We were excited to attend the presentation by Mary Foote, RN, MSN, ANP, CWCN-AP, ED.Dc. and Tammera Banasek of HeplerBroom LLC, COVID Wounds: Clinical Insights, at the September DRI Senior Living and Long Term Care Litigation Seminar in Las Vegas.  Ms. Foote’s informative clinical talk differentiated wounds caused by pressure with those due to skin failure related to critical illness, including COVID-19.  Of special interest to Excelas was her emphasis on the importance of explicit medical record documentation, which is key in developing medical chronologies and other analytical tools to support the defense of claims and litigation.

Pressure Wounds

Citing industry standards as put forth by the National Pressure Injury Advisory Panel and the Wound, Ostomy, and Continence Nurses Society (WOCN), Ms. Foote explained that localized damage to the skin and/or underlying soft tissue is defined as a pressure injury if it is a result of prolonged pressure, or a combination of pressure and shear, over a bony prominence.  These wounds are influenced by the stability of the resident’s underlying co-morbid conditions, and the Braden Scale is commonly used to identify the risk of pressure ulcer development.  The Centers for Medicare & Medicaid Services classifies pressure injuries as:

• Unavoidable: in which the pressure injury developed despite the facility’s evaluation of the resident’s clinical condition and risk factors, interventions following patient goals and standards of practice, and implementation and monitoring of interventions.
• Avoidable: in which documentation does not support unavoidability of wound development.

CMS imposes monetary fines in relation to avoidable pressure injuries; therefore, the importance of medical record documentation to support severity stratification of wounds, risk status, and unavoidable skin failure is key.

A key take-away from the lecture was providers of care must show restraint in classification of a wound as a pressure injury versus breakdown associated with an underlying condition.  The NPIAP 2020 White Paper notes purple areas on non-pressure loaded surfaces that lack a pressure shear etiology should not be classified as pressure injuries.  A true pressure injury may generate heat due to inflammation; however, the skin is cold due to hypoperfusion in a COVID-19 wound.  Injuries due to multi-organ dysfunction cannot overcome reasonable efforts at prevention.

Ms. Foote made clear that wounds related to COVID-19 and its treatment during an acute critical stage may not appear for 2-3 weeks, possibly after the patient has transferred to a long-term care setting.

Differentiation of wound causation entails an in-depth analysis of the medical record including the enumerated tools Ms. Foote cited.  In the skilled nursing or long-term care setting, this in-depth medical record documentation must include:

• A review of the hospital records prior to facility admission.
• Underlying critical illness, including COVID-19.
• Any chronic illness prior to COVID-19 diagnosis, including skin failure, as these are often exacerbated.
• Severity stratification of any presenting wounds on admission.
• Risk factors including:
  • skin failure
  • compromised circulation
  • impaired perfusion
  • prolonged hypotension
  • sepsis
  • impaired nutrition
  • immobility
• Actions related to these risks including pressure redistribution, use of support surfaces, management of moisture, nutrition and hydration, efforts at oxygenation, and product utilization.

Ms. Foote’s well referenced presentation provided clear explanations of the clinical attributes and etiology of wounds.  Whether a wound is pressure related or associated with COVID-19 and/or critical illness, Excelas’ medical analysts can review the medical records and create a Medical Chronology and/or Case Summary that will provide the entire story regarding the development and treatment of wounds.