracious acceptance speech, he explained how it was possible for a multi-hospital system to have no adverse events over an entire year. A perfect record. Wow.

However, I was confused. I worked at one of those hospitals which provided state of the art trauma and cardiovascular care. Among the various intensive care units, I had personally seen some Deep Tissue injuries (DTIs) and Stage 4 pressure ulcers– just like every other institution that cares for critically ill patients. I should add that the hospital system’s stellar quality metrics were not just about hospital acquired pressure ulcers but included surgical site infections, catheter infections, and the rest of the list mandated by CMS. Apparently, none of those adverse events had occurred either. I knew that couldn’t be right, but I was used to things not making sense in Washington, D.C., so I finished my desert, feeling a bit like Alice at the Mad Hatter’s Tea Party.

A few months after the NQF event, I got a call from a lifelong friend who asked me to chat with his daughter about her next career move. A nurse with two master’s degrees from an Ivy League school, she’d gotten her first job in the corporate office of that same hospital system, working in the department responsible for aggregating the quality and safety reports from the various hospitals in the system. She quit because she had been told to falsify the corporate quality reports to ensure a perfect safety record for the system. Since a directive to do that would have to come from someone at or near the top of the corporate C-suite, there was no one to complain to and just she quietly left. Totally by accident, I’d discovered HOW the hospital system was able to report a zero incidence of adverse events across multiple hospitals. However, I still didn’t understand WHY. Then, an article in the paper reported that the aforementioned award-winning hospital administrator was retiring after an illustrious career, and was rewarded with a six figure bonus tied to the hospital system’s safety and quality performance record. One can only assume that is WHY the reports were falsified. I probably should not even mention the above strange story, except that is makes me mad and is a great example of the perverse incentives and misdirected punishments around pressure ulcer reporting.

We are all mad here…

We’ve been blaming the nurses for pressure ulcers/injuries since the era of Florence Nightingale, but it was The Deficit Reduction and Reconciliation Act (DRA) of 2005 that set a series of perverse events in motion. The Centers for Medicare and Medicaid Services (CMS) were told to identify conditions that were high-cost or high-volume or both that, “could reasonably have been prevented through the application of evidence-based guidelines.” If these events happened, the additional cost associated with a “major co-morbid condition” would not be reimbursed by Medicare. CMS never said pressure ulcers were “never events” when they identified the targeted areas of focus. In fact, as a way to reduce the deficit, this plan was reasonable. CMS could use the lever it controlled (payment) to encourage hospitals to reduce the incidence of potentially preventable problems. That’s a great idea! Unfortunately, good ideas often have unintended consequences. Hospitals hired fleets of people to manage quality programs because a lot of money was at stake, thus creating an entire industry focused on the reporting of these events. The misconception that pressure ulcers/injuries were always preventable (“never events”) was strategically and falsely disseminated, often by plaintiff’s attorneys. To make matters worse, on its website, the NQF states that hospital-acquired Stage 4 pressure ulcers are “always due to poor care,” a statement that is proveably false. The NQF list of serious reportable events (“never events”) in the category they call “patient protection events” includes patient death from medication error, artificial insemination with the wrong sperm, and “Any Stage 3, Stage 4, and unstageable pressure ulcers acquired after admission/presentation to a healthcare setting.” With egregious statements like those on the NQF website, it’s no wonder that lawsuits over hospital- and facility- acquired pressure ulcers began to soar and Plaintiff’s websites began to tout pressure ulcer formation as evidence of elder abuse.

All this was occurring despite the fact that the problems then called “pressure ulcers” (previously known as bedsores and then decubitus ulcers and now renamed “pressure injuries”) are known to occur even under the best of care. My favorite prospective study proving this was funded by the California Department of Justice under the leadership of Laura Mosqueda, MD. The Justice Department wanted to know if the presence of a pressure ulcer was a priori evidence of neglect because they didn’t want to pursue legal action against clinicians or institutions for events that were not the fault of clinicians. A geriatrician, the focus of Dr. Mosqueda’s career was elder abuse. When I stumbled on this study, I was so impressed that anyone could get the DOJ to pay for a pressure ulcer study that I called her. She explained that she didn’t know anything about wounds, but she was trying to figure out if the pressure ulcers that formed under the best of care looked any different than those occurring due to neglect. Not only did the study find that pressure ulcers happened despite documented optimal care, but (per her conversation with me), they found that “pressure ulcers that formed during optimal care looked just like the ones that occurred in the setting of neglect.” The reason, of course, is that the pathophysiology of tissue infarction is predicable – death of muscle later followed by the death of the subcutaneous tissue and lastly the skin. We see the same thing in other vascular events. Lest you think that this is a new idea, the vascular nature of pressure ulcers was understood 30 years ago when Roberta Abruzzese, the revered editor of the journal that used to be called “Decubitus,” suggested calling them “vascular occlusion ulcers.”

Based upon an analysis of Medicare claims data, pressure ulcer incidence among Medicare beneficiaries was the same in 2019 as it was in 2014 (paper in review). We’ve probably gotten it as low as we can with our current strategies. We need new strategies. The incidence of pressure ulcers/injuries can’t ever be reduced to zero because we can’t stop some patients from going into shock, needing vasopressors or dying. However, there remains no way to objectively identify the medically unpreventable pressure ulcers/injuries. When a hospital provides world class care to the sickest of patients and they survive against all odds, the hospital is rewarded with a lawsuit over a pressure ulcer. Financial incentives at many levels are tied to the reported incidence of pressure ulcers/injuries.

Hospitals are being blamed for events that are not their fault so it is understandable why some have begun to manipulate adverse event reporting. We keep getting fed the same “treacle” of prevention protocols and interventions like foam bandages, rather than funding studies to identify the hemodynamic thresholds that might define medically unpreventable DTIs and Stage 4 pressure ulcers. And we argue over what to call them. The latest in a series of naming fads is to call them “skin failure” so we have some way of transmitting the concept that, “This one wasn’t my fault.” It’s all mad. We could fix it, but there are so many perverse incentives to keep it the way that it is, I am not sure where we will find the motivation to change.

I am just Alice at the Mad Hatter’s tea party. And I can only say, “If I had a world of my own, everything would be nonsense. Nothing would be what it is, because everything would be what it isn’t. And contrary wise, what is, it wouldn’t be.”


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