A case of acute skin failure misdiagnosed as a pressure ulcer, leading to a legal dispute

Abstract

It is difficult to differentiate acute skin failure (ASF) from pressure ulcer (PU). ASF is defined as unavoidable injury resulting from hypoperfusion caused by severe dysfunction of another organ system. We describe a case of ASF mistaken as PU that resulted in a legal dispute. A 74-year-old male patient was admitted to our intensive care unit with sepsis due to bacterial pneumonia. Despite the use of air cushions and regular position changes, skin ulcerations occurred over his occiput, back, buttock, elbow, and ankle. After improvement in his general condition, he was transferred to the department of plastic and reconstructive surgery. Debridement was performed immediately, followed by conservative treatment (including a vacuum-assisted closure device) for 6 weeks. The buttock and occiput wounds were treated surgically. Despite complete healing, his caregivers sued the hospital for failing to prevent PU formation. ASF is a pressure-related injury resulting from hemodynamic instability due to organ system failure. Unlike PU, ASF may occur despite the implementation of all appropriate preventive measures. Furthermore, misdiagnosis of ASF as PU can lead to litigation. Therefore, it is critical for the proper diagnosis to be made quickly, and for physicians to explain that ASF occurs despite proper preventative treatment.

Acute Skin Failure and Pressure Injury in the Patient With Covid-19

“…Especially in the pandemic context in which we find ourselves, evidence-based skin injury prevention strategies are necessary, associated with the performance of a multidisciplinary team and prevention plans under special conditions, such as the prone positioning, prevention of the Medical Device Related Pressure Injury, among others 3,16,17 . It is crucial that the nurse and the health care team have knowledge about the predictive factors of both types of injury, as their differentiation has legal, economic and quality impacts on the institution 18 .…”

“…ASF is still little discussed in the literature, making it difficult to differentiate it from preventable PI in daily practice. It is extremely important to perform the differential diagnosis, since preventable PI is considered an adverse event related to health care, liable to legal and economic impact, and shows the fragility of institutional quality, unlike the ASF that do not compose the indicators of quality and should be excluded from the numerator of the PI indicator 8,11,18 . This article aims to report the case of a critical patient with COVID-19 and to show the main findings related to the lesion considered ASF, as well as to make its differential diagnosis with avoidable pressure injury.…”

Acute Skin Failure E Lesão Por Pressão Em Paciente Com Covid-19

“…Especialmente no contexto pandêmico em que nos encontramos, estratégias de prevenção de lesões de pele baseadas em evidências são necessárias, associadas à atuação em equipe multiprofissional e a planos de prevenção em condições especiais, como é o caso do posicionamento em prona, prevenção de LP relacionada a dispositivos médicos, dentre outras 3,16,17 . É crucial que o enfermeiro e a equipe de assistência à saúde tenham conhecimentos sobre os fatores preditores de ambos os tipos de lesão, pois a sua diferenciação tem impactos jurídico, econômico e sobre a qualidade assistencial da instituição 18 .…”

«Acute skin failure», unreasonably lost term

“…Принципиальное различие между пролежнями и острой кожной недостаточностью состоит в том, что существует много способов предотвратить первое, тогда как острая кожная недостаточность проявляется, несмотря на надлежащие профилактические меры [17]. Необходимо строго дифференцировать пролежни как инфекцию, развившуюся в стационаре (что подразумевает регистрацию данного состояния как внутрибольничную инфекцию) [18], от проявлений острой кожной недостаточности.…”