Pressure Ulcers- The Extent of the Problem and Clinical Challenges. Keith Harding

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1 Pressure Ulcers- The Extent of the Problem and Clinical Challenges Keith Harding Head of Department of Dermatology & Wound Healing Director of Innovation & Engagement School of Medicine Clinical Director Wound Healing Cardiff & Vale NHS Trust

2 Definition of Pressure Ulcers an area of localised damage to the skin and underlying tissue caused by pressure, shear, friction and or a combination of these (EPUAP 1998, NICE 2003) aka pressure sores/bed sores/decubitus Pressure ulcers are graded according to the extent of skin and soft tissue destruction Keith Harding - BGS Aut 2009

3 Classification Systems EPUAP (1999) Grades 1-4* NICE (2003) Stages 1-4* NPUAP 2007 New 6 stage system. NPUAP/EPUAP Categories *Both are similar in terms of classifying degree of tissue damage Keith Harding - BGS Aut 2009

4 Category I: Description The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. Indicates at risk individuals Keith Harding - BGS Aut 2009

5 Category II Description Presents as a shiny or dry shallow ulcer without slough or bruising. This category should not be used to describe skin tears, tape burns/epidermal stripping, incontinence associated dermatitis, maceration or excoriation. Keith Harding - BGS Aut 2009

6 Category III Description The depth of a category III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and category III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep category III pressure ulcers. Bone/tendon is not visible or directly palpable. Keith Harding - BGS Aut 2009

7 Category IV Description The depth of a category IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. Keith Harding - BGS Aut 2009

8 Prevalence and Incidence Prevalence Incidence Uses Indicates burden of pressure ulcers Aids assessment of resource requirements and health service planning Can aid differentiation of community versus facilityacquired pressure ulcers May collect data that indicates compliance with prevention and treatment protocols Indicates rate of pressure ulcer Increasingly used as indicator of quality of care Tracking of incidence data may indicate effectiveness of preventive measures May collect data that indicates compliance with prevention and treatment protocols and additional prevention strategies Limitations Not as direct a measure of quality of care or efficacy of prevention protocols as incidence Keith Harding - BGS Aut 2009 May be more time-consuming and therefore more expensive than prevalence studies Int Consensus 2009

9 Prevalence of Pressure Ulcers Consider the following figures: Dept of Health 6.7% (1992) UK: 18.6% of adult hospital beds (O Dea 1995) 4-10% of patients following admission to a UK DGH (Cullum et al 2001) Prevalence in UK Hospitals range from 5 32% (Kaltenthaler et al 2001) 2002 figures suggest 18.1% (Clark et al 2002) Keith Harding - BGS Aut 2009

10 Incidence of pressure ulceration Grade Distribution Annual Incidence Grade I 34.9% 140,000 Grade II 41.2% 170,000 Grade III 12.9% 50,000 Grade IV 11.0% 50,000 Keith Harding - BGS Aut 2009 Bennett Dealey Posnett 2004

11 Costs Of treating one patient with a grade IV ulcer calculated at 25,905 (1988) Increased LOS from days To the NHS 60 million in million in million in million in 1987 Keith Harding - BGS Aut 2009

12 Financial: Costs Estimated that 2.6% (Franks 2007) - 4% (Bennett et al 2004) of the total current NHS Budget is spent on PUs Estimated costs billion per annum (Fleurence 2005) Average cost of healing a Grade III PU = 7,976 Franks (2007) Patient Costs: Psychological Social Occupational Physical Keith Harding - BGS Aut 2009 (Franks et al 2002, Spilsbury 2007 & Franks 2007)

13 Pressure ulcers A recent study of 25 hospitals in 5 European countries found prevalence of pressure ulcers of 20% - in the UK, the rate was 22% This means around 1 in 5 hospital beds is occupied by a patient with a pressure ulcer Typically, 60%-80% of these pressure ulcers are hospital-acquired Between 30%-35% of pressure ulcers are at Keith Harding Stage 3 - BGS or above Aut 2009

