clarissa young - launceston general hospital - the moving feast
TRANSCRIPT
The moving feast
Clarissa Young MCN MNS Nurse Practitioner Wound Management
Launceston General Hospital
The Moving Feast • Staging definitions
• MASD IAD & PI
• Pathways into practice
• Making a difference
Changes
• Torrance, NPUAP
• 2009 Changed to NPUAP 4 stages until
• 2012 Pan Pac 6 stages
• 2012 PI term Pan Pac
• 2016 more changes + mucus membranes NPUAP
• 2016 NPUAP Pressure Injury
• PI NPUAP not yet EPUAP
Current
A pressure ulcer is a localised injury to the skin and/or underlying tissue usually over a bony prominence, resulting from sustained pressure (including pressure associated with shear). A number of contributing or confounding factors are also associated with pressure ulcers: the primary of which is impaired mobility
Proposed www.npuap.org
A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device.
The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.
Stage 1 PI Current
• Intact skin with non blanchable redness of localised skin usually over a bony prominence
• May be painful, firm soft, warm/cool compared to adjacent skin
Proposed • Intact skin with localised
area of non blanchable erythema of intact skin
• Blanchable erythema, changes sensation, temp. firmness, may precede visual changes
• Does not include purple maroon
Stage 2 PI Current
Partial thickness skin loss of dermis, shallow ulcer red, pink no slough
May present shallow intact/ruptured serum blister
With slough or bruising (not skin tears, tape burns, perineal dermatitis)
Proposed Partial thickness skin loss with exposed dermis
Wound bed viable pink or red, moist intact or ruptured serous blister Fat not visible, granulation, slough eschar not present
over pelvis & heels microclimate & shear
not used for MASAD or IAD MARS
Stage 3 Current
• Full thickness tissue loss fat may be visible but bone tendon muscle not exposed
• Slough may be present but does not obscure depth – may undermine & tunnel
• Depth varies body bridge nose, occiput, malleolus no subcut fat –shallow
• Large fat can develop deep ulcers
Proposed • Full thickness skin loss fat
visible, granulation and epibole slough may be visible
• Depth varies anatomical location undermining & tunnelling
• Fascia, tendon, bone not exposed if unable to see base U
Stage 4 Current
• Full thickness tissue loss, exposed bone, tendon, muscle slough may be present + undermining
• Depth varies according to anatomical site
Proposed • Full thickness skin loss
exposed or palpable fascia, muscle tendon or bone
• Slough & eschar may be visible
• Epibole undermining & tunnelling
• Depth varies anatomical location
• U if slough eschar
Unstageable Current -Depth Unknown
• Full thickness tissue loss base covered slough/eschar
• Depth cannot be determined until base of wound exposed
• Heels without fluctuant/erythema eschar left ‘biological cover’
Proposed - Obscured full thickness skin & tissue loss
• Extent of damage cannot be confirmed obscured slough eschar
• If removed stage 3 or 4 revealed
• Stable eschar dry adherent without erythema/fluctuance on heel or ischemic limb left intact
Deep tissue Current - Suspected Deep Tissue Injury: depth unknown
• Purple or maroon localised intact skin or blood filled blister
• Evolution may include thin blister over dark wound bed
• May develop thin eschar
Proposed – Deep Tissue PI: Persistent non-blanchable deep red, maroon or purple discolouration
• Intact or not, localised area of persistent non blanchable deep red, maroon purple or blood filled blister
• Injury intense/prolonged pressure shear bone muscle interface
• Not vascular, traumatic, neuropathic derm. conditions
Medical Device Related PI
• Use of device designed and applied for diagnostic or therapeutic purposes
• conforms to the shape of device
• staged using the system
Mucosal Membrane PI • Found in mucous membranes from device with a
history of medical device in use at the location of injury.
• Cannot be staged due to the anatomy of the tissues
Summary changes NPUAP • Still 6 stages
• Pressure Ulcer to Pressure Injury (April 2016)
• Staging classifications (Arabic numbers)
• Suspect removed from DTI
Additional • Medical Device Related PI
• Mucosal membrane PI
The Journey
• 1996 – 1st point prevalence survey
• 6 set reporting criteria
• Annual for 10 years until 2005
• Snap shot 2014
• Going again Oct 2016
Incidence
• Counted admissions & Occupied bed days
• Celebrated 15 years 2013
• Data collection
Last survey 2013 PI prevalence is expressed in the following formula
Total number of patients with pressure injuries 159 x 100 1.6%
Separations 9934
PI incidence is a measure of new cases (individuals) by separation over a defined period of time.
