They’re Not Called Mystery
Ulcers.
Stop Pressure Injuries Now!
Speaker
Disclosure
Karen A. Lerner, RN, MSN, ATP, CWS
Regional VP, Clinical
Drive DeVilbiss Healthcare
NPIAP.ORG
Skin
Largest organ in the body
15% of total body weight
21 square feet
9 lbs.
11 miles of blood vessels
300 million skin cells
Renews itself every 28 days
½ dust in your home is dead skin
No extra holes
Pressure Injury
Semantics and Acronyms
6
• Bedsore
• Decubitus
• Decubitus Ulcer
• Pressure Sore
• Pressure Damage
• Pressure Lesion
• Pressure Ulcer, PU
• Pressure Injury, PI
• Stage 1, 2, 3 and 4
• Stage I, II, III or IV
• Deep Tissue Injury (DTI)
• Suspected Deep Tissue Injury (sDTI)
• Group 1 and Group 2 Support Surfaces
• Group I and Group II Support Surfaces
• Pressure Reducing Support Surfaces - PRSS
60K # of Pressure
Injury Hospital Acquired
Conditions (HACs)as cause of death
17KPressure Injury related lawsuits/yr
Wheelchair users who develop Pressure Injuries within 1st year
2.5 million annual # of Americans who
get Pressure Injuries
Health Care Facilities
Health Care Facilities
https://www.ahrq.gov/sites/default/files/wysiwyg/professiona
ls/quality-patient-safety/pfp/pfphac.pdf
Society
Medical errors – 3rd4th*
leading cause of death
in US
* Covid-19 has taken over
the 3rd spot
Society• Pressure Injury prevalence predicts whether a nursing home
will readmit residents to hospitals (HSR- Health Services Research).
• Pressure Injury prevention is used as quality of care indicator
• Pressure Injury prevention is top priority for ALL health care facilities
Society
Who gets pressure injuries?
Who gets pressure injuries?
• Spinal Cord Injuries -
25% - 85%
• Elderly with Femoral
Fractures - 66%
• Quadriplegics - 60%
• Skilled Nursing
Facilities - 23%
• 66% of pressure
ulcers develop in
pelvic region
Who gets pressure injuries?Describe your typical your clients
Top Pressure Injury Intrinsic Risk Factors
• Immobile and partially immobile
• Incontinent
• Insensate
• Heavily medicated
• Nutritional impairment
• Weight loss
• Elderly
• Excess moisture or dryness
• Medical conditions affecting blood flow
• Smoking
• Limited alertness
• Muscle spasms
Who gets pressure injuries?
• Spinal cord injury
• Traumatic brain injury
• Cerebral palsy
• Muscular dystrophy
• Spina bifida
• Osteogenesis imperfecta
• Arthrogryposis
• Amyotrophic lateral sclerosis
• Multiple sclerosis
• Paralysis or paresis
Who gets pressure injuries?
• Alzheimer’s & Non-Alzheimer’s Dementia
• Parkinson’s
• Debility
• Cancers
• Chronic Kidney/ESRD
• CVA/Stroke
• Congestive Heart Failure (CHF) & other heart diseases
• Failure to Thrive
• Liver failure
• Pneumonia & non-infectious respiratory
Who gets pressure injuries?
Kids
• 27% PICU patients
• 0.47% - 13% Non-critical hospitalized pediatric patients
• 20% - 43% Spina Bifida
Definition
Localized damage to skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device.
Intact skin or an open ulcer and may be painful
Result of intense and/or prolonged pressure or pressure in combination with shear
Microclimate, nutrition, perfusion, co-morbidities and soft tissue condition affects tolerance
Stages
Defined in 1975
Changed in 2007; updated in 2016 (6 stages)
Provides a name to the amount of anatomical tissue loss
Confusing to many clinicians
Inaccurate staging
Normal, Healthy Skin
Epidermis Epidermis
Dermis
Adipose
Muscle & Tendons
Bone
Medical Device Related
Describes an etiology
Covid Mask
• Do not use petroleum jelly or mineral oil
• Do not use thin prophylactic dressing
• Remove the mask Q2 for 15 minutes
• Treat abrasions
https://cdn.ymaws.com/npiap.com/resource/resmgr/position_statements/Mask_Position_Paper_FINAL
_fo.pdf
Stage 1
Intact skin: Non-blanchable erythema or redness
Stage 1
Stage 2
Partial-thickness skin loss with exposed dermis
ITD
MASD
IAD
Does Not Include:
MARSI
Trauma
Stage 3
Full thickness tissue loss• Adipose (fat)
• Granulation tissue
• Epibole (rolled wound edges)
• Undermining & Tunneling
• Slough & Eschar
Stage 4
Full-thickness skin and tissue loss with
exposed or directly palpable
• Fascia
• Muscle
• Tendon or Ligament
• Cartilage or Bone
Deep Tissue Injury
Persistent non-blanchable deep red, maroon
or purple discoloration
Unstageable
Obscured full thickness tissue loss
• Slough Eschar
Implications• Q: If a beneficiary has an unstageable ulcer
on the buttocks, does the beneficiary qualify for a pressure reducing mattress? We receive referrals from licensed clinical medical professionals, but they are unable to give a stage on the ulcers. They just state that they are unstageable.A: The beneficiary would not qualify for a Group 2 until the ulcer is able to be staged.
