Pressure Ulcers: Changing Occupational Therapy Practice Jeanette Boily & Linda Boronowski Health Care Innovations Conference and Trade Show December 2,

Pressure Ulcers: ChangingPressure Ulcers: ChangingOccupational Therapy Occupational Therapy

PracticePractice

Jeanette Boily & Linda Boronowski

Health Care Innovations Conference and Trade Show December 2, 2009; Calgary

Vancouver Coastal Health & Providence Health Care

Yellow Areas

Practice IssuePractice Issue

Occupational Therapists in Vancouver Coastal Health & Providence Health Care identified concerns regarding variability in their practice of skin care.

The areas of concern were assessment, prevention and management of pressure ulcers.

How to bring a large number of occupational therapists involved in skin care management together across the region to develop consistent practice?

The Challenge

The Football Huddle

Purpose of a huddle:

Coach and players identify strategies

A plan will be adapted to the situation on the field

Make the most of limited time and to determine actions

The Practice Huddle

Purpose of an OT practice huddle?

OTs identify evidence-based practice

Develop a plan that applies to all areas of therapy and sites

Time limited project with frontline OT’s creating a best practice guideline

Goal

To develop a guideline for use as a clinical reasoning tool versus an answer guide for occupational therapists new (and old) to this area of practice

Timeline

Identified Need Spring ‘05

OT Council April ’07 &Jan 08

Huddle 2 Oct ‘06Huddle 1 Nov ‘05

Roll out September ‘08

Evaluation June ‘09

Development

Approval Im

plementation

Evaluation

Review Huddle 3 Sept ‘07

HAIAC March ‘08

Guideline Development

Guideline was developed using:

Research evidence

Existing interdisciplinary guidelines

National Institute for Health and Clinical Excellence (NICE) model

Consensus from occupational therapists

Guideline Content Schematic

Best Practice Recommendations Assessment Care Plan Occupational Therapy Intervention

Appendices

SCHEMATIC OF BEST PRACTICE FOR THE PREVENTION AND TREATMENT OF PRESSURE ULCERS

Holistic assessment, management and intervention are the responsibility of the inter-professional tea

Skin assessment • Should be done based on vulnerability and condition of individual • Is best completed by an interdisciplinary team • Inspect all vulnerable areas • Look for: - persistent erythema - non-blanching redness - blisters - localized heat - localized oedema - localized induration (hardened area)

- purplish/bluish localized areas - localized coolness if tissue death occurs - skin breakdown noting location, possible cause(s) and status of wound

Record assessment • Document the assessment noting all relevant risk factors

• Use of Braden Scale is recommended for prediction of pressure sore risk

Develop care plan Develop an inter-professional care plan for person(s) with pressure ulcer(s) or those vulnerable to skin breakdown

Risk assessment

Risk factors include:

Person • Previous skin breakdown

• Sensory impairment • Decreased consciousness

• Cognition • Pain • Psycho-emotional status

• Decreased mobility • Skeletal deformity,

muscular atrophy and contractures

• Posture • Nutrition/hydration status • Incontinence • Positioning preferences • Extremes of age

Environment • Pressure • Shearing • Friction • Moisture • Socio-economic status • Support surfaces over a 24-hour period

Occupation • Lifestyle choices • Caregiver supports

Reassessment • Reassess risk on an ongoing basis and, in particular, if the person’s circumstances change • Review intervention in response to altered level of risk, condition or needs • Participate in a review of the interdisciplinary care plan

Occupational Therapy Intervention Any intervention must take into consideration the identified risk(s) and causative factor(s) of the skin breakdown. The following are possible options to consider and should not be viewed as an exhaustive list. Referrals should be made to interdisciplinary team members as appropriate.

Professional Practice • Ensure knowledge of up-to-date equipment,

consider strength of evidence and evaluate application

• Incorporate new evidence into practice

Nutrition • Facilitate self-feeding and drinking • Assess for appropriate diet texture to maximize

food and fluid intake

Moisture • Limit use of layers • Avoid folding incontinence pads • Facilitate continence i.e. toileting equipment,

transfers • Consider selection of products that facilitate

airflow and moisture absorption

Communication

• Use plain language for instruction and education

• Facilitate ongoing communication with the team to ensure creation and follow- through of an interdisciplinary care plan

Education • Educate person and care provider(s) about

risk factors and ways to minimize risks • Teach recommended techniques and use of

equipment • Reinforce ongoing monitoring Encourage

individuals or their care providers to inspect the skin regularly using a mirror if necessary

Perform or access information from the initial risk assessment in the person’s first episode of care

Positioning Schedule

• Consider all support surfaces throughout a 24-hour period, causative factors and environmental limitations

