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1 Suspected Deep Tissue Injury (sDTI) Challenges and Solutions Karen Zulkowski, DNS, RN,CWS WOCN 2013.

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Presentation on theme: "1 Suspected Deep Tissue Injury (sDTI) Challenges and Solutions Karen Zulkowski, DNS, RN,CWS WOCN 2013."— Presentation transcript:

1 1 Suspected Deep Tissue Injury (sDTI) Challenges and Solutions Karen Zulkowski, DNS, RN,CWS WOCN 2013

2 2 BACKGROUND sDTI was first introduced as a pressure ulcer concept by NPUAP in 2003 It became part of the NPUAP staging system in 2007 It was again discussed at the NPUAP 2013 consensus conference

3 3 SUSPECTED DEEP TISSUE INJURY Salcido R, Lee A, Ahn C. Heel pressure ulcers: purple heel and deep tissue injury. Adv Skin Wound Care. Aug 2011;24(8): ; quiz VanGilder C, MacFarlane GD, Harrison P, Lachenbruch C, Meyer S. The demographics of suspected deep tissue injury in the United States: an analysis of the International Pressure Ulcer Prevalence Survey Adv Skin Wound Care. Jun 2010;23(6): Gefen A, Farid KJ, Shaywitz I. A review of deep tissue injury development, detection, and prevention: shear savvy. Ostomy Wound Manage. Feb 2013;59(2): NPUAP. Suspected Deep Tissue Injury: State of the Science and Results of the NPUAP Consensus Conference. Paper presented at: SDTI Consensus Definition Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear Description The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler than adjacent tissue Deep tissue injury may be difficult to detect in individuals with dark skin tone Evolution may include a thin blister over dark wound bed. The wound may further evolve and become covered by thin eschar Evolution may be rapid exposing additional layers of tissue even with treatment

4 4 SUSPECTED DEEP TISSUE INJURY: Identifying an sDTI Damage is to deeper tissue and when you see a purplish area it is too late to prevent Heralding sign of Stage III or IV May be from: – Falls – Long OR/ER or transportation times – Splints – Accidents Salcido R, Lee A, Ahn C. Heel pressure ulcers: purple heel and deep tissue injury. Adv Skin Wound Care. Aug 2011;24(8): ; quiz VanGilder C, MacFarlane GD, Harrison P, Lachenbruch C, Meyer S. The demographics of suspected deep tissue injury in the United States: an analysis of the International Pressure Ulcer Prevalence Survey Adv Skin Wound Care. Jun 2010;23(6): Gefen A, Farid KJ, Shaywitz I. A review of deep tissue injury development, detection, and prevention: shear savvy. Ostomy Wound Manage. Feb 2013;59(2): NPUAP. Suspected Deep Tissue Injury: State of the Science and Results of the NPUAP Consensus Conference. Paper presented at: SDTI Consensus

5 5 IDENTIFYING sDTI: ISSUES Difficult to say with certainty a wound is a sDTI as outer skin may be intact – Sometimes it really is a bruise Document exactly what you see

6 6 BACKGROUND: OVERALL IPUP RESULTS Catherine VanGilder MBA, BS, MT, CCRA, et al; Prevalence of suspected Deep Tissue Injuries: Analysis of the 2012 International Pressure Ulcer Prevalence™ Survey, 2012 NPUAP Consensus Panel, Biennial meeting, Oral presentation

7 7 OVERALL PREVALENCE BY US CARE SETTING: Catherine VanGilder MBA, BS, MT, CCRA, et al; Prevalence of suspected Deep Tissue Injuries: Analysis of the 2012 International Pressure Ulcer Prevalence™ Survey, 2012 NPUAP Consensus Panel, Biennial meeting, Oral presentation

8 8 FA PREVALENCE BY US CARE SETTING: Catherine VanGilder MBA, BS, MT, CCRA, et al; Prevalence of suspected Deep Tissue Injuries: Analysis of the 2012 International Pressure Ulcer Prevalence™ Survey, 2012 NPUAP Consensus Panel, Biennial meeting, Oral presentation

9 9 % BY WORST STAGE – PATIENT LEVEL ANALYSIS Catherine VanGilder MBA, BS, MT, CCRA, et al; Prevalence of suspected Deep Tissue Injuries: Analysis of the 2012 International Pressure Ulcer Prevalence™ Survey, 2012 NPUAP Consensus Panel, Biennial meeting, Oral presentation

10 US DATA: OP AND FA BY STAGE (ALL ULCERS) Catherine VanGilder MBA, BS, MT, CCRA, et al; Prevalence of suspected Deep Tissue Injuries: Analysis of the 2012 International Pressure Ulcer Prevalence™ Survey, 2012 NPUAP Consensus Panel, Biennial meeting, Oral presentation 9.5 % 13.4 %