3 Legged Stool
Support SurfacesSupport surfaces are (were?) considered
adjunctive treatment for pain management
& comfort
Pressure Redistribution
What caused this?They’re not called Mystery Ulcers or Injuries
PressureShear and Friction
Moisture
CMS LCD
CMS (TPE, RAC, CERT, SMC)
Changes
– ICD-10s
• L89 Pressure Ulcer Diagnosis code
– Includes body location and stage
Not qualifying
Qualifying
• L89 Pressure Ulcer
Diagnosis code
• Includes body location
and stage
ICD 10s
Initial Qualifications -
Option #1
andPatient has been on a comprehensive
ulcer
treatment program for at least the past
month
which has included:
• use of an appropriate Group 1 Support
Surface
• regular assessment
• appropriate turning
• positioning and wound care
• moisture and incontinence management
• nutritional assessment and intervention
Multiple Stage II pressure ulcers located on the trunk
or pelvis that have failed to improve over the last
month
38
Initial Qualifications -
Option #2
Large or multiple stage III, IV or unstageable
pressure ulcer(s) located on the trunk or pelvis
Unstageable Pressure Injury
39
Initial Qualifications -
Option #3
Recent myocutaneous flap or skin graft
for a pressure ulcer on the trunk or pelvis
(surgery within the past 60 days)
and Patient has been on a Group 2 or 3
support surface immediately prior to a
recent discharge from a hospital or
nursing facility (discharge within the past
30 days).
40
Myocutaneous
flap
Skin Graft
Progression
No Reverse Staging
42
Support Surface Standards
Initiative (S3I) History
42
2001
National Pressure Ulcer Activity Panel
20152007 2011 2014
NPUAP established Support Surface Standards Initiative (S3I) as a task force
First 4 standards are approved by ANSI
S3I is sanctioned by American National Standards Institute (ANSI) through RESNA to develop technical standards for support surfaces
International Organization of Standards (ISO) creates committee to develop international standards for support surfaces
Terms and Definitions developed and validated
2019
Standards published for manufacturers
and suppliers of full body support surfaces
who wish to provide consistent, quality
information to clinicians about their
products
S3I 2017 Update
Characteristics of “high specification foam”
• Mattress height or depth: 6”
• Density: 35- 130 Kg/M2
• IFD: 1.75- 2.4
• MVTR of cover: >300g/m2/24 hours
S3I 2018 Update
S3I 2019 UpdatesS3I Subcommittee of the NPUAP Approves New Support
Surface Standards Tests
S3I 2018
Update
S3I Updates
S3I 2018
Update
S3I Updates
S3I 2018
Update
S3I Updates
S3I 2018
Update
S3I Updates
S3I- How Do You Use This
Information?Which Support Surface is Better?
• Peak Sacral Pressure: 39.5 mmHg or 26.4 mmHg?
• Shear: 22.3 N or 1.8 N?
• Evaporative Capacity: 17.4 g/m2-hr or 1080 g/m2/hr?
• Heat Dissipation: 120 W/m2 or 53 W/m2?
• IFD: 1.0 or 5.0 pcf?
• Density: 25 or 150 Kg/m2
• Regression graphs and regression analysis, P Value?
