Critical Care and Cardiovascular Conference

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1 1 Critical Care and Cardiovascular Conference Hoag Memorial Hospital Monday, September 24 th, Sandy Dien, RN Clinical Ladder II CCU/CVICU and Mary Jane Nicolas-Morimoto, RN, MSN, ACNS-BC, CNS, CCRN-CSC Clinical Ladder IV CCU/CVICU 3 Objectives 1. Identify four risk factors for skin breakdown for the critically ill patient. 2. Define unavoidable and avoidable pressure ulcer. 3. Differentiate a present on admission (POA) and hospital acquired pressure ulcer (HAPU). 4. Discuss three areas where nursing can promote and minimize the risk for skin breakdown 5. Describe at least ten of the twelve key components in essential documentation for the nurse.

2 Disclosure We do not have any affiliation, financial or otherwise, with any commercial organization that may have a direct or indirect content to this presentation. Statistics-NDNQI FY2011Q4 FY2012Q1 CCU 75 TH percentile 75 th percentile CVICU 0 10 TH percentile ICU 50 TH percentile 50 th percentile CCU-HHI 0 50 th percentile quarter report (Gallagher, 2003) Above benchmark At benchmark Below benchmark (Alderden, 2011) Vasopressors and pressure ulcers The Skin is an organ too! What effects does hypotension pose to the skin? Patients who receive vasopressor therapy are 5 TIMES less likely than other patients to have their pressure ulcers heal. Examples of devices /equipment that can cause pressure ulcers: endotracheal tubes, nasal cannulas, nasogastric tubes, embolic stockings, SCDs, orthotic devices (braces/casts), or securement devices such as stat locks for radiology tubes and foley catheters.

3 Co-Morbidities r/t pressure ulcers RISK Assessment Tools: Braden scale Score Risk Risk or mild risk Moderate risk High risk 9 and less Very high risk OTHER RISK FACTORS for HAPU: Longer hospital stay, vasopressor infusion, spinal cord injury, surgical time, older age, low body mass index, diabetes, renal insufficiency, cardiovascular disease, & weight lost. (Cox, 2011, Alderden, 2011) Bed Rest & Cardiovascular Implications (Vollman, 2012) Nursing Care Planning Allow for physiological rest before activity/turning Monitor for tolerance after 5-10 minutes ( BP, oxygen sats, HR) For high risk patients use the right lateral position first. Left lateral position: there is potential for greater cardiovascular instability. Reduce the speed of the turn Consider bed rotation therapy if pt. does not tolerate manual turning Bed Rest & Skin Implications The incidence of PU s 0.4%-38% in acute care >70 mmhg of pressure sustained for >2 hours, irreversible skin damage is likely Even 5 minutes of pressure relieved every 2 hrs decreases PU risk The use of Low Air Loss Mattresses have reduced skin breakdown (make sure it is property inflated) Prolonged chair position/ or up in a chair on a nontherapeutic surface increases risk of PU (assess your pt. s risk and needs, consider reposition in chair at least q 1 hour and waffle chair cushion PRN) (Winkelman, 2009)

4 10 Fun Fact #1 11 Armstrong,et al, 2008 & Hrehocik, 2009) HAPU Hospital Acquired Pressure Ulcer (HAPU) Pressure ulcer develops during hospitalization Centers of Medicare Services (CMS) won t reimburse for stage III or stage IV that develops inpatient (IP) (Ayello, et al, 2009) 12 POA Present on Admission (POA) Pressure Ulcer (PU) at the time the order for admission occurs Outpatient (OP) locations: ECU, observation, OP surgery are considered POA

5 13 (Ayello, et al, 2009 HAPU vs POA Reimbursement of services Providers must document PU for the hospital s financial health Performance improvement Patient outcomes 14 Nursing Documentation and Liability Legal Nightmare A plaintiff lawyer can argue that if an action was NOT recorded, then it was NOT performed=negligence by the facility and the health care worker (ECRI, 2011)

6 Legal Nightmare Our actions don t speak louder than words Effects you personally & professionally Monetary penalty will increase due to absent legislation Highest long-term care: $114 million in 2010 (Geary, 2010) Legal Nightmare Time will pass and what will you be able to recall from looking at the chart? Your documentation will be compared to state regulations, policy & procedure, and hospital guidelines. (Plawecki, et al, 2010 and Ayello, et al, 2009) Failure to follow may be basis for MALPRACTICE Overlooking one body system to maintain another body system is NOT defensible. (Lockhart, 2002, page 64) accessed May, 1, 2012

7 A 2000 study of 173 lawsuits of inpatients identified common factors in favor to healthcare providers 1. Documentation in the MR that the standard of care for pressure ulcer was followed 2. Verification in the record that underlying disease or complications that made the development of the pressure ulcer inevitable 3. Adherence to comprehensive programs to prevent and treat pressure ulcers (ECRI, 2011) Patient & Self Advocacy Minimize the patient s length of stay Minimize the cost of care Reduce opportunity for liability to self and to facility Components of Proper Documentation 1. Stage of the pressure ulcer 2. Dates & times when assessment & reassessments performed 3. Change in the plan of care (ECRI, 2011)

