pressure ulcers the forgotten enemy

PRESSURE ULCERS The Forgotten Enemy

Enhancing Patient Safety in the Intensive Care Unit Workshop Intensive Care Unit Hospital Taiping

14 June 2012

THE SKIN

EPIDERMIS

Thin outer layer of the skin which consists of the following three parts:

1. Stratum corneum (horny layer) 2. Stratum spinosum (squamous cells) 3. Stratum basale

EPIDERMIS

STRATUM CORNEUM

This layer consists of fully mature keratinocytes which contain fibrous protein (keratins).

The outermost layer is continuously shed. Stratum corneum prevent the entry of foreign substances

as well as the loss of fluid from the body

EPIDERMIS

STRATUM SPINOSUM

Squamous cells layer This layer, just beneath the stratum corneum contain

living keratinocytes (squamous cells) which mature and form stratum corneum

EPIDERMIS

STRATUM BASALE

Deepest layer of the epidermis containing basal cells Basal cells continually divide, forming new keratinocytes,

replacing the old ones that are shed from skin surface.

The epidermis also contains melanocytes, which are cells that produce melanin (skin pigment)

DERMIS

The dermis is the middle layer of the skin. The dermis contains the following:

1. Blood vessels 2. Lymph vessels 3. Hair follicles 4. Sweat glands 5. Collagen bundles 6. Fibroblasts 7. Nerves

SUBCUTANEOUS LAYER

Also known as subcutis layer Deepest layer of the skin Consist of network of collagen and fat cells.

Helps to conserve body heat and protect body from injury by acting as a shock absorber

PRESSURE ULCER

INTRODUCTION

Pressure ulcers are associated with an adverse patient outcomes and contribute to:

1. Pain 2. Depression 3. Loss of function and independence 4. Increased incidence of infection and sepsis 5. Additional surgical interventions 6. Significant economic costs 7. Prolonged hospital stay 8. Medico-legal ramifications

DEFINITION

Pressure ulcer is a localized injury to the skin or underlying tissue usually over the bony prominence as a result of pressure or pressure in combination with shear and or friction

National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP) 2009

Stage I


Non-blanchable erythema or intact skin, usually over bony prominence

Darkly pigmented skin may not have visible blanching. Its color may differ from the surrounding area

The area may be painful, firm or soft, warmer or cooler than surrounding tissue

Stage II


Partial thickness of dermis, shallow open ulcer with red pink bed without slough

Shiny or dry shallow ulcer without slough or bruising

Intact or open or ruptured serum-filled or serosanguinous-filled blister

Stage III


Full thickness skin loss with subcutaneous tissue damage or necrosis that may extend down to but not through the underlying fascia

The ulcer is a deep crater with or without undermining of adjacent tissue

Stage IV


Full thickness skin loss with extensive tissue destruction, tissue necrosis, damage to muscle, bone or supporting structures (tendon, joint capsule etc).

Undermining and sinus tracts may be seen concurrently

Mechanism Consequences

Local ischemia Capillary perfusion decreases with mechanical loading Lack of local vital nutrients

Impaired interstitial fluid flow and lymphatic drainage

Accumulation of metabolic waste products

Reperfusion injury Restoration of blood flow may lead to toxic level of oxygen free radicals

Sustained deformation of cells Local cell damage and death

PATHOPHYSIOLOGY Pathophysiology of pressure ulcer: soft tissue response to mechanical loading

RISK FACTORS Intrinsic Extrinsic

Extreme of Age

Health Status

Level of Consciousness

Sensory Impairment

Systemic Signs of Infection

Nutritional Status/Body Weight

Previous Pressure Damage

Pain Status

Psychological and Social Status

Medications

Cognitive Status

Blood Flow

Pressure

Shear and Friction

Heat

Moisture

Incontinence

Posture

Multi-factorials

EPIDEMIOLOGY : GENERAL HOSPITAL POPULATION

In one large study of hospitalized patients with pressure ulcer, the overall incidence was 8.4% and 3.2% of patients had pressure ulcer at the time of admission

Bergstrom et al noted an incidence of 14 per 1000 patient-day (including stage I). Incidence of pressure ulcer excluding stage I was between 0.2 to 0.56 per 1000 patient-days

Gosnell DJ, Johannsen J, Ayres M Pressure ulcer incidence and severity in a community hospital. Decubitus 1992; 5: 56-62 Bergstrom N, Braden B. A prospective study of pressure ulcer risk among institutionalized elderly. J Am Geriatric Soc. 1992; 40: 747-758 Smith DM, Winsermius DK, Besdine RW. Pressure sore in the elderly: can this outcome be improved? J Geriatric Intern Med 1991; 6: 81-93 Brandies GH, Morris JN. Nash DJ et al. The epidemiology and natural history of pressure ulcer in elderly nursing home residents. JAMA 1990; 264: 2905-2909

