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2013 YP Award Essay 2
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2013 Winner - Essay 2

The Doctors Company Foundation Young Physicians Patient Safety Award


Last year, I admitted a patient with severe dementia. My attending asked if I had checked for ulcers. I hadn’t. Even after this oversight, pressure ulcers still weren’t at the forefront of my mind – until my dad developed his own.


My Dad
My dad’s final stroke was in May 2012. He died in October. His course was wrought with patient safety errors, including mismanagement of his blood pressure immediately after his stroke and 5 days without dialysis prior to his death. But the problem that will forever haunt me is his sacral ulcer.


After the acute hospitalization, he was discharged to a Long-Term Acute Care Facility (LTAC). On the facility tour, we were told the standard of care to prevent decubitus ulcers included repositioning patients every two hours. Our guide handed us a brochure advertising the facility’s wound care management program.


Upon transfer, my dad’s sacrum had a 1 cm shallow erosion. Though disappointed, we had high hopes the LTAC would reverse it. In two weeks, the erosion progressed to a 2 x 5 cm smooth eschar framed on by 3 cm of shallow ulceration. The ulceration extended further down his buttocks; everything was surrounded by purpura.


At the LTAC, sign-in sheets recording patient care (position changes, dressing changes, etc.) would be empty from 9:00am to 4:00pm. Magically, at 4:30pm they were filled despite the fact that I had only seen the nursing staff once or twice. Polite reminders that my father had not been repositioned in several hours were brushed off: the staff “was busy with other patients.” Annoyed reactions when we requested his soiled diaper be changed made us question whether we were over-advocating. My mother became concerned that if she was perceived as the “irritating” family member, my father would receive worse care. Not all the staff was terrible, but all an ulcer needs to flourish is a few minutes of ischemia, and we couldn’t choose our nurse/techs. Despite formal complaints, the care remained steadily poor. Eventually, removal of the bandage revealed more than ulceration. First muscle. Then bone.


Who Is to Blame?
My interest in patient safety started with a research project I participated in a few years ago. We evaluated the misdiagnosis rate of cellulitis, an intervention to improve diagnosis and hoped to reduce unnecessary hospitalizations and antibiotic administration. A lesson learned was that sometimes it is our system of learning and decision making that is flawed, not the individual. Similarly, while I was angry at my dad’s hospital(s) and staff, the truth is, the problem was bigger than the individuals themselves. I’ve spent a lot of time mulling over these problems, and I see 3 systemic areas for improvement: (1) increasing accountability, (2) changing how we view ulcers and (3) improving incentives surrounding ulcer prevention. One potential tool to address the issues could be a mobile application (App).  


(1) Accountability. My proposed App starts with a simple alert system that reminds caretakers to reposition their patients. Then caretakers take a photo of the repositioned patient. Photos are electronically time-stamped making it impossible to falsely record actions not performed. Electronic data can be compiled and reviewed by management. Furthermore, knowledge that actions are monitored increases accountability among nursing staff and managing physicians. Drawbacks include protection of patient privacy. However, I feel most patients would consent to photography if they knew it was to improve outcomes. Furthermore, many App developers are familiar with HIPAA regulations, and photos can be stored in a Cloud rather than on phones. The App also includes a section to photograph wounds. Having immediate access to this picture series can be powerful. Improvements in wounds motivate providers to do more, while evidence of further deterioration can trigger reassessment of management. The process adds time, but the few extra minutes may improve quality of life and potentially reduce health care costs.


(2) Changing how we view ulcers. Providers must believe they can prevent ulcers. My father’s first stroke was in Istanbul. He was transferred to Zurich for the remainder of his care. Though comatose for 2 months, it was ingrained in the nursing culture that decubitus ulcers were preventable. Because of their attention, he did not develop a single bedsore.


In the United States, the Centers for Medicare & Medicaid Services thinks decubitus ulcers are preventable (denying reimbursement for ulcers developed during hospitalization). But the belief doesn’t seem to be pervasive. At the acute hospital and LTAC there seemed to be an unconscious assumption that ulcers were inevitable, not preventable. We need to empower providers with proof that their efforts can make a difference. A nice example is a 48-month initiative performed by the New Jersey Health Association which resulted in a 78% decrease in the incidence of new pressure ulcers through collaborative multidisciplinary efforts.*


I hypothesize that the inability to make personal connections with patients contributes to apathy. As with care of babies, a large part of the nursing care for patients with ulcers includes jobs like cleaning. Unlike infants, who reward caretakers with sweet wide-eyed gazes or the grasp of a tiny palm, many adult patients, like my father cannot communicate. Consequently, relationships are not formed, and nursing feels like a burden.


(3) Changing incentives: Rewards over penalties. It’s important to create positive associations: reward success with gift certificates for providers who turn their patients on time, parties for teams that reduce ulcer incidence, public acknowledgement within the hospital. The App itself can be gamified by including random scenes, like seeing a herd of sheep run across the phone screen after User A has turned a patient 10 times. Similar, funny screen scenes can occur at varied time intervals. Lastly, an underappreciated incentive is the opinion of peers. Free access to the performance of peers encourages low performers to improve, and rewards high performers with pride.


Pressure ulcers occur daily throughout the world. I now have a personal understanding of their impact on the individual (pain, suffering, indignity) and society (cost, time). Knowing this, there would be no better way to honor my father than by making even the smallest contribution toward the extinction of this problem.


*Werkman H, Simodejka P, DeFilippis J. Partnering for prevention: a Pressure Ulcer Prevention Collaborative project. Home Healthc Nurse. 2008 Jan;26(1):17–22.

Please note that all pieces of possible identifying information (names, dates, locations, etc.) have been changed for purposes of privacy.


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