8 Components of Proper Documentation 4. Specific preventative measures 5. Methods to manage pain 6. Treatments 7. Any worsening of the patient s condition that could effect the healing process (ECRI, 2011) Components of Proper Documentation 8. Skin Assessment 9. Risk Assessment 10. Describe the wound thoroughly & obtain a photograph 11. Education the patient/family member(s) 12. Notify the physician (Ayello, et al, 2009, Hrehocik, 2009 & Plawecki, et al, 2010) Prevention & Treatment Bundle by New Jersey Hospital Association N O Nutrition and fluid status Observation of skin U L C E R S Up and walking OR turn and position Lift (don t drag) skin Clean skin and continence care Elevate Heels Risk Assessment Support Surfaces for pressure redistribution (Ayello & Lyder, 2007)

9 Prevention & Treatment Bundle created by Ascension Health S K I N Surface selection Keep turning Incontinence management Nutrition (Ayello & Lyder, 2007) 26 (Black, et al, 2011) Unavoidable & Avoidable Why are these terms relevant to nursing? Definition Unavoidable situations: Hemodynamic instability may preclude turning or repositioning Refusal after education of that moment Interventions are identified and implemented according to patient s needs and goals 27 Empowering Nursing

10 Nutrition & Nursing Team approach for nutritional risk assessment & intervention by including the Registered Dietician (RD) Check hospital s nutritional screening protocols At Hoag,screening protocols are evidenced based & reviewed annually (Hoag Evidence-Based Medical Nutrition Therapy Guidelines) All in-patients are screened by day #2 of admission unless they have triggers: Albumin: 2.7 mg/dl Pre-albumin: <12 GFR<30 TPN or tube feed Nutritional consult ordered Certain diagnosis Nutrition & Nursing (Hoag Evidence-Based Medical Nutrition Therapy Guidelines) Encourage increased intake of calories, protein, micronutrients, (in adherence to medical condition; i.e. renal disease). Maintain adequate fluid to maintain good skin turgor and blood flow to pressure ulcers Offer oral supplements as needed (the RD can provide supplements according to the current diet) Nutritional Supplements Indicated for Pressure Ulcers: 1. Ensure, Ensure Plus, Ensure Pudding (ProSource Liquid Protein) 2. Modified Beverage Indicated for Pressure Ulcers 3. Homemade Protein Fortified Milkshakes 4. Juven: Therapeutic Nutritional Mix with a Patented blend protein. (Hoag Evidence-Based Medical Nutrition Therapy Guidelines, K/DOQI, 2002) Fun fact #2 Decreased Serum Albumin can be from inflammatory cytokine production or other co-morbidities not reflective of nutritional status. What does this mean? On the other spectrum, Albumin Levels can be falsely elevated with dehydration. There is a correlation between GFR<60ml/min and Albumin Level

11 31 Progressive Mobility 32 (Timmerman, 2007) Progressive Mobility Planned movements with various positioning techniques. Impediments to patient mobilization: Competing priorities Nurses knowledge Motivation Thus, patients suffer an iatrogenic event 33 (Timmerman, 2007) Progressive Mobility Program Changes in position (includes elevating HOB) Elevating HOB to 45 degrees or reverse Trendelenburg Elevate HOB and descend legs to partial chair position Full chair position Dangle at bedside Stand patient with support and patient bears weight Transfer to chair with 1-2 steps only. For up to 2 hours only Walk with assistance Walk independently

12 (Adapted from European Pressure Advisory Panel and National Pressure Ulcer Advisory Panel) Daily checklist Part 1 PATIENTS AT RISK FOR PRESSURE ULCER DEVELOPMENT INCLUDE: All patients with alterations in intact skin, such as dry skin, excessive moisture, or redness Patients with signs of altered nutrition (including anemia, low serum albumin, decreased intake, and/or body weight) Patients with perfusion problems (diabetes and/or alterations in oxygenation and blood pressure) Older age Increased friction and shear and/or altered mobility Decreased sensory perception (Adapted from European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel) Daily Checklist Part 2 Regularly assess each patients skin for: Redness or change in color Dryness or excessive moisture Blanching response Localized heat Edema Hardness (induration) Areas of discomfort or pain that may be related to pressure Medical devices pressing on skin Incontinence-Related Dermatitis (not classified as pressure ulcer) Perineal dermatitis: inflammatory condition of the skin in the perineal area, upper part of the thigh, & buttock associated with incontinence. Aka: IAD, MASD S & Sx: redness to denuded areas of skin, itching, or pain. Nursing Implications: Preventive cleansing & application of a protectant reduce the incidence of pressure ulcers by as much as 59%. Routine perineal skin care: 1.Gentle cleaning (perineal skin cleaner vs. soap & water is drying) 2.Use of moisturizers for dry skin (i.e. aloe vesta) 3.Apply a moisture barrier after each incontinent event (i.e. calmoseptine=intact skin, Inzo= for broken skin) (Driver, 2007)

