Pressure Ulcers & Pressure Ulcer Prevention Second Annual Wound Care Conference April 14 & 15, 2016 Deena Patek RN BSN WCC OMS Clinic Coordinator Wound & Ostomy Services Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. Objectives Definitions & Stages of Pressure Ulcer Pressure Ulcer Prevention & Interventions PUP Studies Strategies to Improve Incidence of Hospital Acquired Pressure Ulcers 2 We all remember 9/11/2001. How many lives were affected? 2753 people died that day How many lives are affected by pressure ulcers each year???????? 3 1
How many patients die each year form complications of a pressure ulcer? About 60,000 patients die as a direct result of a pressure ulcer each year. (From AHRQ) 4 Did you know? The incidence of pressure ulcers is becoming an increased problem as population ages Impact on the patient: *Morbidity, mortality, quality of life, disfigurement, pain, infection, cost to the patient. Financial Impact: AHRQ estimates pressure ulcers cost the healthcare system 9.1 to 11.6 billion dollars annually Stage III and IV pressure ulcers are CMS reportable and impact hospital organization s financial standing A quality measure - HAC pressure ulcers are being tracked, trended and reported and is a reflection of nursing care in organization (NDNQI) AHRQ- There are more than 17,000 pressure related lawsuits filed annually (second only to wrongful death lawsuits) Normal Skin Skin is the largest organ of the body Receives 1/3 of our blood volume Every day we are shedding new skin cells Many functions: Our first line of defense from the environment around us Prevent fluid and electrolyte loss Sensory organ 6 2
What is a pressure ulcer? A pressure ulcer is skin breakdown to the skin caused from pressure or shear. What is NOT a pressure ulcer? Skin breakdown caused by incontinence (Incontinent associated dermatitis) Wounds caused by trauma- skin tears, abrasions or laceration, hematomas Atypical wounds- cancer, shingles other lesions, rashes, dermatological conditions etc. Chronic wounds such as diabetic, arterial, venous wounds Surgical wounds IAD= Incontinent Associated Dermatitis Definition: Inflammation of the skin from exposure to stool or urine. How to describe: Redness, eroded, denuded, epidermal loss (partial thickness or full thickness) Treat: What is the cause. Bowel and bladder training/ q2 voiding # of products that are barrier ointments (may have zinc base), fecal or urinary containment devices 3
Pics of IAD +Candida Pressure ulcers are caused from shear or pressure NPUAP has defined 6 categories: Stage I Stage II Stage III Stage IV Suspected Deep Tissue Injury Unstageable Not all blisters are pressure ulcers. Look at what caused blister. Serous filled blister (stage II) Blood filled blister (sdti) Medical Device Related Pressure Ulcers Tubing Braces Ace wraps Oxygen tubing Casts Cervical collars Trach tubing 12 4
Bony Prominences Most common location is the sacrum Second common location is the heel. 13 Stage I Pressure Ulcer Category/Stage I: Non-blanchable erythema Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. 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. May indicate at risk persons. 14 Pics of Stage I Knee 5
Stage II Category/Stage II: Partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation. *Bruising indicates deep tissue injury. Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. Stage II 17 Stage II (Serous Filled Blister) 6
Stage III Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. Stage III Category/Stage III: Full thickness skin loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. 20 Stage III Sacrum Heel 7
Healing Stage III (Leaves a Visible Scar) Sacrum & Buttocks Stage IV Pressure Ulcer Category/Stage IV: Full thickness tissue loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage 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/Stage 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. Stage IV Pressure Ulcer 8
Suspected Deep Tissue Injury Suspected Deep Tissue Injury depth unknown 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. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.!!!!!!!!!!!!!!!!!!!!! Tip of the Iceberg When you see a suspected deep tissue injury..the true depth of the injury is uncertain 26 Suspected Deep Tissue Injury 9
Pics of Suspected DTI Unstageable Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. Unstageable Pressure Ulcer Unstageable/Unclassified: Full thickness skin or tissue loss depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body s natural (biological) cover and should not be removed. 10
Pics of Unstageable Pressure Ulcer Majority of wound with eschar or slough, true depth undeterminable Heel - slough Ischium Black Eschar Heel Eschar Documentation Tips Be specific Body Location Type of Ulcer Stage of ulcer Measure Length x Width x Depth(Length is head to toe)(width is 45 degree turn from head to toe) Tunneling Undermining Drainage- color, amount, odor, consistencey Peri wound Edges of wound Undermining Tissue destruction underlying the skin along wound margins Tunneling Course or pathway that extends in any direction from the wound Ulcer Is 2 x 2 x 4 cm deep 2 Ulcer is 1.5 x 3 cm x 2cm Undermining at 2 to 4 o clock 2cm & Tunnels At 5 o clock 2 more cm 33 11
