Tissue damage in trauma patients: Where does it start?

Abstract

Trauma patients are at higher risk for tissue damage, and subsequently pressure ulcers (PU), for reasons that go beyond identified nursing risk factors. These reasons include the factors inherent in the common progression of trauma care: acute trauma support at scene, immobilization on a rigid spine board (RSB) for transport to local hospital, additional transport on RSB to urban hospital if from rural, transfer to firm surface for emergent treatment, possible surgical intervention, followed by recovery in a hospital bed. Moreover, trauma patients are physiologically at greater risk due to a number of factors including hypovolemia and subsequent hypotension, hypermetabolic state, sensory impairment, and paralyzing spinal injuries. Recognition and documentation of tissue damage, or potential pressure ulcer development, prior to hospital admission may not be possible because of damage originating at the bone-soft tissue interface instead of at the surface tissue. Since pressure ulcers are becoming a "never event" by the Centers for Medicare and Medicaid Services (CMS) it is important to recognize that tissue damage may have, in fact, occurred prior to admission and was not due to poor hospital practices. Thus, it is our view that trauma patients meeting certain criteria should be excluded from CMS's pay-for-performance penalties.