EPIDEMIOLOGY : INTENSIVE CARE UNIT

Studies from Europe, South Africa, South America and Canada shows that the incidence of pressure ulcer is anywhere between 5% to over 40%

Stawicki SP, Grossman M. Stretching negative pressure wound therapy: can dressing change interval be extended in patients with open abdomen? Ostomy Wound Manage 2007; 53: 8-11

Allman RN, Goode PS, Burst N et al. Pressure ulcers, hospital complications and disease severity: Impact on hospital costs and length of stay. Adv Wound Care 1999; 12: 22-30

Boyle M, Green M. Pressure sores in intensive care: defining their incidence and associated factors and assessing the utility of two pressure sore risk assessment tools. Aust Crit Care 2001; 14: 24-30

EPIDEMIOLOGY : INTENSIVE CARE UNIT

Incidence of pressure ulcers among all admission to ICU was 28 per 1000 patient-days

High risk patients (APACHE II >15) had an incidence of 52 per 1000 patient-days

Bergstrom N, Demuth PJ, Braden BJ. A clinical trial of Braden Scale for prediction of pressure sore risk. Nursing Clin North Am 1987; 22: 417-426

Inman KJ, Sibbald WJ, Schneider H et al. Clinical utility and cost effectiveness of an air suspension bed in the prevention of pressure ulcer. JAMA 1993; 269: 1139-1143

Malaysian ICUs

National Audit on Adult Intensive Care Reports 2006-2008

Malaysian Registry on Intensive Care Report 2010

NAICU Report 2003-2007 showed an incidence of pressure

ulcer between 3.0 to 4.1%

Incidence from 2008-2010 reported as between 6.6 and 7.7

per 1000 patient-days

17.3

10.5 9.7

0

2

4

6

8

10

12

14

16

18

20

2008 2009 2010

Incide

nce p

er 10

00 pa

trient-

days

stay

Incidence of Pressure Ulcer in Hospital Taiping 2008-2010

0

5

10

15

20

25

30

35

Taiping Kuala Lumpur Alor Setar Pulau Pinang Seremban Johor Bahru

Incide

nce p

er 10

00 pa

tient-

days

stay

Incidence of Pressure Ulcers 2008-2009 in 6 Hospitals

2008

2009

2010

Pressure Ulcer and Age

70% of pressure ulcers occurs in people above 65 years old

Thomas DR. Prevention and treatment of pressure ulcers. J Am Med Dir Assoc 2006 Jan; 7(1): 46-59

SITES FOR PRESSURE ULCERS

Temporal

Occipital Shoulder

Elbow Sacrum 32%

Trochanter

Ischium 11%

Ankle 9%

Toe

Heel 29%

PRESSURE ULCER AND BODY SITES

Clark M, Bours G, Defloor T. Summary report on the prevalence of pressure ulcers. EPUAP Review 2002; 4:49-56

Location Belgium Italy Portugal Sweden UK Total

Sacrum 25.6 40.9 26.9 25.3 37.5 532

Heel 34.9 31.9 33.9 30.0 26.2 484

Ischium 12.2 7.6 2.7 11.6 13.7 186

Ankle 3.6 9.1 10.2 24.5 6.4 149

Elbow 14.3 0.0 6.9 3.0 10.3 143

Hip 9.3 10.6 19.3 5.6 5.8 136

Total 301 132 186 233 778 1630

PROBLEMS AND OUTCOMES Pressure ulcers are associated with an adverse patient outcomes and contribute to:

1. Pain 2. Depression 3. Loss of function and independence 4. Increased incidence of infection and sepsis 5. Additional surgical interventions 6. Significant economic costs 7. Prolonged hospital stay 8. Medico-legal ramifications Eachempati SR, Hydo LJ, Barie PS. Factors influencing the development of decubitus ulcer in critically ill surgical patients. Critical Care Med. 2001; 29: 1678-1682 Nelson T. Pressure ulcers in Australia: Pattern of litigation and risk management issues. Primary Intention 2003; 11(4): 183-184 and 186-187

SEPSIS

In patients with stage III and IV pressure ulcers manifesting signs of sepsis, the wound is considered as a primary source until proven otherwise.