Evidence
“Currently, it is impossible to determine the most effective surface for either prevention or treatment.” (Guidance, 2001)
“Selection of a support surface plays a major role in preventing pressure ulcers.” (CMS 2007)
“Many specialized beds appear to be effective in reducing the development of pressure ulcers when compared to standard mattresses.” (Agnostini et all, 2001)
“The occurrence of pressure sores and their severity can be significantly reduced when patients at risk receive an interface pressure decreasing mattress.” Hofmann et all. Lancet, 1994)
Evidence
Outcomes Matter
Our health care system moves from the fee-
for-service model to collaborative care model
• Patient Driven Payment Model (PDPM)
• Patient Driven Groupings Model (PDGM)
• Accountable Care Organizations (ACOs)
National Pressure Injury Advisory Panel (NPIAP)
• Survive COVID and die from a pressure injury?
• 2019 guidelines include Support Surfaces
They’re not called “Mystery
Injuries”
Increased # of Pressure Injuries
Covid and Pressure Injuries
Support SurfacesSupport surfaces are (were?) considered
adjunctive treatment for pain management
& comfort
Group 2 Support Surfaces are
not just for Pressure Injuries• Enhancing quality of life
• Sleep
• Pain & comfort
• Respiratory conditions
• Reduce turning & repositioning
• Reduce falls
Shift the Focus
Shift the Focus
• Support surfaces help care giving
– Turning and repositioning
(autofirm feature) are easier
and less painful to the client
– Turning often hurts.
Patients MAY go to every or
q4 or q6 hours turn
schedule rather than q2
hour turning
• Enhance comfort so patients may
require fewer pain meds (narcotic
analgesics) and complain to DME
Provider less frequently
– “Classics”• Local Physicians and Hospitals
• Wound Healing Clinics
• Sub-acute/Short Term Rehab Facilities
– Other Channels• Home Health Agencies (HHAs)
• Long Term Care/Skilled Nursing Facilities
• Assisted Living Facilities
• Outpatient therapy
• Hospice
• Retail/Ecommerce
Who treats Pressure
Injuries?
3 Legged Stool
Intrinsic Risk Factors
• Nutrition
• Demographics
• 02 delivery system
• Chronic Illness
• Medications
• Pain
Nutrition
Don’t miss:• Losing weight
• Won’t or can’t eat
• Too tired to eat
• Non-healing pressure injury
Medicare adults ≥ 65 yo at risk for pressure injury- 76% were malnourished
Low BMI, reduced food intake, impaired ability to eat – 4x higher risk
Nutrition
• Valid Screening Tools (to determine who’s at risk for malnutrition)
• Mini Nutrition Assessment (MNA)
• Malnutrition Universal Screening Tool (MUST)
• Nutrition Risk Screening (NRS-2002)
• Short Nutrition Assessment Questionnaire (SNAQ)
• Encourage
• Hydration
• Protein
• Vitamins and Minerals
Nutrition
• Punitive damages of $92 million, later lowered to $11,855,000, were imposed where malnutrition and dehydration were proven against a nursing home.1
• A dietary manager for a nursing home told state surveyors that her nursing home had "dropped the ball" on a resident's nutrition needs when that resident had lost 17 pounds in 75 days; a $1,385,000 settlement was reached.2
• Malnutrition with a loss of 27% of body weight in 15 months led to a $380,000 settlement just before trial.3
3 Legged Stool
World Union of Wound
Healing Societies
Dressings
• Get rid of dead tissue
• Identify and eliminate infection
• Obliterate dead space
• Absorb excess exudate
• Maintain a moist wound surface
• Provide thermal insulation
• Protect from trauma or bacterial invasion
CMS’ Comprehensive Wound
Treatment Plan
• Regular assessment
• Appropriate turning
• Positioning and wound care
• Moisture and incontinence management
• Nutritional assessment and intervention
Pressure Injuries:
Clinical Education
Part 2
68
Drainage and Odor
• Exudate: Fluid from wound
• Amount, type and odor
• Light, moderate, heavy
• Drainage
• Clear
• Sanguineous (bloody)
• Serosanguineous (blood-tinged)
• Purulent (cloudy, pus-yellow, green)
• Odor: Most wounds have an odor
• Faint, moderate, strong
Debridement
Removal of necrotic tissue
• Mechanical
• Enzymatic or Chemical
• Sharp
• Autolytic
• Biosurgical
Unstageables qualify for group 2 support surfaces
Tissue Type% of each type• Granulation tissue: Red, cobblestone appearance
• Necrotic: Slough, Devitalized, Eschar
• Additional Tissue Damage
Undermining Tunneling
Shear
Pressure Injuries are a
Patient Safety Issue• Timeliness: Pressure Injury can occur in 2 hours
• ID at Risk– Braden Scale (<18)
