The Who What and Why s of Pressure Ulcers atom Alliance Healthcare Quality Summit

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1 The Who, What and Why s of Pressure Ulcers Harriet Jones Medical Director Wound Management Services Clinic April 14, 2015 The Who What and Why s of Pressure Ulcers atom Alliance Healthcare Quality Summit April 14, 2015 Harriet Jones, MD, FAPWCA Associate Professor of Medicine Medical Director Wound Management Services University of MS Medical Center 1

2 Objectives Appreciate the impact of Pressure Ulcers (PrUs) Healthcare Dollars/Mortality/Morbidity Become more familiar with PrUs Characteristics of/mechanisms of development Better understand Staging System of PrU Help equip organizations to develop and/or improve institutional PrU programs Association Advancement of Wound Care (AAWC) American Professional Wound Care Association (APWCA) Pr-U Definition Localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination w/shear and/or friction. 2

3 Types of Wounds not PrUs Skin tears Arterial ulcers Venous ulcers Neuropathic ulcers Diabe=c Foot ulcers How Many. Overall prevalence 10-38% in acute care facilities New PrU cases million people per year 7% new PrU in acute care patients 3

4 4/8/15 Burden Annual cost $11 billion Cost per PrU $500 to $70k Stage IV PrU cost including related complications $130k for a single hospitalization Financial burden * now shifted to the patient and the hospital; *stage 3 & 4 ulcers now never event Classification System National Pressure Ulcer Advisory Panel (NPUAP) System used by CMS for LTC facilities Based on the type of tissue affected or seen in the wound bed rather than the depth of the wound in centimeters 4

5 NPUAP Staging System: based on extent of?ssue loss Stage 1 intact skin with nonblanchable redness of a localized area usually over a bony prominence Stage 2 involve partial thickness skin loss; presenting as a shallow open ulcer w/a red pink wound bed w/out slough Stage 3 - Full thickness tissue loss; subcutaneous fat may be visible but bone and tendon/muscle are not exposed Stage 4 can extend into muscle and/or supporting structures (fascia/tendon/joint) Unstageable -one that cannot be accurately assessed b/c the FT tissue loss in which the base of the ulcer is covered by slough and/or eschar in wound bed Suspected DTI defined by purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear Pr U Prevention Consists of both risk assessment applica=on of preven=ve measures and interven=ons 5

6 Using the AAWC Pressure Ulcer (PU) Guidelines to Manage Pressure Ulcers 3 Steps to manage a PU pa=ent: Assess and document pa=ent, skin & PU Prevent PU with care plan focused on reducing risk Treat pa=ent and PU to heal and prevent recurrence See Website for guideline details, references, implementa=on tools, pa=ent brochure and evidence Instrument to Evaluate PrU Risk Braden Scale Based on 6 subscales measuring 2 etiologic factors in PrU development Intensity and duration of pressure Sensory perception; activity; mobility Tissue tolerance for pressure Nutrition; moisture; friction/shear Subscales scored 1-4; Friction/sheer 1-3 Possible score 6-23 Lower scores indicate greater risk for PrU development 6

7 Known Associations for PrU Development Obesity vs Normal weight BMI > 30kg/m2 Physiological changes in skin affected by dysfunction of Barrier function Sebaceous glands; sebum production Sweat glands Lymphatics Collagen structure and function Subcutaneous fat Weight of pannus Increased skin:skin contact Torsion; gravity; larger in motion mass AAWC For guideline details, references, implementa=on tools, pa=ent brochure and evidence please see: - Assess and document patient s skin - Prevent pressure ulcers (PU) as feasible focusing on those at risk of developing a PU - Treat patient and PU to heal as feasible 7

8 Recommendations Document pressure ulcer progress weekly using reliable, valid measures: - length x width to estimate area - partial- or full-thickness depth assessment Address all patient PU risk factors identified limited mobility, activity, cognition, sensation Manage skin moisture Here is what we did at UMMC HAC Reduc=on Oversight CommiRee Looked at data from the CMS HAC Reduc=on Program Launched variety of performance improvement teams for HAC Teams led by nurse manager and physician champion PU, Falls with Injury, Iatrogenic, PTX Teams challenged with reducing occurrences by 50% from prior fiscal year Teams review best prac=ce, current UMMC prac=ce, and barriers to change Report generated and presented to the HAC Oversight CommiRee - > to Quality Board Organiza=onal wide HAC informa=on tracked by DIS Report can be filtered by numerous possible variables including Unit, date, HAC, Payor, Limita=on dependent on input New CMO has requested more real =me clinical data input Source: UMMC HAC oversight commiree 8

9 4/8/15 Source: UMMC HAC oversight commiree Source: UMMC HAC oversight commiree 9

10 Source: UMMC HAC oversight commiree Source: UMMC HAC oversight commiree 10

11 Source: UMMC HAC oversight commiree Source: UMMC HAC oversight commiree 11

12 Thank You For more information contact your state s QIN-QIO representative: 23 This material was presented on behalf of atom Alliance, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO), coordinated by Qsource for Tennessee, Kentucky, Indiana, Mississippi and Alabama under a contract with the Centers for Medicare & Medicaid Services (CMS), a federal agency of the U.S. Department of Health and Human Services. Content does not necessarily reflect CMS policy. 15.SS.MS D 12

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