My Scope of Practice: Law & Order PUF: Pressure Ulcer Forensics

    The term forensic (of, relating to, or used in legal proceedings) carries an aura of intrigue — visions of diligent detectives on a quest for clinical information to prove an illusive point (or perhaps this editor has fallen prey to the glut of Law & Order incarnations). In reality, medical forensics answers questions, determining whether negative outcomes are the result of substandard care or worse. For Forensic Nurse Specialist (FNS) Kathi Thimsen, RN, ET, MSN, CWOCN, forensics is one aspect of her multifaceted business, Research Analysis Results and Economic Outcomes (RARE) Consulting Group (now located in Bella Vista, Ark.), an endeavor that includes providing home care for frail elderly, new technology research, and reviewing and developing information for legal suits involving alleged elder abuse in nursing homes and the home health environment.

    Kathi has been involved in wound management since 1979 (“I was the ninety-third person to be certified in enterostomal therapy,” she says) and has been in home care since 1983. A champion of the multidisciplinary care paradigm, Kathi always has been driven by procedure and protocol, highly valuing assessment and documentation. Working in various capacities, she honed an interest in evidence-based care paths that addressed the triad of outcomes — clinical, quality, and financial.

    RARE was born of her varied interests. Kathi also has worked with Glenda Motta, RN, MPH, ET, President of GM Associates, Inc., Mitchellville, Md., coordinating clinical trials for clients trying to market new technology or obtain reimbursement coding for their products. Kathi’s work with Glenda includes authoring The Reimbursement Sourcebook, in which reimbursement is defined, billing is explained, and coding information kept current through subscription updates. Documentation is continually emphasized in all publications. “I recruit clinicians for clinical trials on prevalent issues, such as wound irrigation practices, electrical stimulation, and wound healing,” Kathi says. Her brother, a physician and epidemiologist, provides additional guidance on statistical and epidemiologic aspects of study project development. She also works with an ethicist to ensure all legal and moral bases are covered. Much of her work is accomplished from a virtual office. “Wound photography and web casts increase the expeditious nature of what I do,” she says.

    Forensics is a relatively new focus for Kathi. Attorneys have come to rely on her expertise to substantiate or refute evidence of elder abuse in extended care settings. Cases often turn on pressure ulcer occurrence. “I put all the pieces together,” Kathi says. “I conduct chart reviews and interview staff, family, and the patient if he or she is still alive. In some instances, bodies must be exhumed and re-studied. The evolution of DNA and biochemical analysis affords extensive information relative to supporting a breech of standard-of-care claim. In addition to my input in civil cases, I obtain information via reviews and research to support or dispute charges of fraud where negative outcomes are relative to standard of care. If a facility is found negligent, the government can lodge fines plus return of reimbursement for care. This can amount to $5 to $6 million outside of any civil case awards.”

    “I see my role as building programs to assist healthcare systems, corporations, and agencies decrease the potential for these cases,” Kathi says. “In many instances, wound care is not taken very seriously. There is a plethora of unqualified wound care consultants who believe they are experts because they have taken a course but who never address key components of wound care such as nutrition, hydration, and labs. People need to be aware that not everyone who calls himself a specialist is one, as well as the fact that some big institutions do not follow standard of care. The key is to establish standards for education, which, in turn, will provide a standard of care to serve as a basis for contrast in terms of care compliance.”

    “Care must be more consistent and comprehensive,” Kathi continues. “Clinicians must look at the whole patient and consider all contributory factors. Care should be patient-focused, not product driven. Most importantly, people should not assume that everyone on staff ‘knows his stuff’ or that physicians are informed of the presence of a pressure ulcer. Michael Kogut, Esquire, defense attorney of the firm, Murtha, Cullina (Hartford, Conn. and Boston, Mass.), will attest to the fact that many cases involving pressure ulcers and tube feedings are brought against facility staff for non-compliance to standards. Many wrongful deaths, false claims, and malpractice claims can be avoided by instituting and complying with standards of care and clinical practice guidelines. We are developing publications on regulatory and HIPAA policy development to underscore their relevance to provision of care.”

    Kathi has developed a standard compliance checklist that details the role of the clinician along with the role the patient’s physical status played in his/her demise. This report includes photographs that may eliminate the necessity for litigation and/or the sensationalism of exhumation. This practice correlates with reports out of funeral and undertaker literature that 25% of bodies of persons older than 65 years at the time of death and embalming had pressure ulcers that could have developed on the morgue table or while awaiting transport. Such information is vital when litigation is pending. “The skin can fail just like any other organ system’,” Kathi says. “Clinicians are not 100% to blame when skin break down occurs. Proper documentation and comprehensive evaluation can prove that.”

    Kathi also has found that debridement is performed too frequently, which carries the potential for suspicion of fraud. In response, she has offered a debridement course in cooperation with the local Medical Society, using recycled cadavers with pressure ulcers. “Heel lesions were most prolific,” she notes.

    “Creating the evidence-based research and standard of care database was my biggest challenge,” she says. “Basically, though, I love what I do and I do what I love. It’s an interesting, growing business that allows me to collaborate with many wonderful people willing to share their different approaches. As a forensic and legal consultant and clinical trial coordinator, there is continuous evolution in my scope of practice.”