Identification and Prevention Pressure Ulcers in the ED

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1 Identification and Prevention Pressure Ulcers in the ED Evidence Based Practice Project UC Davis Medical Center s Nurse Residency Program Janine Taylor R.N., B.S.N. Peg Freitag R.N., B.S.N.

2 Hospital Acquired Pressure Ulcers (HAPUs) Patient safety, quality of care, and the patient s (and family s) perception of both have become a major driver for the establishment of best practices. CMS no longer reimburses for never events, events they have designated as entirely preventable (Centers for Medicare and Medicaid Services, 2008).

3 Prevalence Approximately 2.5 million patients are treated for pressure ulcers in acute care facilities in the United States annually, and approximately 60,000 patients die each year of complications related to pressure ulcers (PU). (Tschannen,et al., 2012).

4 What does this have to do with the Emergency Department (ED)? The ED is the single greatest point of entry into the hospital (Denby & Rowlands, 2010). Wait times in EDs are increasing as patient demographics increasingly shift from lifethreatening conditions to acute and critical illnesses Pressure ulcers can develop in only a few hours The equipment and supplies used in the ED are often not designed with reduction of HAPUs in mind (Naccarato & Kelechi, 2011).

5 So What Can We Do? First step is understanding the risk factors and utilizing the nursing process to assess each patient as to what their individual risk is.

6 Risk Factors Alderden, et al. (2011), in their retrospective analysis of HAPUs compiled the following risk factors (see Table 1): Braden Score <16 Use of Vasopressers Incontinent of urine or feces Limited self-mobility Age >65 Diabetes Prior recent hospital stay Emergent admission to the ICU BMI <25 or >35

7 Risk Factors, cont. Other risk factors include (Tschannen, et al., (2012) Recent Cardiac Arrest SHOCK/Sepsis Hx of pressure ulcers Current redness in area Going to the OR? Multiple procedures > 6 hrs Quad/Para/Hemiplegic Stroke/Paralysis

8 Best Practice Intervention Most HAPUs are located in just three areas: heels, sacrum, and coccyx (Denby & Rowlands, 2010). The Institute for Clinical Systems Improvement has identified several key interventions to promote PU prevention, including minimizing/eliminating friction and shear, minimizing pressure, providing support surfaces, managing moisture, and ensuring the patient maintains adequate nutrition/hydration (2012).

9 Additional Interventions UC Davis Medical Center O.R. unit already uses Mepilex borders prophylactically on pts to help prevent the development of HAPUs. Case studies indicate this is a cost-effective intervention with significant real-world results.

10 Case Studies In Connecticut, an ICU that began to use Mepilex (the brand of silicon foam dressing UC Davis utilizes) in their ICU saw sacral HAPU incidence decrease from 12.5% to 7% in one year (Walsh et al., 2012). A Chicago ICU saw an even more significant reduction going from 13.6% to 1.8% during a 6-month prospective study utilizing Mepilex (Chaiken, 2012).

11 What s the Goal? The purpose of this project is to prevent further damage to existing pressure ulcers and to prevent the development of pressure ulcers in those patients found to be at risk. The recommendations for the use of preventative measures are part of an evidence-based care plan.

12 What should We Do? While routine use of a silicone border foam dressing should not be the only intervention employed to reduce HAPU in the ED, it should become standard practice for any patient who meets the criteria for being at risk for potentially developing a pressure ulcer to have a Mepilex foam dressing applied to the sacrum, pelvic area, occiput or heels This is an economically sound measure to prevent the development of a HAPU, and to prevent further damage to an existing PU.

13 Let s Make it Easy Best Practice means nothing if not used quick card reference guide to identify the at risk patient population as part of the assessment Apply the Mepilex Borders when appropriate. The quick card should serve to raise awareness of the importance of the application of the dressing and the patients with which the dressing is appropriate.

14 Quick Card FRONT BACK Apply Mepilex to all patients with: Recent Cardiac Arrest Vasopressor Rx > 48 hrs SHOCK and/or Sepsis Hx of pressure ulcers Current redness in area Emergent OR or ICU dispositions Quad/Para/Hemiplegic Stroke/Paralysis And to pts with 3 or more of the below criteria : Ages or above Fecal or urinary incontinence Prolonged bed rest = or > 4 hrs AND unable to shift weight, independently Diabetes BMI above 35 or less than 25 Liver failure Renal failure Braden Score below 18 Weeping edema or anasarca Malnutrition (albumin at or below 2.5) Remember to: Date, time, and initial with a marker on Mepilex Border prior to application And Note application of Mepilex Border in EMR

15 References: Alderden, J., Whitney, J. D., Taylor, S. M., & Zaratkiewicz, S. (2011). Risk profile characteristics associated with outcomes of Hospital-Acquired Pressure Ulcers: A retrospective review. Critical Care Nurse, 31(4), doi: /ccn Centers for Medicare and Medicaid Services. Medicare and Medicaid move aggressively to encourage greater patient safety in hospitals and reduce never events [press release]. July 31, heckkey=&srchtype=1&numdays=0&srchopt=0&srchdata=&keywordtype=all&chknewstype=1%2c+2%2 C+3%2C+4%2C+5&intPage=&showAll=1&pYear=1&year=2008&desc=false&cboOrder=date. Chaiken, N. (2012). Reduction of sacral pressure ulcers in the Intensive Care Unit using a silicone border foam dressing. Journal of Wound, Ostomy and Continence Nursing, 39(2), doi: /won.0b013e c Denby, A., & Rowlands, A. (2010). Stop them at the door: should a pressure ulcer prevention protocol be implemented in the emergency department?. Journal of Wound, Ostomy & Continence Nursing, 37(1), doi: /won.0b013e3181c68b4b Institute for Clinical Systems Improvement. (2012). Pressure ulcer prevention and treatment: Health care protocol. Institute for Clinical Systems Improvement (ICSI). Naccarato, M., & Kelechi, T. (2011). Pressure ulcer prevention in the Emergency Department. Advanced Emergency Nursing Journal, 33(2), doi: /tme.0b013e Tschannen, D., Bates, O., Talsma, A., & Ying, G. (2012). Patient-specific and surgical characteristics in the development of pressure ulcers. American Journal Of Critical Care, 21(2), doi: /ajcc Walsh, N., Blanck, A., Smith, L., Cross, M., Andersson, L., & Polito, C. (2012). Use of a sacral silicone border foam dressing as one component of a pressure ulcer prevention program in an intensive care unit setting. Journal Of Wound, Ostomy & Continence Nursing, 39(2), doi: /won.0b013e

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