Mortality rate in patients with bacteremia and pressure ulcers are 50%

Rudensky B, Lipschits M, Isaacsohn M. Infected pressure sores: Comparison of methods for bacterial identifications. South Med J 1992; 85: 901-903

OSTEOMYELITIS

Osteomyelitis is a potential complication when pressure ulcer developed over bony prominence

Pressure ulcers located over joint merit close attention for potential development of septic arthritis

Hibbs P. The economics of pressure ulcer prevention. Decubitus 1988; 1: 32-38

MORTALITY

1-year mortality rate of nursing home resident with pressure ulcer was 50% compare to 27% without pressure ulcer

35% of them who developed pressure pressure ulcer within the first 3 months die within 1 year compared to 25% who did not developed pressure ulcer

Brandies GH, Morris JN, Nash DJ. The epidemiology and natural history of pressure ulcers in elderly nursing home residents. JAMA 1990; 264: 2905-2909

COST

1.3 million adults (US) have a pressure ulcer with estimated cost of USD500 to USD40,000 to heal each ulcer

The US Healthcare spends more than USD1.0 billion annually to treat pressure ulcer

Joint Commission on Accreditation of Healthcare Organization (JCAHO). Draft candidate 2007 National Patient Safety Goals Requirements and Implementation Expectations: long term care program on-line cited 2006 May 2ndEd Available from internet: http://www.jointcommission.org/NR/rdonlyres/53EA8AE9A-E21E-4133-898E-97C958B0FD1F/0/07_npsg_ltc.pdf

American Medical Directors Association (AMDA) Pressure ulcers: percentage of patients with pressure ulcers that heal. In: We care: toolkit for the implementation of the clinical practice guidelines for pressure ulcer . 2004

COST

In acute care facility, the average variable costs (additional costs incurred to treat pressure ulcers) has been estimated to be USD 1300 per patient or USD 80 per day

Frantz RA, Gardner S, Harvey P et al The cost of treating pressure ulcers in a long-term care facility. Decubitus 1991; 4: 37-45

COST

Frantz RA, Gardner S, Harvey P et al The cost of treating pressure ulcers in a long-term care facility. Decubitus 1991; 4: 37-45

Estimated treatment cost associated with pressure ulcers

Patients who developed pressure ulcer during hospitalization

USD 6 billions/year

Average added Medicare hospital days due to pressure ulcers

2.2 million-days/year

Estimated treatment cost per pressure ulcer (stage dependent)

USD 2,000 USD 40,000

Cost of reconstructive surgery for pressure ulcer USD 25,000 per patient

Addition variable costs associated with pressure ulcer in acute care

USD 1300 per patient or USD 80 per day

MEDICO-LEGAL ISSUES

The patient development of pressure ulcer while under the care of a healthcare provider is increasingly being viewed as grounds for a professional liability lawsuit.

The mere existence of pressure ulcer is often viewed as physical evidence of medical negligence.

It is not difficult for a plaintiffs attorney to demonstrate to the lay jury that a pressure ulcer is not an overnight occurrence but rather the result of caregiver negligence over time.

MEDICO-LEGAL ISSUES Case 1:

Los Angeles County jurors awarded more than US1.2 million to a 62-year-old long-term care facility resident who required leg amputation after a pressure ulcer on his heel become infected. The residents attorneys alleged that facility staff members did not take steps to relieve pressure such as placing a cushion under his heel and that the facility failed to provide 3.2 hours of nursing care per resident per day as required by California law

Leonard J. Abuse victim wins award. LA Times 2005 Jul 2nd; Sect B:3

MEDICO-LEGAL ISSUES Case 2:

An Ohio skilled nursing facility failed to provide adequate care to prevent pressure ulcers in several residents and paid a civil monetary penalty totaling USD10,500 as recommended by the Centers for Medicare and Medicaid Services (CMS) for non-compliance

Livingstone v. CMS, No. 03-3489 US Ct App 6th Cir. Aug 24th 2005

MANAGEMENT OF PRESSURE ULCER

International NPUAP-EPAUP Pressure Ulcer Prevention Guideline 2009

LEVEL OF EVIDENCE

Level Study

1 Large randomized trial(s) with clear-cut results (and low risk of error)

2 Small randomized trial(s) with uncertain results (and moderate to high risk of error)

3 Non randomized trial(s) with concurrent or contemporaneous control

4 Non randomized trial(s) with historical controls

5 Case series with no control. Specify number of subjects

International NPUAP-EPAUP Pressure Ulcer Prevention Guideline 2009

GRADE OF RECOMMENDATION Strength of Evidence

A The recommendation is supported by direct scientific evidence from properly designed and implemented controlled trials on pressure ulcers in humans (or humans at-risk for pressure ulcers) providing statistical results that consistently support the guideline statement (Level 1 studies required)

B The recommendation is supported by direct scientific evidence from properly designed and implemented clinical series on pressure ulcers in human (or human at-risk for pressure ulcers) providing statistical results that consistently support the recommendation (Level 2,3,4,5 studies)

C The recommendation is supported by direct evidence (e.g. studies in normal human subjects, human with other types of chronic wounds, animal models) and or expert opinion

Admission

Thorough skin assessment

Is there a risk for skin breakdown or pressure ulcer?