13 37 Closing Activity: Photos & New Knowledge Name That Wound! Location: tongue Device related pressure ulcer from ETT. Mucosal pressure ulcers are not staged Document mucosal pressure ulcer only 38 Location: bilateral buttocks 39 Excoriation from incontinence Aka perianal dermatitis, IAD, MASD Hx: frequent incontinence episodes

14 Location: Buttock/ Anus Gluteal Fissure Can be PU or partial thickness wound 40 Location: Bilateral Buttocks Herpes infection Not PU d/t locations on and around bony prominences History helpful; consult CWON for expert consultation Location: Left Nare Device Related Mucosal Pressure Ulcer from nasal cannula Hx: chronic O2 use Frequent assessment, keep mucous membranes moist with ointment to create barrier

15 Location: Bilateral Buttocks Stage II is correct. Shearing occurred on the bilateral ischial tuberosities No slough is noted that indicates a stage II wound 43 Location: Left Heel 44 Unstageable heel The base of ulcer is covered with yellow and brown slough. Slough is obscuring the true depth of the ulcer, therefore making this an unstageable wound References Ahn, C. and Salcido, R. (2008). Advances in wound photography and assessment methods. Advances in Skin and Wound Care, 21(2), Alderden, J., Witney, J., Taylor, S., Zaratkiewicz, S. Risk Profile Characteristics Associated with Outcomes of Hospital- Acquired Pressure Ulcers: A Retrospective Review. Critical Care Nurse. 2011; 31(4): z Armstrong, D. G., Ayello, E.A., Capitulo, K.L., Fowler, E., Krasner, D.L., Levine, J.M., Sibbald, R.G., and Smith, A.P.S. (2008). New opportunities to improve pressure ulcer prevention and treatment: implications of the CMS inpatient hospital care present on admission indicators/hospital acquired conditions policy. A consensus paper from the International Expert Wound Care Advisory Panel. Advances in Skin & Wound Care, 21(10) Ayello, E.A., Capitulo, K.L, Fife, C.E., Fowler, E., Krasner, D.L., Mulder, G., Sibbald, R.G, and Yankowsky, K.W. (2009). Legal issues in the care of pressure ulcer patients: key concepts for health care providers: a consensus paper from the international expert wound care advisory panel. Journal of Palliative Care, 12(11), Cox, J. Predictors of pressure ulcers in adult critical care patients. American Journal of Critical Care. 2011; 20(5): ECRI Executive Summary. (2011, May). Pressure Ulcers. Emergency Care Research Institute, Plymouth Meeting; PA. Estilo, M., Angeles, A., Perez, T., Hernandez, M,, Valdez, M. Pressure ulcers in the intensive care unit: new perspectives on an old problem. Critical Care Nurse (3); European Pressure Ulcer Advisory Panel ( EPUAP) and National Pressure Ulcer Advisory Panel (NPAUP). (2010). Pressure Ulcer Prevention Quick Reference Guide. [cited 2012 May 15]. Available from Internet:

16 References GallagherR, Rowell P. Claiming the future of nursing through nursing: sensitive quality indicators. Nurs Admin Q. 2003; 27: Geary, J., $114 million awarded in abuse case [online]. Ledger Jul 22 [cited 2012 May 15]. Available from Internet: Hrehocik, M. (2009). Pressure ulcer litigation: Its impact on long-term care. Long-Term Living 58(11), Jankowski, I. Tips for protecting critically ill patients from pressure ulcers. Critical Care Nurse (2); Institute for Healthcare Improvement (IHI). (2011). How-to Guide: Prevent Pressure Ulcers. [Cited 2012, may 17]. Available from Internet: K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification Retrieved from Lachenbruch, C. Skin cooling surfaces: estimating the importance of limiting skin temperature. Ostomy Wound Manage. 2005;51(2): Lockhart, D.G. (2002). The legal implications of pressure ulcers in acute care. Critical Care Nurse Quarterly, 25(1), Rennert, R., Golinko, M., Kaplan, D., Flattaue, A. And Brem, H. (2009). Standardization of wound photography using the wound electronic medical record. Advances in Skin and Wound Care, 22(1), Vollman, K. Hemodynamic Instability: Is it really a barrier to turning critically ill patients? Critical Care Nurse (1): Winkelman, C. Bed rest in health and critical illness. AACN Advanced Critical Care (3): Questions? We will also be available during the break & after the conference for further questions p/w: Skin Much thanks to Jeanie Dao, RN CCU/CVICU Skin Care Representative Melissa Vitasa, RN CCU/CVICU Skin Care Representative Bob Lindner, RN, CWON, Enterostomal Therapist Susan MacMackin, RN, CWON, Enterosomal Therapist Debbie Lepman, MPH, CEN, RN, Department Director, CCU/CVICU/Sub-ICU Your support is greatly appreciated

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