Never Say Never

Never Events vs. Unavoidable Pressure Injuries

Never events are not new concepts, but it never hurts to brush up on what they mean for wound care.

Never events are not new concepts, but it never hurts to brush up on what they mean for wound care. In 2006, the National Quality Forum (NQF) identified 29 events, particularly medical errors, deemed so severe that a patient should never have to endure them. Defined ‘Never Events’ included incidents such as leaving foreign objects in a patient’s body post-surgery, or amputating the wrong limb. Although rare, these egregious events have actually happened, and were required to be reported.

But guess what also made the list. Hospital acquired pressure injuries (HAPIs). Wounds classified as Stage 3, 4, or deep tissue injuries (DTIs) that occurred after a patient was admitted were now considered never events. And after the NQF released the list, CMS upped the ante, announcing the reduction in payments for these avoidable events. 

The important caveat in the ruling, however, was “present on admission.” If facilities had clear documentation that the pressure injury began before entry, they wouldn’t bear the financial burden. But the lesson for healthcare facilities and caregivers was clear: HAPIs happen, and they weren’t going unnoticed. Preventing the avoidable was expected and would now be enforced. But are all pressure injuries avoidable? This debate has been raging since the 19th century, with modern research suggesting that the answer isn’t so cut and dried. Physiological changes happen, particularly at the end of life, that make it difficult to prevent all pressure injuries, regardless of the quality of care. Identifying these changes was a huge hurdle to overcome. 

Kennedy Terminal Ulcers

In 1983, Karen Lou Kennedy-Evans was a clinician in Indiana taking a closer look at the pressure ‘ulcer’ problem within her facility, particularly on patients at the end-of-life. Dying patients were rapidly developing pressure injuries on the sacrum with distinct characteristics. What started out as a Stage 2, pear-, butterfly-, or horseshoe-shaped abrasion, progressed to a Stage 3 or 4 virtually overnight. The borders were irregular, and the onset was sudden. Eventually dubbed ‘Kennedy Terminal Ulcers’ (KTU), these were larger than typical PIs and ran the gamut of colors from red to yellow to black.

An investigation conducted by Kennedy and additional committee members found that over 50% of the LTC patients who developed a KTU died within six weeks. While the exact cause of these lesions is unknown, they’re thought to be connected with the dying process. The skin is an organ. The largest. So, when a patient’s organs start to fail, it stands to reason the skin would also be affected. 

3:30 Syndrome

As if the KTU wasn’t enough, the team in Indiana also uncovered a second event occurring on the dying patients. Small specks, resembling dirt, were appearing under the patients’ skin. While the spots resembled deep tissue injuries, these were not avoidable events. Presenting fast and furious, these lesions rapidly grew in size in a matter of hours. Patients with normal, intact skin in the morning were, by 3:30 pm, experiencing areas of black discoloration. Named for the timeframe in which these lesions occurred, the life expectancy of patients developing the 3:30 Syndrome was only 8-24 hours. 

Trombley-Brennan Terminal Tissue Injury (TB-TTI)

Finally, a decade later, a new team of clinicians provided further validation on the existence and severity of the terminal pressure injury/ulcer. Patients on the palliative care unit were experiencing sudden skin alterations. Similar to the KTU, these bruise-like tissue injuries were shaped like butterflies and varied in color. Again, while resembling deep tissue injuries, the TB-TTI were ruled unavoidable regardless of the preventative measures taken by the wound care team. Once identified with these tissue injuries, patients died within 2 and 72 hours.

So, are all pressure injuries avoidable? Maybe not. After multiple debates, conferences and panel discussions, the influencers within the wound care industry — CMS, NPUAP, and WOCN Society — did reach a consensus on how to define unavoidable pressure injuries. According to CMS, avoidable pressure injuries form when the healthcare provider fails to do one or more of the following: properly evaluate the patient’s condition and PI risk; define and implement appropriate interventions; and/or monitor and evaluate interventions and revise as appropriate. 

Unavoidable pressure injuries, however, were indicated when all of the above precautions, interventions, and evaluations were performed, but PIs still developed. For more information on proven solutions to prevent the preventable pressure injuries, click here!