Develop an individualized care plan for treating and preventing further

skin breakdown

Assess pressure ulcer risk daily. Braden scale or validated tool

Complete holistic review for risk factors

Is there risk for skin breakdown or pressure ulcer? Braden Score >18

Reassess the skin and pressure ulcer risk daily

Braden Score 18 or other risk factors

Develop targeted interventions to address each risk area and include in

the individualized care plan

Assess pressure ulcer risk daily

Review outcomes of plan and interventions

Pressure Ulcer : Acute Care Assessment and Prevention Pathway Consensus Paper from the International Expert Wound Care Advisory Panel 2008

Yes

Yes

No

No

Admission




skin breakdown











Yes

Yes

No

No

A thorough head-to-toe skin assessment within 6 hours of

admission Document all findings

THOROUGH SKIN ASSESSMENT ON ADMISSION

SKIN ASSESSMENT

Skin assessment:

1. Ensure that a complete skin assessment is part of the risk assessment screening policy in place in all health care setting

2. Educate professionals on how to undertake a comprehensive skin assessment that includes the technique for identifying blanching response, localized heat, edema and induration

3. Inspect skin regularly for signs of redness in individuals identified as being at risk of pressure ulceration

National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP) Pressure Ulcer Prevention Guideline 2009

SKIN ASSESSMENT Skin assessment:

4. Skin inspection should include assessment for localized heat, edema or induration, especially in individuals with darkly pigmented skin

5. Ask individuals to identify any areas of discomfort or pain that could be attributed to pressure damage

6. Observe the skin for pressure damage caused by medical devices

7. Document all skin assessments, noting details of any pain possibly related to pressure damage


Admission




skin breakdown











Yes

Yes

No

No

Initiate treatment if skin breakdown is present on

admission

IF PRESSURE ULCER PRESENT

National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel 2009 Guidelines

1. Classification of pressure ulcer 2. Assessment of healing 3. Nutrition 4. Pain assessment and management 5. Support surface 6. Cleansing 7. Wound debridement

IF PRESSURE ULCER PRESENT

National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel 2009 Guidelines

7. Wound debridement 8. Dressing 9. Assessment and treatment of infection 10.Biophysical agents 11.Biological dressing 12.Pressure ulcer management in individuals receiving palliative

care

TREATMENT: Classification of Pressure Ulcer

1. Use a validated pressure ulcer classification system to document the level of tissue loss (C)

2. Do not use pressure ulcer classification system to describe tissue loss in wound other than pressure ulcers (C)

3. Confirm the reliability of classifications among the professionals for classifying pressure ulcers (B)

4. Do not classify pressure ulcers on mucous membrane (C)

TREATMENT: Assessment Individuals With Pressure Ulcers

1. Complete health/medical and social history 2. A focused PE that includes

a) Nutritional assessment b) Pain related to pressure ulcers c) Risk for developing additional pressure ulcers

3. Psychological health, behavior and cognition 4. Social and financial support 5. Functional capacity, particularly in regards to positioning, posture and need for

assistive equipment and personnel 6. The employment of pressure-relieving maneuvers 7. Adherence to pressure-relieving maneuvers 8. Integrity of seating and bed surfaces 9. The individuals/family members knowledge and belief about developing and

healing pressure ulcers

TREATMENT: Pressure Ulcer Assessment

1. Assess the pressure ulcer initially and reassess it at least weekly, documenting findings (C)

2. Assess and accurately document physical characteristics such as location, stage, size, tissue type, wound bed and peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudates, necrotic tissue, odor, presence of granulation tissue, and epithelialization (C)

TREATMENT: Methods for Monitoring Healing

1. Assess progress toward healing using one or more of the following methods: PUSH Tool, or the Bates-Jensen Wound Assessment Tool (BWAT) (B)

2. Consider using baseline and serial photography to monitor pressure ulcer healing over time. Use standard photographic techniques (C)

3. Signs of deterioration should be addressed immediately (C)

MONITORING PROGRESS USING PRESSURE ULCER HEALING SCORE (PUSH)

Length X Width (in cm2)

