Pressure Ulcer Competencies in Medical Education

  About 2.5 million people develop pressure ulcers (PUs) every year.¹ Because a PU is a common, yet undesired event, it is vital that an interdisciplinary team of providers collaborate to minimize PU incidence and competently care for patients with PUs.   Regulations regarding care of patients with PUs have increased. On October 1, 2008, the Centers for Medicare and Medicaid Services (CMS) started denying payments for hospital-acquired Stage III and Stage IV PUs, categorizing these wounds as preventable conditions.^2,3 The regulation also mandated that coders examine physician documentation for PUs.⁴ Therefore, while prevention and treatment require interdisciplinary team effort, the focus is on physicians to be more accountable for PU prevention and treatment.   Physicians may not be ready for this increased accountability. Developing knowledge about skin and wound assessment traditionally has not been a priority in physician education. A survey of 50 American medical schools in 2005 showed there were only, on average, 2.5 total hours of education in physiology of tissue injury and approximately 4 total hours of education in the physiology of wound healing in the first 2 years of medical school, and none provided in the last 2 years.⁵ A survey of 48 geriatric fellows also pointed to a need for improvement in PU knowledge and care — only 48% of them correctly identified the Braden Scale as a PU screening tool, 67% correctly identified a description of a Stage I PU, and 52% correctly identified a description of a Stage IV PU.⁶ A survey of family physicians found that 70% did not feel adequately prepared to care for patients with PUs. As such, PU education for medical trainees is urgently needed.⁷   In the current era of competency training, organizations monitoring physician training have created lists of competencies for each learner level. As part of the Association of American Medical Colleges (AAMC) and American Geriatrics Society (AGS), workgroups have created competencies for each learner level — medical student, resident, and fellow — as related to the care of geriatrics patients.^8-10 Thirty-five competencies were eventually identified and have been adopted for medical students.⁸ Twenty-six competencies have been created and adopted for resident medical education.⁹ For geriatric medicine fellows, a workgroup created 150 competency-based learning objectives in 16 content domain areas.¹⁰ PUs are mentioned as part of these competencies (see Table 1).   The AGS, American Medical Association, and Council on Medical Specialties support the need for the competencies to be on a continuum for the learner.¹¹ The competencies for PUs adhere to this guideline. For example, medical students are to be aware that PUs are a hazard of hospitalization and be able to perform a skin surveillance examination with description of any existing ulcers and consider prevention strategies. Building upon that base, residents in internal medicine and family medicine are expected to evaluate patients for PUs and start treatment if needed. Geriatric fellows are expected to be able to assess risk factors, create treatment plans that include surgical and non-surgical options, understand the complications, and work with an interdisciplinary team to prevent and reduce PUs in older patients.   It is gratifying that PU issues have been included as suggested competencies for each learner level. PU care expectations have evolved rapidly in the last few years for physicians, indicating that competencies need to be re-examined to assess whether they reflect current expectations of practicing physician knowledge and task accountability. Therefore, given the current changes and requirements of the CMS, a graduating medical student should be able to demonstrate knowledge, comprehension, and application levels of staging and documenting PUs. A resident should not only be able to identify and mitigate PU risks, identify, stage, and document, and treat existing PUs, but also be able to work with an interdisciplinary team to that end. The fellow should be able to master the above tasks and apply available tools and scales, such as the Braden and PUSH scales.   PU knowledge and skills for physicians are crucial to the care of patients with PUs and can reflect financially on their institution or practice if not performed correctly. Competencies need to be updated in order to keep up with current practice demands and regulations. As practitioners involved in wound care and wound care education, we need to be aware of whether the established competencies are reflective of what is required in practice. If not, we need to revise them so that each learner level can reach the necessary competencies to care for patients in the best possible manner.

 Dr. Suen is an Assistant Professor of Medicine and Dr. Brandeis is an Associate Professor of Medicine at the Boston University School of Medicine, Boston Medical Center, Section of Geriatrics, Boston, MA. Please address correspondence to: Winnie Suen, MD, MSc, LMT; email: winnie.suen@bmc.org.

References

1. Berlowitz D, VanDeusen Lucas C, Parker V, et al. Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. AHRQ. Available at: www.ahrq.gov/research/ltc/pressureulcertoolkit/. Accessed January 11, 2012. 2. Centers for Medicare and Medicaid Services. Hospital Acquired Conditions. Available at: https://www.cms.gov/HospitalAcqCond/06_Hospital Acquired_Conditions.asp#TopOfPage. Accessed January 11, 2012. 3. Centers for Medicare and Medicaid Services. (Hospital-Acquired Conditions (HAC) in Acute Inpatient Prospective Payment System (IPPS) Hospitals. Available at: https://www.cms.gov/HospitalAcqCond/downloads/HACFactsheet.pdf. Accessed January 11, 2012. 4. Centers for Medicare and Medicaid Services. Present on Admission (POA) Indicator Reporting by Acute Inpatient Prospective Payment System (IPPS) Hospitals. Available at: https://www.cms.gov/HospitalAcqCond/downloads/HACFactsheet.pdf. Accessed January 11, 2012. 5. Patel N, Granick MS. American medical students are inadequately trained in wound care. Ann Plast Surg. 2007;59:53–55. 6. Odierna E, Zeleznik J. Pressure ulcer education: a pilot study of the knowledge and clinical confidence of geriatric fellows. Adv Skin Wound Care. 2003;16:26–30. 7. Kimura S, Pascala J. Pressure ulcers in adults: family physicians knowledge, attitudes, practice preferences, and awareness of AHCPR guidelines. J Fam Pract. 1997;44:361–368. 8. Leipzig RM, Granville L, Simpson D, et al. Keeping Granny safe on July 1: A consensus on minimum geriatrics competencies for graduating medical students. Acad Med. 2009;84:604–610. 9. Williams B C, Warshaw G, Fabiny A R, et al. Medicine in the 21st century: recommended essential geriatrics competencies for internal medicine and family medicine residents. J Grad Med Ed. 2010;2(3):373–383. 10. Portal of Geriatric Online Education. Geriatric Fellow Learning Objectives Linked to ACGME Competencies. Available at: https://www.pogoe.org/Fellowship_Objectives. Accessed January 15, 2012. 11. Section for Enhancing Geriatric Understanding and Expertise Among Surgical and Medical Specialists (SEGUE). Retooling for an aging America: building the healthcare workforce. A white paper regarding implementation of recommendation 4.2 of this Institute of Medicine Report of April 14, 2008, that “All licensure, certification and maintenance of certification for healthcare professionals should include demonstration of competence in care of older adults as a criterion.” J Am Geriatr Soc. 2011;59(8):1537–1539. For more information on physician preparedness for pressure ulcer care, please see the April issue of Ostomy Wound Management.