• Participate in creating a positioning schedule • Consider position changes consistent with

demands of ADLs and lifestyle choices • Consider positioning and assess for bottoming

out if the person has to sit up in bed for any length of time

• Limit HOB to 30o or at the lowest degree of elevation consistent with medical condition

Repositioning/Transfers

• Minimize skin injury due to friction and shearing

• Consider use of sliding sheets and lifting devices

• Consider use of full electric hospital beds and tilt sitting surfaces

• Teach effective weight shift

Support Surfaces

• Support surfaces must -Promote postural alignment -Correct flexible deformities -Accommodate fixed deformities -Optimize pressure distribution -Offload vulnerable areas

Pain • Implement measures to alleviate or control

pain

Major Theme

Holistic assessment, management and intervention are the responsibility of the inter-professional team

Risk Assessment

Identify Vulnerable Clients

Access information from the interdisciplinary records

Perform risk assessment and repeat on a regularly scheduled basis, or when there is a significant change in the individual’s condition.

ACTIVITY Degree of physical activity

1. BEDFAST: Confined to bed. Completely immobile. Does not make even slight changes in body or extremity position without assistance.

2. CHAIRFAST: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.

3. WALKS OCCASIONALLY Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.

4. WALKS FREQUENTLY: Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours.

Braden Scale

© 1998 Barbara Braden et Nancy Bergstrom. Reprinted with permission. Braden BI, Bergstrom N. Clinical Utility of the Braden Scale for Predicting Pressure Sore Risk. Decubitus. 1989; 2:44-51

Braden Scale

Braden Score for Pressure Ulcer Risk Screening tool to assist in identifying

patients at risk Predictive validity of cut off scores varies

across different populations: 16 for acute care settings 18 for nursing home residents 19 for home health patients

From: Predicting Pressure Ulcer Risk: Using the Braden scale with hospitalized older adults: the evidence supports it. AJN November 2007 Vol. 107, No. 11 (PDF available at www.nursingcenter.com)

Risk Factors

Person

Previous skin breakdownSensory impairmentDecreased consciousnessCognitionPainPsycho-emotional statusDecreased mobilityDeformity, muscular atrophyPostureNutrition/hydration statusIncontinencePositioning preferencesExtremes of age

EnvironmentPressureShearingFrictionMoistureSocio-economic statusSupport surfaces during 24 hour period

OccupationLifestyle choicesCaregiver supports

Skin Assessment

Best completed by interdisciplinary team

OT needs to access information required for clinical reasoning / problem solving process

Inspect all vulnerable areas for: Persistent erythema; Non-blanching redness; Purplish / bluish localised areas, blisters, localized heat, coolness, oedema, or induration, & skin breakdown

Record Assessment

Risk factors

Comments Care Plan Triggered?

Date/ Initials

Previous skin breakdown

Yes No

Sensory Impairment

Yes No

OT Skin Care Risk Assessment Form Template

Record Assessment

Sensory impairment

Does the client/caregiver regularly check the skin visually?

Does the client compensate during functional activities? For example, uses hand to check for rough surfaces before putting on shoe.

Client awareness of impairment

Sensory impairment? Where?

Care Plan ConsiderationsSensory Impairment

Teach client to visually check Teach effective weight shiftingCreate a positioning scheduleProvide equipment, or teach techniques to compensate for sensory impairment during functional activitiesTeach the consequences of skin breakdown

OT interventions

Professional Practice

Communication

Education

Nutrition

Repositioning/Transfers

Support Surfaces

Positioning schedules

Pain

Moisture

OT interventions

Example:

Positioning Schedule

Consider all support surfaces throughout the 24-hour period, causative factors, and environmental limitations.

Participate in creating a 24-hour schedule for persons vulnerable to skin breakdown or with existing pressure ulcers.

OT interventions

Example:

Support Surfaces

Consider use of full electric hospital beds and tilt-in-space sitting surfaces so the person and care giver can reposition for pressure redistribution and comfort.

Reclining chairs and reclining wheelchairs increase the risk of friction and shearing and so should be avoided.

Mattress and Overlay Support Surfaces Decision Tree for Persons at Risk or With Existing Wound(s)

Is the person able to sustain multiple positions or adjust posture to avoid prolonged weight bearing on at risk area(s)?