14 Where are the costs? Most costs are in staffing for the treatment of patients with wounds For Pressure ulceration, in-patient stay for complications account for a 8% of overall costs and 30% of grades III and IV pressure ulcers Costs of dressings, bandages, antibiotics and pressure relieving equipment is relatively low Keith Harding - BGS Aut 2009

15 Concept of Healing circa 1970 s Keith Harding - BGS Aut 2009

16 HAEMOSTASIS Keith Harding - BGS Aut 2009

17 Keith Harding - BGS Aut 2009 INFLAMMATION

18 PROLIFERATION Keith Harding - BGS Aut 2009

19 REMODELLING Keith Harding - BGS Aut 2009

20 Concept of Wound Healing circa 2000 BMJ 2006

21 Wound Healing in Clinical Practice Improve Fluctuate Static Deteriorate

22 Alternative approach Evolution Resolution Terminal

23 If you correct factors influencing healing Can you increase healing speed?

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25 SCI patients with Pressure Ulcers Rappl IWJ 2008

26 Systemic Factors Influencing Repair Age Anaemia Arthritis Cancer Diabetes Drugs Hypoxia Irradiation Nutrition Renal disease Steroids Zinc deficiency

27 Effect of Age Decreased - vascularity - barrier function - epidermal proliferation - pain perception - immune response - growth factor production Hormones Healing and Ageing Ashcroft 1999

28 Increased tissue damage Diabetes and Wound Healing Diabetes Decreased neutrophil function Increased blood and cellular glucose Increased metabolic rate Thickening basement membrane AGEs Increased risk of infection Decreased red cell deformability Increased free radical release Decreased tissue oxygen Impaired microcirculation Activation inflammatory cells

29 Effect of Drugs NSAID s inflammation tensile strength - Haws 1996 collagen synthesis - Haws 1996 GAGs - Nishimora NSAID s & Colchicine - fibroblast contraction - Ehrlich 1983

30 Effect of Drugs Steroids - inflammation - platelet adhesion - phagocytosis - cytokines - cell division - collagen synthesis - wound contraction

31 Do both of these patients have the same prospects for healing?

32 Pressure Ulcer Prevention Strategies Aetiology & Risk Factors Risk assessment Patient repositioning Use of equipment Skin Care Nutritional Support Getting the right care to the right individual at the right time Improved pressure ulcer prevention

33 PRESSURE trial-hta Report Technical problems with mattresses 207 (on 131 overlays) and 370 (on 223 replacements) Problems were:

34 Poor use of equipment Overlays on bed frames Replacements on top of mattresses Mattresses up side down Patient sat in chair with no cushion Patient on incontinence pads Blankets or pillows under heels

35 Poor use of equipment

36 Clinical issues Risk assessment tools (Waterlow, Braden etc.) are not well validated Literature review supporting new guidelines clearly identifies factors where risk is clear However these are not reflected in many of the risk assessment tools Despite many years of assessing risk and implementing huge quantities of equipment the numbers of patients with PUs do not seem to be reducing

37 Clinical challenges Pressure for zero tolerance / never incident status Is this achievable? Patients are much sicker May conflict with saving their lives We can not clearly define when a PU occurred in relation to when we first see it, new data is demonstrating tissue damage detectable by thermographic imaging which is not clinically visible for 10 days

38 Clinical challenges Changes in patient population Increasingly elderly Increasingly confused Increasingly large (bariatric) Changes in where care is delivered Vowden and Vowden (2009) identified that only 11% of patients with grade 4 PUs were in the acute care setting.

39 International Initiatives Holland-Front page of Newspapers as 3 rd most expensive health care problem Japan-Nominated Dr and Nurse in Charge for each facility USA-Nov 2008 No reimbursement for preventable complications Superman dies of PU

40 T: +44 (0)