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

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Presentation on theme: "Pressure Ulcers: Changing Occupational Therapy Practice Jeanette Boily & Linda Boronowski Health Care Innovations Conference and Trade Show December 2,"— Presentation transcript:

1 Pressure Ulcers: Changing Occupational Therapy Practice Jeanette Boily & Linda Boronowski Health Care Innovations Conference and Trade Show December 2, 2009; Calgary

2 Vancouver Coastal Health & Providence Health Care Yellow Areas

3 Practice 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.

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

5 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

6 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

7 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

8 Timeline Identified Need Spring ‘05 OT Council April ’07 &Jan 08 Huddle 2 Oct ‘06 Huddle 1 Nov ‘05 Roll out September ‘08 Evaluation June ‘09 Development Approval Implementation Evaluation Review Huddle 3 Sept ‘07 HAIAC March ‘08

9 Guideline Development Guideline was developed using:  Research evidence  Existing interdisciplinary guidelines  National Institute for Health and Clinical Excellence (NICE) model  Consensus from occupational therapists

10 Guideline Content  Schematic  Best Practice Recommendations  Assessment  Care Plan  Occupational Therapy Intervention  Appendices


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

13 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.

14 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

15 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

16 Risk Factors Person Previous skin breakdown Sensory impairment Decreased consciousness Cognition Pain Psycho-emotional status Decreased mobility Deformity, muscular atrophy Posture Nutrition/hydration status Incontinence Positioning preferences Extremes of age Environment Pressure Shearing Friction Moisture Socio-economic status Support surfaces during 24 hour period Occupation Lifestyle choices Caregiver supports

17 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

18 Record Assessment Risk factorsCommentsCare Plan Triggered? Date/ Initials Previous skin breakdown  Yes  No Sensory Impairment  Yes  No OT Skin Care Risk Assessment Form Template

19 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?

20 Care Plan Considerations Sensory Impairment  Teach client to visually check  Teach effective weight shifting  Create a positioning schedule  Provide equipment, or teach techniques to compensate for sensory impairment during functional activities  Teach the consequences of skin breakdown

21 OT interventions  Professional Practice  Communication  Education  Nutrition  Repositioning/Transfers  Support Surfaces  Positioning schedules  Pain  Moisture

22 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.

23 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.

24 Is the person able to sustain multiple positions or adjust posture to avoid prolonged weight bearing on at risk area(s)? 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? 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 Review  Related care plan  Support surface selection and setup Repeated negative outcome With the interdisciplinary team, review treatment goals and plan of care

25 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 shear Shear is minimized by enabling skin and body structures to move in the same plane Grey Box Example: SHEAR

26 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

27 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

28 Appendices  Glossary of terms  Grading levels of evidence  Braden Scale  Assessment, Care plan, & Intervention tools  References, Search strategies, & Bibliography

29 Timeline Roll out September ‘08 Evaluation June ‘09 Knowledge Broker Project May 09 Implement Evaluate Knowledge Translation Re-evaluate

30 From Paper to Practice Awareness Agreement Adoption Adherence (Pathman, Konrad, Freed, Freeman & Koch, 1996)

31 Awareness Distribute Guideline:  OT leaders  Skin Care champions  Wound Care nurses  Electronic access Use local networking to create a buzz:  Rounds, staff meetings, informal discussion groups

32 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

33 Agreement  Opinion leaders (champions, huddle participants, clinicians)  Identify knowledge, skills, attitudes

34 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

35 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

36 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

37 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

38 Questions ?

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