0 0

1 2410

Exudate Amount

0 None

1 Light

2 Moderate

3 Heavy

Sub-score

Tissue Type 0 Closed

1 Epithelial

Tissue

2 Granulation

Tissue

3 Slough

4 Necrotic Tissue

Sub-score

Total Score


Pressure Ulcer Score

PRESSURE ULCER HEALING CHART National Pressure Ulcer Advisory Panel

PUSH Tool Score Pressure Ulcer Healing Graph 17

16

15

14

13

12

11

10

9

8

7

6

5

4

3

2

1

Healed = 0

Date

TREATMENT: Nutrition

1. Screen nutritional status for each individual with pressure ulcer at admission and with each condition change (C)

2. Provide sufficient calories (B), 30-35 kcal/kg/day for individual under stress with a pressure ulcer (C)

3. Provide adequate protein (B), offer 1.25-1.5 gm/kg/day when compatible with goal of care, and reassess as condition changes

4. Provide and encourage adequate daily fluid intake for hydration (C)

TREATMENT: Pain Assessment and Management

1. Assess all individuals for pain related to pressure ulcer or its treatment (B) using a validated scale (B).

2. Reduce pressure ulcer pain by keeping the wound bed covered and moist, and using a non-adherent dressing (B)

3. Use dressing that less likely to cause pain and require less frequent dressing changes e.g. hydrocolloids, hydrogels, alginates, polymeric membrane foams, foam, soft silicone dressing and ibuprofen impregnated dressings (C)

TREATMENT: Cleansing

1. Cleanse the pressure ulcer and surrounding skin at the time of each dressing change (C)

2. Cleanse healing, clean pressure ulcers with normal saline or portable water (i.e. water suitable for drinking) (C)

3. Clean the pressure ulcer using an irrigation solution and apply sufficient pressure to cleanse the wound without damaging tissue or driving bacteria into the wound (C)

TREATMENT: Debridement

1. Debride devitalized tissue within the wound bed or edge of pressure ulcers when appropriate to the individuals condition and consistent with overall goals of care (C)

2. Perform debridement in the presence of advancing cellulitis, crepitus, fluctuance and/or sepsis secondary to ulcer-related infection (C)

3. Surgical debridement must be performed by specially trained, competent, qualified and licensed healthcare professionals (C)

TREATMENT: Dressing

1. Assess pressure ulcers at every dressing change and confirm the appropriateness of current dressing regimen (C)

2. Follow manufacturer recommendations, especially related to frequency of dressing change (C)

3. Choose a dressing to keep the wound bed moist (C) 4. Choose a dressing that remains in contact with the wound

bed or skin barrier product to keep the periwound dry and prevent maceration (C)

TREATMENT: Hydrocolloid Dressings

1. Use hydrocolloid dressing for stage II pressure ulcers in body area where they will not roll or melt (B)

2. Consider using hydrocolloid in non-infected, shallow stage III pressure ulcer (B)

3. Consider using filler dressing beneath hydrocolloid dressings in deep ulcer to fill in dead space (B)

4. Consider using hydrocolloid dressings to protect body areas at risk for friction injury or risk of injury from tape (C)

TREATMENT: Transparent Film Dressing

1. Consider using film dressings to protect body areas at risk for friction injury or risk from tape (C)

2. Consider using film dressing as a secondary dressing for ulcers treated with alginates or other wound filler that will likely remain in the ulcer bed for an extended period of time e.g. 3-5 days (C)

3. Do not use film dressings as the tissue interface layer over moderately to heavily exudating ulcers (C)

4. Do not use film dressings as the cover over enzymatic debridement agent, gels or ointments (C)

TREATMENT: Hydrogel Dressings

1. Consider the use of hydrogel dressings on shallow, minimally exudating pressure ulcers (B)

2. Consider the use of hydrogel dressings for treatment of dry ulcer beds so that gel can moisten the ulcer bed (C)

3. Consider the use of hydrogel dressings for painful pressure ulcers (C)

4. Consider the use of hydrogel for pressure ulcers with depth and contours and/or body areas that are at risk for dressing migration (C)

TREATMENT: Alginate Dressings

1. Consider alginate dressings for the treatment of moderately and heavily exudating ulcers (B)

2. Consider alginate dressing in infected pressure ulcers when there is proper concurrent treatment of infection (C)

3. Consider lengthening the dressing-change interval or changing the type of dressing if alginate dressing is still dry at the schedule time for dressing change (C)

TREATMENT: Foam Dressings

1. Consider using foam dressings on exudative stage II and shallow stage III pressure ulcer (B)

2. Avoid using single small piece of foam in exudating cavity ulcers (C)

3. Consider using foam dressing on painful ulcer (C) 4. Consider placing foam dressings on body areas and pressure

ulcer at risk for shear injury (B)