– Norton Scale (<14)
• Adhere to your institution’s Pressure Injury Prevention Guidelines
– Inspect skin (thoroughly and often)
– Document all efforts
• Work together (interdisciplinary)
– Continuity of care
• Use prevention dressings on bony prominences
PeriwoundTissue around wound• Viable, macerated, inflamed
• Color
• Erythematous
• Pale
• Texture
• Dry or moist
• Boggy (soft)
• Indurated (firm)
• Macerated (white, soggy appearance)
• Edematous (swollen with watery fluid)
• Temperature
• Cool or warm
• Skin integrity
• Lesions, excoriation, maceration, denuded (loss of epidermis)
Infection
• Contamination-microorganisms on wound surface
• Colonization-bacteria growing in wound bed without signs or symptoms of infection
• Critical Colonization-bacterial growth causes delayed wound healing, but has not invaded the tissue
Infection
Bacteria invade soft tissue, cause systemic response
• Inflammation
• Pus
• Increase/change in exudate
• Fever
• Pain
• Delirium in elderly
Measurements
Length x Width x Depth in cm
Stage and Anatomical location
What is a large pressure ulcer? (stage III or IV pressure ulcer criterion for Medicare group 2 support surface coverage)
➢ No standard definition
➢ 8cm? (Length X Width X Depth)
➢ Q: What is considered a large stage III or IV ulcer?
A: There is not a standard definition of 'large stage III or IV’ ulcer. There are things that can be helpful in
determining the size of the ulcer and they include information such as the beneficiary's height, weight,
measurements of the ulcer(s) and any undermining and/or tunneling
Flaps and Grafts
Total 60 days of Group 2 or Group 3 Support Surface
Movement Monitors
Display patient movement data:
• Identify patients who were
self‐turning & patients in need of
assisted turns
Potential benefits:
• Prevention of falls & pressure
injuries
• More accurate triaging of patient
care needs with regard to patient
turning
Inside Out
It detects changes in the sub-epidermal moisture, which
can indicate localized edema and tissue fluid related
inflammation days before visually discernible skin damage.
Portable thermal sensor for spotting
elevated temperature on the skin, a
parameter that can point to infection or
active healing, depending on where the
heat around the wound is produced
Pressure Injury Best Practices
• National Pressure Ulcer Advisory Panel, European Pressure Ulcer
Advisory Panel and Pan Pacific Pressure Injury Alliance. (2014).
Prevention and Treatment of Pressure Ulcers: Quick Reference Guide.
• Agency for Healthcare Research and Quality (AHRQ). (2011). Preventing
Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care.
Rockville, MD: U.S. Department of Health and Human Services.
• Veterans Health Administration. (2011). VHA Handbook 1180.02
Prevention of Pressure Ulcers.
• Institute for Healthcare Improvement (IHI). (2011). How-to Guide: Prevent
Pressure Ulcers. Cambridge, MA: Institute for Healthcare
Improvement.
NPIAP
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Resources
NPIAP
NPIAP
NPIAP
NPIAP
Hospice Hospice patients are at greater risk of pressure injury development than most patients
Wound Pain
• May be indicator of inadequate wound management, untreated underlying cause and/or infection.
• Frequently happens during dressing change, debridement, from the pressure of exudate, around wound edges, and in the infected wound.
• 50% of patients with pressure injuries have pain, particularly those with Stages 3 and 4 injuries.
• Regardless of support surface in use, each patient should be assessed periodically for comfort.
Hospice• Protect wound edges with barrier cream or hydrocolloid wafer
cut to fit around wound.
• Allow patients to do their own dressing change if possible.
• Allow patients to call time out.
• Let patients know that there are “no points for bravery”; blood flow can decrease during episodes of pain.
• Pre-medicate prior to dressing change and debridement..
• Encourage the use of compression bandages, hose and binders to decrease swelling and thereby decrease pain.
• Consider the use of dressings least likely to adhere and cause pain like hydrogels, hydrofibers, alginates, and soft silicones.
• Dressings such as gauze and others that can dry out can cause tremendous pain, especially when removed.
• Limit tape; try tubular net bandages
Recap
• They’re NOT Mystery
Injuries
Thank you!
Questions?
Anything you’d like to discuss?
Future topics?
Karen [email protected]
Drive Medical
516-998-4600