DEFINITION “A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated” NPUAP/EPUAP 2009 Decubitus ulcer is NOT synonymous with pressure ulcer as decubitus implies lying position or bed confined.
MAGNITUDE OF THE PROBLEM NYSDOH “War on the Sore” 2007 NYS overall nursing home PU prevalence is 9.1% (5% target). Ranks #32 in nation. 1999 study of 42,817 pts in acute care facilities across U.S. showed PU prevalence of 14.8%, with nosocomial PU rate of 7.1% (Amlung, et al; 1999) 1999 analysis reported $2.2 – $3.6 billion dollar cost associated with1.6 million PU’s annually. (Beckrich,Aranovich; 1999)
PRESSURE ULCERS AND LITIGATION Perceived by public (and advertised by lawyers) as poor quality care, ie, PU = Negligence! 1987 OBRA legislation stated “a resident who enters a facility without a pressure sore does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable” (Meehan and Hill; 2001) Avoidability and preventability are key! Based on initial risk evaluation, and documentation Most common reason for nursing home lawsuits!
PATHOPHYSIOLOGY Old Hypothesis: Pressure on trapped soft tissues exceeds mean capillary pressure leading to ischemia and necrosis. Now Understood: First evidence of damage in subcutaneous tissue with epidermis showing no signs of necrosis until quite late. Epidermal cells more able to withstand lack of oxygen than metabolically more active tissues. Final pathway to PU is hypoxia/ischemia The skin is an organ; it can fail like other organs! Witkowski and Parish; 1982
THERMODYNAMICS, METABOLISM AND PRESSURE Thermodynamic factors in skin/surface interface As temperature increases, skin becomes more metabolically active and 02 demands increase With increased pressure, metabolic demands not able to be met and skin becomes hypoxic Hypoxic skin more susceptible to breakdown Adding friction and shear to already fragile skin is “perfect storm”
THE 4 FORCES Pressure: Force applied to soft tissue between hard surface and bony prominence Friction: Resistance of one body sliding or rolling over another Shear: Contiguous tissues sliding relative to each other parallel to their plane of contact Strain: Tissue deformation in response to pressure
PRESSURE AND FRICTION Images Courtesy of Hill-Rom
PRESSURE ULCER STAGING NPUAP – Nat. Pressure Ulcer Advisory Panel Most recent revision in 2007 Consists of 4 stages plus unstageable and DTI Many limitations and criticisms but widely accepted and utilized Many misconceptions and tends to be subjective Shea system (1975) most widely used through the 80’s and similar to NPUAP, I – IV plus closed NPUAP/EPUAP 2009 – minor modifications
2009 NPUAP – EPUAP GUIDELINES More information and discussion – doesn’t really change what we do Agreement on same 4 stages + DTI and Unstag. More discussion around: Holistic patient assessment Changing assessment = changing treatment Use of validated tool, ie, PUSH for progress Assessment and management of malnutrition Assessment and management of pain
STAGE 1 Viewed by NPUAP as sign of risk “Intact skin with non-blanchable erythema of a localized area, usually over a bony prominence” Darkly pigmented skin may simply demonstrate color change compared to surrounding tissue May be painful, soft, firm, warmer or cooler than surrounding area BEWARE: Do not confuse with deep tissue injury !
STAGE II Updated definition to clarify for pressure ulcers “Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister” Blood blisters indicate damage deeper than dermis and are not stage II Should not be used to describe skin tears, tape burns, maceration, dermatitis or denudement
STAGE III Goal of update was to address variations in appearances of stage III PU’s “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 depth of tissue loss. May include undermining and tunneling” Depth of stage III varies by anatomic location
STAGE IV Very little revision for 2007 “Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and/or tunneling” Depth varies according to anatomic location Exposed bone/tendon usually directly visible and/or palpable
UNSTAGEABLE Goal of revision to reduce tendency to classify any ulcer with necrotic tissue as unstageable, when the depth of the ulcer can be seen. “Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed” If portion of base is visible – it is stageable. Wounds obscured by appliances, dressings, etc are NOT unstageable. Move the stuff and look!
DEEP TISSUE INJURY Newest PU in updated staging system “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” Difficult to detect in dark skinned individuals Commonly mistaken as stage I May evolve rapidly in spite of optimal care as damage already done
PREDICTING RISK BRADEN SCALE: 6 parameter instrument 1) Sensation 2) Activity 3) Mobility 4) Moisture 5) Friction 6) NutritionHigh Risk: 18 or less in elderly or darkly pigmented skin 16 or less in other adults (http://www.bradenscale.com)
PREDICTING RISK BRADEN Q SCALE: 7 parameter for Peds 1) Mobility 2) Activity 3) Sensory Perception 4) Moisture 5) Friction-Shear 6) Nutrition 7) Tissue Perfusion and OxygenationHigh Risk: 16 or less (7 for modified Braden Q) (HTTP://www.nichq.org/pdf/PUBradenQScale.xls)
TREATMENT OBJECTIVES Identificationof problem Debridement of necrotic tissue Moist wound care without maceration Control of infection/bioburden Management of pain Pressure redistribution/Offloading Choice of wound care products is individual preference as long as above objectives met.
GROUP 1 SUPPORT SURFACES Pressure overlay, foam, air, water and gel pressure mattresses Covered if patient meets following criteria: 1) Completely immobile (cannot move w/o assistance) or 2) Limited mobility PLUS numbers 4-7 or 3) Any stage pressure ulcer on trunk or pelvis PLUS 4-7 or 4) Impaired nutritional status 5) Fecal or urinary incontinence 6) Altered sensory perception 7) Compromised circulatory status
GROUP II SUPPORT SURFACES Powered, advanced pressure reducing mattresses and overlays. Low air loss, microclimate management, air fluidized therapy Covered if patient meets following criteria: 1) Multiple stage II ulcers on trunk or pelvis AND 2) Pt has been on comprehensive PU treatment program for past month including Group I surface and ulcers are same or worsened or 3) Large or multiple Stage III or IV PU’s on trunk or pelvis OR 4) Recent myocutaneous flap or skin graft for PU on trunk or pelvis (60 d) AND 5) Pt has been on a group II or III surface immediately prior to discharge from hospital or SNF (within 30 days)
AVAILABLE PROTOCOLS AHCPR (Agency for Healthcare Policy and Research. Now known as AHRQ (Agency for Healthcare Research and Quality). AHCPR Clinical Practice Guideline #3: Pressure Ulcers in Adults: Prediction and Prevention. (AHCPR #92-0047: May 1992) AHCPR Clinical Practice Guideline #15: Treatment of pressure Ulcers. (AHCPR #95-0652, Dec 1994). WOCN Guideline for Prevention and Management of Pressure Ulcers, 2003 (www.ahrq.gov/news/pcubcat/c_clin.htm#clin014) (www.wocn.org)
COMMON SENSE ! Document complete initial skin evaluation on day of admission wherever you are (ED, OR, ICU etc) Complete and document initial risk stratification/score Develop and follow your protocol Implement, monitor & document turning and positioning Monitor, manage and document incontinence Use good quality moist wound care Document daily skin sheets on nurses notes Document wounds completely in terms of size, depth, drainage, slough/eschar, odor etc Document wound treatments and changes in treatments “Common sense is not so common” - Voltaire
FUTURE FOCUS AREAS Nutritionassessment and management Pain assessment and management Proper choice of support surfaces Prevention