[email protected]2017 1 Joyce Black, PhD, RN, CWCN, FAAN University of Nebraska Medical Center Omaha, NE [email protected]1 Study of Adult Nursing Units using NDNQI data ◦ 1381 hospitals from all 50 states from 2008-2010 Outcome data, changes in rates after ruling/payment change of: ◦ Pressure ulcers ◦ Injurious falls ◦ Central line associated bloodstream infections ◦ Catheter-associated urinary tract infections Waters, Daniels, Bazzoli et al. Effect of Medicare’s nonpayment for Hospital Acquired Conditions: lessons for future policy. JAMA 2015, 175 (3), 347-354 [email protected]2 11% reduction in CLABSI’s - sustained 10% reduction in CAUTI’s – sustained .5% reduction in rates of falls - flat 1% reduction in rates of stage III and IV pressure ulcers – sustained slow decline “We acknowledge the concern that not all pressure ulcers are avoidable. However, we believe improving screening to identify ulcers on admission will improve quality of care.” Institutes of Medicine, 2007 [email protected]3 Standardized practices had been developed and tested for CLABSI and CAUTI Practice change was fewer steps Practice change may have only had to occur once or once a day Practice change involved fewer people and products [email protected]4 Pressure injury reduction requires more than admission assessments to change the outcomes! Processes of care are more nebulous with some decisions made at the bedside Nurses carry out assessment and planning but may not do the turning However, the positive outcomes from multilayer foam dressings was just emerging! [email protected]5 Reduce the intensity of the pressure ◦ Support surfaces ◦ Multilayer foam dressing to reduce the pressure ◦ Offload the heel Reduce the duration of the pressure ◦ Turning and repositioning Reduce the effect of shear ◦ Keeping the head of the bed low ◦ Multilayer foam dressings to reduce shear forces Improve the health of the skin ◦ Giving nutrition and hydration ◦ Keeping the skin clean and dry ◦ Protecting damaged skin [email protected]6
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The Anatomy of a Pressure Injury Prevention Program Boise … · Use of turning and positioning systems ... Present current HAPI/FAPI rates and cost ... Brem, Maggi, ...
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11% reduction in CLABSI’s - sustained 10% reduction in CAUTI’s – sustained .5% reduction in rates of falls - flat 1% reduction in rates of stage III and IV
pressure ulcers – sustained slow decline
“We acknowledge the concern that not all pressure ulcers are avoidable. However, we believe improving screening to identify ulcers on admission will improve quality of care.” Institutes of Medicine, 2007
Consider applying a polyurethane foam dressing to bony prominences (e.g., heels, sacrum) for the prevention of pressure ulcers in anatomical areas frequently subjected to friction and shear (B/1)
Lack of clarity in discussion about actual structure of dressing
Not all studies cited used polyurethane foamMany polyurethane foam dressings on the
marketImportant to know how they work and if they
can reduce pressure, shear or microclimateDressings do not replace the rest of prevention! (C/1)
Use of prophylactic dressings over bony prominences reduced the relative risk of pressure ulcers by 0.21 (p = 0.0006) ◦ Moore and Webster, The Cochrane Database of Systematic
Reviews, 2013, 8 (8) Use of prophylactic dressings reduce pressure
injury in immobile patients ◦ Clark, Systematic review of the use of dressings in the
prevention of pressure ulcers, Int Wound J 2014,11,(5),460-471
Braden does not predict heel ulcer risk well◦ Braden score 15 +/- 3
Aspects missing◦ Leg mobility Can vs does◦ Diabetes or Peripheral
neuropathy ◦ Vascular status or perfusion
Delmore, B. Risk factors associated with heel pressure ulcers in hospitalized patients. JWOCN 2015, 42 (3), 242-248
Does the patient movelegs independently?◦ Does versus can
Does the patient have normal or delayed capillary refill? Palpable pulses?
Does the patient have normal sensation?
Does the patient wear TEDs?