How would you chart this? Right heel red non blanchable with intact skin (stage I) measuring 3 x 4 cm with dry skin and boggy. Suspected deep tissue injury of right and left sacrum. Purple maroon skin discoloration intact skin to right sacrum measuring 14 x 4 cm & left sacrum measuring 4x 4 cm. Right Heel Right & Left Sacrum 34 Pressure Ulcer Interventions & Prevention Starts With a Good Assessment Start with Skin Assessment & Skin Risk Assessment! How often are you required to document on your patient? How often are you required to document a skin risk assessment on your patient? How often are you required to measure the wound? Have a Clear Plan of Care Does the information about the patient get communicated from shift to shift, unit to unit, transitions in care? Are the dressings orders clear? Is the documentation consistent? 36 12
Braden Scale 6 Subcategories: Sensory Perception Moisture Activity Mobility Nutrition Friction Shear *The risk score should help guide your interventions. 37 Purpose of the Risk Assessment The risk assessment score (Braden Scale Score) helps to determine at what risk the patient is to developing skin breakdown. The lower the number, the higher the risk. If the Braden Scale Score of <18, patient should be on a turning schedule of every 2 hours. If the Braden Scale Score is <15, consider specialty mattress. Braden Scale Score Interventions #1 Intervention is turning your patient every two hours Use of pillows and devices to protect bony prominences Pressure relief when patient is in the chair (every 15 minutes). Preventative dressings specialized for body locations examplesacral or heel dressings Moisturize the skin. Choose moisturizer that retains moisture. Nutrition consults Hydration Managing Incontinence Use guidelines(based off risk score) for specialty beds 39 13
Tracking Incidence & Prevalence Incident Reporting (ongoing count) PUP Studies- Pressure Ulcer Prevalence Studies Stage III and IV that are hospital acquired are required to be mandatorily reported to CMS and care associated with the ulcers is non reimbursable. Tracking Incidence Incidence of pressure ulcers that are hospital acquired tracked daily. Wound Care coordinates a huddle/swarm. Event reporting system Monthly reports shared with associates, managers, leaders, unit council COUNT OF PRESSURE ULCERS TIME 41 Creating an Organization of High Reliability It takes a team. You can t do alone 14
Hospital Acquired Pressure Ulcer Discovered Report Process Huddle/Swarm Process Risk/ Quality Review Actions to Improve 43 Prevalence of Pressure Ulcers Prevalence is defined as the total number of patients at a particular point in time with a pressure ulcer / total number of patients in the population studied at a particular point in time (percentage rate) HAPU Rate- count of number of patients who acquire a pressure ulcer after admission to the hospital. At Saint Vincent Healthcare, quarterly PUP studies are completed. This is a snapshot of how we are doing on a given day. National Database for Nursing Quality Indicators (NDNQI) 44 Prevalence 0.12 0.1 Rate: Number of 0.08 hospital acquired pressure ulcer /number surveyed 0.06 on a given day 0.04 0.02 0 Each Bar represents a specific day survey was completed 45 15
PUP Studies Over Time 46 PUP Studies- Track Prevalence 47 Compare with National Benchmarks St. Vincent Healthcare National Benchmark 48 16
PUP Studies Demographics- age/ gender/ BMI (height, weight) Number of Pressure Ulcers- HA/ POA/ by unit/ by stage/ body location/ device related Bed surface Albumin Last skin assessment Risk Score Last risk score PUP interventions OR time ED time Layers of linen Head of bed Restraints Incontinent questions 49 Your data can help guide improvements What unit has the highest occurrence? What body location is most common at your facility? Are there commonalities as to what the causes might be? Does the documentation match what is found on the survey? Is the Braden Scale Scoring appropriate? Consistent? Are there interventions in place for high risk patients? Patient at high risk, on the appropriate beds? Are we checking albumin levels? Nutrition Consults? What is the average layers of linen house wide? By department? Are there daily weights? 50 Look for the greatest opportunity for Improvement 7 6 Example- Number of Pressure Ulcers by Unit 5 4 3 2 1 0 Unit A Unit B Unit C Unit D Unit E Unit F What is unit A doing differently than Unit D, E and / or F? 51 17
Number of Pressure Ulcers by Body Location 7 6 5 4 3 2 1 0 Sacrum Heel Hip Knee Nose Elbow 52 Shared Governance & Unit Work 2014- One of our inpatient units had second highest rate of hospital acquired pressure ulcers comparer to other units. 8 Hospital Acquired Pressure Ulcers 2014. 2015- Same unit had 2 Hospital Acquired Pressure Ulcers. They implemented in 2015 through unit work: New admission/ discharge nurse. This nurse helps do 2 nurse assessment upon admission for every patient. Other tactics to improve pressure ulcer reduction included: Braden Scale Score education Turning schedules developed & set plan at beginning of shift Trialed turning systems to help turn patients Proactively seeking out Wound Care for consultation. Unit Work 18