TREATMENT: Gauze Dressings

1. Avoid using gauze dressings for clean, open pressure ulcer because they are labor-intensive to use, cause pain when remove if dry, and lead to desiccation of viable tissue if they dry (C)

2. When other forms of moisture-retentive dressings are not available, continually moist gauze is preferable to dry gauze (C)

3. Use gauze dressings as the cover dressing to reduce evaporation when the tissue interface layer is moist (C)

4. Use loosely woven gauze for highly exudative ulcers; use tightly woven gauze for minimally exudative ulcers (C)

TREATMENT: Gauze Dressings

5. Use gauze packing frequently to promote absorption of exudate (C)

6. Use single gauze strip/roll to fill deep ulcers; do not use multiple single gauze dressings, because retained gauze in the ulcer bed can serve as a source of infection (C)

7. Consider using impregnated forms of gauze to prevent evaporation of moisture continuously moist gauze dressing (C)

Admission




skin breakdown











Yes

Yes

No

No

Risk Assessment

RISK ASSESSMENT

RISK ASSESSMENT Risk assessment policy:

1. Establish risk assessment policy in all healthcare settings (C)

2. Educate healthcare professionals on how to achieve accurate and reliable risk assessment (B)

3. Document all risk assessments (C)


RISK ASSESSMENT Risk assessment practice:

1. Use structural approach to identify individual at risk of developing pressure ulcer (C)

2. Risk assessment should include assessment of activity and mobility (C)

3. Use risk assessment that includes a comprehensive skin assessment to evaluate any alteration to intact skin (C)

4. Risk assessment that is refines through the use of clinical judgment informed by knowledge of key risk factors (C)


RISK ASSESSMENT Risk assessment practice:

Consider the potential impact of the following factors on an individuals risk of pressure ulcer development:

1. Friction and shear 2. Sensory perception 3. General health status 4. Body temperature


Scale Author and Year of

Publication

Setting Design Sample Size Sensitivity Specificity Positive Predictive Validity

Negative Predictive Validity

Braden Bergstrom 1987

ICU Clinical trial 60 83 64 61 85

Braden Beekman 1996

Ortho ICU 42 89 88 84.8 91.4

Braden Van den Bosh 1996

ICU Longitudinal Study

103 59 59 36.1 78.6

Waterlow Westrate 1998

Surgical ICU Prospective Study

594 80 29 9 95

Braden Fife 2001

Neuro ICU Cohort Study 186 91.4 Not mentioned 27.3 Not mentioned

Braden Cubbin-Jackson Douglas

Seongsook 2004

ICU Longitudinal Study

112 112 112

79 89 18

26 61 18

37 51 34

95 92

100

Braden Modified Norton 4 Factor Model

Feuchtinger 2005

Cardiac Surgery ICU

Explorative Prospective

Study

53 53 53

97 58 85

5 47 31

69 70 70

50 35 38

Shahin ESM, DassenT, Halfens RJG. Predictive validity of pressure ulcer risk assessment tools in intensive care patients. The World of Critical Care Nursing 2007 Vol.5 No.3 Pgs. 75-79

Studies examining the predictive validity of pressure ulcer risk assessment scales (PURAS) in the intensive care patients

DATE OF ASSESSMENT

SKIN PERCEPTION 1 Completely Limited 2 Very Limited 3 Slightly Limited 4 No Impairment

Ability to respond meaningfully to pressure-related discomfort

Unresponsive (does not moan, flinch or grasp) to painful stimuli, due to diminished level of consciousness or sedation OR Limited ability to feel pain over most of body

Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR Has a sensor impairment that limits the ability to feel pain or discomfort over of body

Responds to verbal commands, but cannot communicate discomfort or need to be turned OR Has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities

Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain discomfort

MOISTURE 1 Constantly Moist 2 Very Moist 3 Occasionally Moist 4 Rarely Moist

Degree to which skin is exposed to moisture

Skin is kept almost constantly by perspiration, urine etc. Dampness is detected every time patient is moved or turned

Skin is often, but not always, moist. Linen must be changed at least once a shift

Skin is occasionally moist, requiring an extra linen changed approximately once a day

Skin is usually dry, linen only requires changing at routine intervals

ACTIVITY 1 Bedfast 2 Chairfast 3 Walks Occasionally 4 Walks Frequently

Degree of physical activity Confined to bed Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheel chair

Walks occasionally during day, but for a very short distance with or without assistance. Spends majority of each shift in bed or chair

Walks outside the room at least twice a day and inside room at least every 2 hours during waking hours

MOBILITY 1 Completely Immobile 2 Very Limited 3 Slightly Limited 4 No Limitation

Ability to change and control body position

Does not make even a slight changes in body or extremity position without assistance

Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently

Makes frequent though slight changes in body or extremity position independently

Makes major and frequent changes in position without assistance

NUTRITION 1 Very Poor 2 Probably Inadequate 3 Adequate 4 Excellent

Usual food intake pattern Never eat a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid supplement OR Is NPO and/or maintain on clear liquids of IVs for more than 5 days

Rarely eats a complete meal and generally eats only about of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement OR Receives less than optimum amount of liquid diet or tube feeding

Eats over or most meals. Eats a total of 4 servings of protein (meat or dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered OR Is on tube feeding or TPN regimen, which meets most of nutritional needs

Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation

FRICTION AND SHEAR 1 Problem 2 Potential Problem 3 No Apparent Problem

Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheet is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation lead to almost constant friction

Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down

Moves in bed and chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair

TOTAL SCORE

Braden Scale for Pressure Ulcer Risk Assessment

Admission




skin breakdown











Yes

Yes

No

No

Applying SSKIN Bundle to prevent development of

pressure ulcer in individual at-risk

SKIN CARE PLAN

SSKIN CARE BUNDLE

Images from: Anne Cuyvus Pressure Ulcer: A Pressing Matter. Jessa Ziekenhuis. Jessa Hospital, Hasselt, Belgium

FREQUENT THOROUGH SKIN INSPECTION

SURFACE SELECTION: PRESSURE DISTRIBUTION

SUPPORT SURFACE General statement

1. Prevention in individuals at risk should be provided on a continuous basis during the time that they are at risk. (Strength of Evidence = C)

2. Do not base the selection of a support surface solely on the perceived level of risk for pressure ulcer development or the category/stage of any existing pressure ulcers. (Strength of Evidence = C)

3. Choose a support surface that is compatible with the care setting. (Strength of Evidence = C)


SUPPORT SURFACE General statement

4. Examine the appropriateness and functionality of the support surface on every encounter with the individual (C)

5. Verify that the support surface is being used within its functional life-span, as indicated by the specific manufacturers recommended test method before use of the support surface (C)


SUPPORT SURFACE

Mattress and bed:

1. Use high specification foam mattress rather than standard hospital mattress for all individuals assessed as being at risk for pressure ulcer development (A)

2. There is no evidence of the superiority of one higher-specification foam mattress over alternative higher-specification foam mattresses (A)

3. Use an active support surface (overlay or mattress) for patient at higher risk of pressure ulcer development where frequent manual repositioning is not possible (B)


SUPPORT SURFACE Mattress and bed:

4. Alternative-pressure active support overlays and replacement mattresses, have a similar efficacy in term of pressure ulcer incidence (A)

5. Do not use small-cells alternating-pressure air mattress or overlays (C)

6. Continue to turn and reposition, where possible, all individual at-risk of developing pressure ulcer (C)


SUPPORT SURFACE Product Types:

1. Comfort aids 2. Overlays

b. Static overlays c. Dynamic overlays

3. Replacement mattress 1. Static replacement mattress 2. Dynamic replacement mattress

4. Specialty beds 1. Air fluidized bed 2. Low air loss devices

Pressure Ulcer Prevention and Management Practices: Integration of Evidences. Hospital Safety and Quality Control. South Australian Department of Health

SUPPORT SURFACE Support surfaces to prevent heel pressure ulcers:

1. Ensure that the heels are free of the surface of the bed (C) 2. Heel protection devices should elevate the heel completely

(offload them) in such a way to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. The knee should be in slight flexion (C)

3. Use a pillow under the calves so that the heels are elevated (i.e. floating) (B)

4. Inspect the skin of the heel regularly (C)


SPECIAL POPULATION Patients in the operating room:

1. Refine risk assessment of individuals undergoing surgery by examining other factors that are likely to occur and will increase risk of pressure ulcer development, including:

a. Length of operation b. Increased hypotensive episodes c. Low core temperature during surgery d. Reduced mobility on day one postoperatively

National Pressure Ulcer Advisory Panel NPUAP and European Pressure Ulcer Advisory Panel Pressure Ulcer Prevention Guidelines 2009

SPECIAL POPULATION

Patients in the operating room:

2. Use pressure-redistributing mattress on the operating table for all individuals identifies as being at-risk of pressure ulcer development (B)

3. Position the patient in such a way as to reduce the risk of pressure ulcer development during surgery (C)

4. Elevate the heels completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting all the pressure on the Achilles tendon. The knee should be in slight flexion (C)


SPECIAL POPULATION

Patients in the operating room:

5. Pay attention to pressure redistribution prior to and after surgery

a. Place the individual on a pressure-redistributing mattress both prior to and after surgery (C)

b. Position the individual in a different posture preoperatively and postoperatively, than the posture during surgery (C)


KEEP TURNING

REPOSITIONING

The use of repositioning should be considered in all at-risk individuals

1. Repositioning should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body (A)

2. The use of repositioning as a prevention strategy must take into consideration the condition of the patient and the support surface in use (C)


REPOSITIONING FREQUENCY

Frequency of repositioning will be influences by variables concerning the individual (C) and the support surface in use (A)

1. Repositioning frequency will be determined by the individuals tissue tolerance, his/her level of activity and mobility, his/her general medical condition, the overall treatment objectives and assessment of the individual skin condition (C)

2. Repositioning frequency should be influenced by the support surface used (A)


REPOSITIONING TECHNIQUE Reposition contributes to the individuals comfort, dignity and functional ability (C)

1. Reposition the individual in such a way that pressure is relieved or redistributed (C)

2. Avoid subjecting the skin to pressure and shear forces (C) 3. Use transfer aids to reduce friction and shear. Lift dont

drag- the individual while repositioning (C) 4. Avoid repositioning the individual directly onto medical

devices such as tubes or drainage system (C)


DOCUMENTATION

Record repositioning regimes, specifying frequency and position adopted, and include an evaluation of the outcome of the repositioning regime. (Strength of Evidence : C)

National Pressure Ulcer Advisory Panel NPUAP and European Pressure Ulcer Advisory Panel Pressure Ulcer Prevention Guidelines 2009

INCONTINENCE MANAGEMENT AND MOISTURE CARE

SKIN ASSESSMENT

Skin care:

1. Whenever possible, do not turn the individual onto a body surface that is still reddened from previous episode of pressure loading (C)

2. Do not massage for pressure ulcer prevention (B) 3. Do not vigorously rub skin that is at risk for pressure ulceration (C) 4. Use skin emollients to hydrate dry skin in order to reduce risk of

skin damage (B)

5. Protect the skin from exposure to excessive moisture with a barrier product (C)


NUTRITION

NUTRITION

General recommendation:

1. Screen an assess the nutritional status of every individual at risk of pressure ulcers in each healthcare setting

1.1. Use a valid, reliable and practical tool for nutritional screening that is quick and easy to use

1.2. Have a nutritional screening policy in place in all healthcare settings, along with recommended frequency of screening for implementation


NUTRITION

General recommendation:

2. Refer each individual with nutritional risk and pressure ulcer risk to a registered dietitian and also if needed to a multidisciplinary nutritional team

3. Offer each individual with nutritional risk and pressure ulcer risk a minimum of 30-35 kcal per kg body weight with 1.25 1.5 gm/kg/day protein and 1 ml of fluid intake per kcal per day


NUTRITION

Specific recommendation:

1. Offer high-protein mixed oral nutritional supplements and/or tube feeding, in addition to the usual diet, to individuals with nutritional risk and pressure ulcer risk because of acute or chronic diseases, or following surgical intervention (A)

2. Administer oral nutritional supplements and/or tube feeding in between the regular meals to avoid reduction of normal food and fluid intake during regular mealtimes (C)


Admission




skin breakdown











Yes

Yes

No

No

AUDITING

Date

Frequency of Care Delivery

Time

Surface tick when checked

Mattress appropriate

Cushion appropriate

Functional/integrity check of equipment performed

Skin inspection tick when pressure area checked record N if no damage present or Y if damage present and grade in evaluation over page

All pressure areas checked

Redness/discoloration present

Keep moving tick which position patient is in when encourage/assisted to move

Bed Right side (30 tilt)

Left side (30 tilt)

Back

Chair

Incontinence record Y if patient dry record N if patient incontinent of urine/feces or both

Urine

Bowel

Nutrition tick when checked

Diet (please state)

Fluids (please state)

Supplements (please state)

Initial(s) please state

NHS Scotland Quality Improvement: Pressure Care Plan SSKIN Bundle

Use the following codes as applicable: O = off ward, R = refused (record comment on Evaluation Sheet), V = variant (record comment on Evaluation Sheet)

Date and Time SSKIN Element Number Evaluation Initial

Name CHI DoB

Pressure Care Plan SSKIN Bundle 1.Surface 2.Skin Inspection 3.Keep Moving 4.Incontinence 5.Nutrition

THANK YOU FOR YOUR ATTENTION

pressure ulcers the forgotten enemy

Documents

result of pressure

skin epidermis

intact skin

stratum corneum horny

shallow open ulcer

subcutis layer deepest

dry shallow ulcer

pigmented skin