When these factors are present… patients are at risk
Heels need to be floated from the bed
Boots can be used◦ Often cannot ambulate◦ Often too hot to wear
Pillows can be used◦ Don’t stay under the calf◦ Migrate to under the knee◦ Fall off of the bed◦ Don’t fully elevate the heel◦ Are placed under the heel
• As organizational “Pressure Ulcer” rates decreased MDR PrIs became much more apparent
• MDRPrIs often were misidentified or “excused”• That’s just what happens
when...”• Not typically tracked, trended or
reported• May not be easy to prevent
• device may be an essential diagnostic/therapeutic component of treatment
• Although most are avoidable, not all are
What is a “medical device”? Fit the device to the patient◦ Measure devices for proper fit
Pretreat the skin with thin foam dressings ◦ Work with other disciplines to assure this
happens Remove or move daily to see the skin Be aware of edema Devices can be “lost” in bariatric
A powerful, validated tool for analyzing tissue deformationFinite Element Modelling
Within Wound care FE modelling can facilitates quantification of internal strains and stresses in weight bearing parts (heels and buttocks) ‐ Levy & Gefen, 2016
Red indicates elevated stress levels
Blue indicates no increase in stress
Multinational expert panel examined evidence on dressings for PIP and MDR PI prior to guidelines in 2014◦ Black, IWJ 2013
◦ Study of 74 patients in which the change in body position was recorded every 15 minutes for an average observation time of 7.7 hours◦ 49.3% of observed time showed no body position
change for >2 hrs, and 2.7% had every-2-hour demonstrable body position change
Positioning prevalence2
◦ Prospectively recorded, 2 days, 40 ICUs in the United Kingdom◦ Average time between turns, 4.85 hours
1.Krishnagopalan S, et al. Crit Care Med. 2002;30:2588-2592.2.Goldhill DR, et al. Anaesthesia. 2008;63:509-515.
Q 2 hr turning with interface pressure map to highlight areas of pressure◦ Sig reduction in PI
over stage 2
◦ Behrendt, 2014
Q 2hr turning with a turn team◦ Sig reduction in PI
Study of residents in long term care on foam mattresses◦ 942 Residents at moderate to high risk for PI◦ Turned randomly Q 2,3 and 4 hrs◦ Compliance with turning measured
Outcomes◦ Pressure injury formation was the same at all frequencies Q 2 hr = 2.5% Q 3 hr = 0.6% Q 4 hr = 3.1%
◦ Pressure injury formation did not differ by riskHigh risk = 1.8%
Moderate risk = 2.1%Bergstrom, et al, 2013 JAGS
Turning to 30 degrees may be difficult◦ Quality of pillows◦ Number of pillows
Use of wedges Use of turning and positioning systems Improved outcomes with use of a turn and
position system (Powers, 2016)◦ Fewer pressure ulcers (6 in SOC, 1 in PPS, p = .042)◦ Angle of turn better (31° in PPS, 22° in SOC)◦ Patients remained in position after 1 hour
Incontinent patients risk for PI higher◦ Prevalence increased from 4.1% to 16.3% ◦ Incidence also higher from 2.6% to 13.6%
Multiple layers of linen each increase the pressure on the sacrum regardless of HOB elevation ◦ Pressure at sacrum on LAL increased from 20 to 64%◦ Pressure at sacrum on foam increased from 6 to 29%
Lachenbruch, Ribble. Pressure Ulcer Risk in the Incontinent Patient. JWOCN. 2016, 43 (3), 235-241.Williamson, Lachenbruch, The effect of multiple layers of linens on surface interface pressure: results of a laboratory study. Ostomy Wound Management 2013, 59 (6), 38-47
Create a list of attributes for the product◦ What do you want the product to do? Or not do?◦ Create a grid that lists Clinical benefits Safety features Ease of use Look at 360 degrees of product use◦ Involve direct caregivers (Magnet)◦ Development of grid provides data devoid of opinion
Root Cause Analysis on all Full Thickness HAPI Goal to determine when and where ulcer began◦ Not to blame, but to guide care and focus education
Start with first notation of PI, stage, location◦ Go back into the record and examine events 48 hours for DTPI 72 -96 hours for Stage 3,4 and Unstageable ◦ Consider location of ulcer and determine position of
patient at the time pressure was applied to body◦ Ask “could anything been done differently at that