Goal of intervention Prevent skin breakdown Promote wound healing Prevent further deterioration

Yes No

Select support surface that offers minimal immersion* and envelopment*

Consider products that help redistribute* pressure over the contact areas of the person’s body

Can be made of a solid* material that does not flow perceptibly under stress such as viscoelastic* foam

Select support surface with limited resistance to immersion and low shear

Consider products featuring a fluid (air*, water*, viscous fluid*) to allow immersion of the person into the support surface, to optimize envelopment and to decrease tissue shear strain

Can be powered, non-powered or zoned support surfaces

Key setup consideration - Assess for bottoming out Does the mattress provide adequate immersion in supine, side-lying and, in sitting if the head of the bed needs to be elevated for activities such as eating sitting up in bed? Monitor

Is the skin intact? Is healing occurring? Are there new or recurring

wounds? Is moisture a problem? Is mattress set up and used as

needed?

Positive Outcome

Continue to monitor skin integrity and wound healing regularly

Negative Outcome Review Related care plan Support surface selection

and setup

Repeated negative outcome

With the interdisciplinary team, review treatment goals and plan of care

Is the person able to sustain multiple positions or adjust posture to avoid prolonged weight bearing on at risk area(s)?

MonitorIs the skin intact?Is healing occurring?

Are there new or recurring wounds?Is moisture a problem?

Is mattress set up and used as needed?

Select support surface that offers minimal immersion* and envelopment*

Consider products that help redistribute* pressure over the contact areas of the person’s body

Can be made of a solid* material that does not flow perceptibly under stress such as viscoelastic* foam

Yes

Select support surface with limited resistance to immersion and low shear

Consider products featuring a fluid (air*, water*, viscous fluid*) to allow immersion of the person into the support surface, to optimize envelopment and to decrease tissue shear strain

Can be powered, non-powered or zoned support surfaces

Key setup consideration - Assess for bottoming out Does the mattress provide adequate immersion in supine, side-lying and, in sitting if the head of the bed needs to be elevated for activities such as eating sitting up in bed?

No

Positive Outcome

Continue to monitor skin integrity and wound healing regularly

Negative Outcome

ReviewRelated care planSupport surface selection and setup

Repeated negative outcome

With the interdisciplinary team, review treatment goals and plan of care

OT intervention

Equipment Considerations: Shear

Shear is a mechanical force that moves the overlying skin and soft tissue in an opposite direction to the underlying bony structures. This can result in breakdown of skin from the inside out.A common example of shear strain occurs during raising/lowering of the head of the hospital bed. In this example, skin overlying the trunk and pelvis “sticks” to the mattress as deeper tissues and structures (e.g. spine and pelvic girdle) move in the opposite direction. In this scenario, it is common to see skin breakdown over the coccyx and sacrum.A wound caused by shear forces can appear irregular or elongated in shape.How to minimize shearShear is minimized by enabling skin and body structures to move in the same plane

Grey Box Example:

SHEAR

OT intervention Factors increasing the need for monitoring :

The greater the risk of skin breakdown, the severity of the wound and the complexity of the intervention

Role of OT Active problem solver in implementation

phase Ensure appropriate set-up Develop an explicit monitoring plan

Reassessment

Reassess risk on an ongoing basis and, in particular, if the person’s circumstances change

Review intervention in response to altered level of risk, condition or needs

Participate in a review of the interdisciplinary care plan

Appendices

Glossary of terms

Grading levels of evidence

Braden Scale

Assessment, Care plan, & Intervention tools

References, Search strategies, & Bibliography

Timeline

Roll out September ‘08

Evaluation June ‘09

Knowledge Broker ProjectMay 09

Implement

EvaluateKnowledge Transla

tion

Re-evaluate

From Paper to Practice

AwarenessAgreement

Adoption

Adherence(Pathman, Konrad, Freed, Freeman & Koch, 1996)

AwarenessDistribute Guideline:

OT leaders Skin Care champions Wound Care nurses Electronic access

Use local networking to create a buzz: Rounds, staff meetings, informal

discussion groups

Charge to the Champions

1. Familiarize yourself with the Guideline

2. Start conversations about roles and responsibilities on your units

3. Identify gaps in your own practice

4. Take advantage of educational resources

Agreement

Opinion leaders (champions, huddle participants, clinicians)

Identify knowledge, skills, attitudes

Adoption

Depends on the service delivery model, team clarity and agreement on roles and responsibilities, equipment available

Can’t do everything at once; choose pieces that are most likely to succeed

What is likely to succeed ?

Processes that: Show an advantage Are compatible with current practices Are relatively less complex Are easy to trial Can see results

Adherence/sustainability

This is a multi-factorial, complex area of practice

The processes for implementation are not clear cut nor straight forward

Problem-solving, creativity, garnering resources and supports will be required

This will be an ongoing process of evaluation and development

Lessons Learned Core group of leaders for consistency and

follow through

Frequent communication to maintain momentum and interest

Permission to make mistakes and learn as you go

Alignment with organizational values and priorities

Questions ?