Total number of new cases (individuals) 110 x 100 1.1%
Population at risk (separations) 9934
By occupied bed day PI prevalence by occupied bed days is the measure of the total number of PI’s
Total number of pressure injuries 229 x 1000 3.8%
Occupied bed days 60110
PI incidence by occupied bed days is a measure of acquired PI 4.
Total number of acquired pressure injuries 156 x 1000 2.6%
Occupied bed days 60110
Data collection
• PulcerMan 1998 June 2010
• PI Man July 2010 March 2014
• 2607 individuals
• 5990 PI’s
Gold Coast Journey 2003
Thelma & Louise moment
Count PI’s by location Over 50% posterior pelvis
BMap©
• First presented 2004 Orlando (20 anatomical sites)
• Darwin 2008
• Used LGH 2005 (now 6 anatomical sites)
PI by stage
Bmap total 1 July 2010 – 31 March 2014
Bmap site LGH S1 pre S1 LGH S2 pre S2 LGH S3 pre S3
11 sacrum 34 15 64 54 1 4
12a sacro coc 7 5 38 22
12b cleft 9 7 49 20
12c buttock 23 9 92 55 1
13 trochant 1 6 3
14 ischium 1 3 4 2
73 37 247 161 5 6
LGH S4 pre S4 LGH U pre U LGH SDTI
pre SDTI
1 5 1 1 1 3 2 2 2
0 3 3 3 8 1 Total 546
Audit & Pathway to Practice
• Access databases
• IAD not counted
• Matching records & photographs
Many Stage 2 PI’s now IAD
• Why
• We don’t define IAD in PI guidelines
• Continence & Stomal Nurses?
Three stage 2 pressure ulcers (2008)
Grid 3 Grid 4 Grid 5
IAD & MASD WOCN – 2007 consensus statements
Queensland study ¼ incont. >40% IAD PI rate of 6% 12% incont. had PI (unreported stages) Campbell JL, Coyer FM, Osborne SR. Incontinence-associated dermatitis: a cross-sectional prevalence study in the Australian acute care hospital setting. Int Wound J 2014
2015 Global IAD Expert Panel
Nothing AWMA – WA
Straw poll
Spot the difference
IAD MASD & PI
Standard Education • Across THS North
• Acute facility
• Rural sites
• Community nursing
• Residential facilities
Pressure Injury (PI)
Incontinence-Associated Dermatitis (IAD)
Moisture-Associated Skin Damage (MASD)
Pressure Injury Forum THS-North
A quick guide to each topic
April 2016
THS-North Pressure Injury Forum April 2016
THS-North Pressure Injury Forum April 2016
Pressure Injury (PI) a localised injury to the skin and underlying tissue usually over a bony prominence
History Symptoms
Location
Depth
Shape/Edges
Other
Exposure to pressure/shear
Pain, discomfort
Usually over a bony prominence
Varies from intact skin non blanching erythema to full thickness skin loss
Well defined
Reduced mobility, sensory impairment
THS-North Pressure Injury Forum April 2016
Pressure Injury (PI) a localised injury to the skin and underlying tissue usually over a bony prominence
History Symptoms
Location
Depth
Shape/Edges
Other
Exposure to pressure/shear
Pain, discomfort
Usually over a bony prominence
Varies from intact skin non blanching erythema to full thickness skin loss
Well defined
Reduced mobility, sensory impairment
THS-North Pressure Injury Forum April 2016
Moisture-Associated Skin Damage (MASD) an umbrella term that includes perspiration, wound exudate (+/- urinary & faecal incontinence)
S K I N Surface � support surface –basic
mattress and cushion including inflation
� wrinkle free sheets, pillows
� Roho support surface
Keep moving � PIPP - pressure injury
prevention plan � encourage bed mobility
in/on/out � written advice for
patients/carers
S K I N Inspection � regular skin hygiene � reassess with Braden Risk
Tool at least daily � assess and implement skin
care plans (continence management)
Nutrition � nutritional assessment -
Braden � encourage optimal
intake diet and fluids including nutritional supplements
Making a difference • Continuous education
loops
• Risk Assessments
• Audits &Surveys
• Data
• Champions
Questions and discussion
We all change with time…… it will be OK