11 US ACUTE CARE sDTI BY UNIT TYPE sDTI AS A PERCENT OF ULCERS Catherine VanGilder MBA, BS, MT, CCRA, et al; Prevalence of suspected Deep Tissue Injuries: Analysis of the 2012 International Pressure Ulcer Prevalence™ Survey, 2012 NPUAP Consensus Panel, Biennial meeting, Oral presentation

12 12 WHAT CAUSES sDTI? Pressure/shear Deep muscle that covers bony prominences may have higher overall pressure Shear lowers the ulceration threshold 6-fold 1 so depending on the circumstances of immobility this may also be a factor Ischemia—Reperfusion Injury Tissue reperfusion following ischemia can result in a cascade of events that leads to inflammation and edema in the tissue 2 Persons with DM are higher risk for reperfusion injury 3 Long transportation, OR, ER times 4 1.Salcido R, Lee A, Ahn C. Heel pressure ulcers: purple heel and deep tissue injury. Adv Skin Wound Care. Aug 2011;24(8): ; quiz Gefen A, Farid KJ, Shaywitz I. A review of deep tissue injury development, detection, and prevention: shear savvy. Ostomy Wound Manage. Feb 2013;59(2): NPUAP. Suspected Deep Tissue Injury: State of the Science and Results of the NPUAP Consensus Conference. Paper presented at: SDTI Consensus Conference2013; Houston TX 4.Zulkowski K, Zinnecker P, Blackwell C, et al. Examination of Skin Injuries/Lesions on Admission to an ICU JWCET. 2007;27(1)..

13 13 IMPACT ON CAREGIVER AND PATIENT Caregiver—Stress is problematic for caregivers with many situations 1 Patient—Anxiety is less if the wound is healing but patients expressed disgust with the wound on their body and dependence on others 2 1.Davis C, Bullard D, Brothers K, Semich B. Time out! Recognizing caregiver fatigue. Nursing made Incredibly Easy. 2012;10(5): Gorecki C, Nixon J, Madill A, Firth J, Brown J. What influences the impact of pressure ulcers on health-related quality of life? A qualitative patient-focused exploration of contributory factors. Journal of Tissue Viability. 2012;21(1):

14 14 PRESSURE ULCERS IMPACT ON PATIENT QUALITY OF LIFE Pain— Pressure ulcer pain can restrict desire to move and reposition, may lead to diminished activities of daily life and social isolation Odor— Malodor from a necrotic pressure ulcer and wound visibility may restrict social interactions Emotional Impac t—Wounds perceived as betrayal of one’s own body; associated with horror movies; shameful; repulsive Financial Impact — “All the medical supplies you need to treat these bedsores. I think in the past two months, I’ve spent close to $300 out of my pocket and I’m on a fixed income.” 1 “We had to live on $302 a month.” 1 Blame— Healthcare professionals often blame patients and caregivers for the development and recalcitrance of pressure ulcers 1. Baharestani, MM. Advances in Wound Care. 1994;7:40-52.

15 15 IMPACT ON FACILITIES Facility—Difference between present on admission and “facility acquired” For NH this is now broken down on MDS and coded on the MDS for Stage II–IV unstagable (sDTI is considered unstagable) Acute Care is not reimbursed for facility acquired Stage II and IV Hospital Acquired Conditions Accessed May 16, 2013.http://www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acquired%20Conditions.asp MDS 3.0 Manuel V HHS; Instruments/NursingHomeQualityInits/MDS30RAIManual.html. Accessed April 16, 2013.http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/NursingHomeQualityInits/MDS30RAIManual.html

16 16 SDTI STATE OF THE EVIDENCE Persons with sDTI were older than the general patient population Theses wounds were more commonly found on the heels (41%) followed by the sacrum (19%) and buttocks (13%)… And were likely to be nosocomial The heel is at greater risk for development of sDTIs. It has a small radii of curvature of the bony prominence and relatively thin overlying soft tissue These factors contribute to a greater index of compression and greater mechanical loading intensity applied by the bony prominence to the overlying soft tissue

17 17 An sDTI can precede admission to a health care facility Given that the standard of care was met, the evolution of a sDTI into a full thickness PU, not present on admission, is NOT evidence of inadequate care A history of friction/shear in the injured tissue makes the diagnosis of sDTI more likely Distinguishing sDTI from other causes of purple/maroon tissue is a complex process SDTI STATE OF THE SCIENCE; KEY CONSENSUS POINTS FROM NPUAP BIENNIAL CONFERENCE

18 18 PREVENTION AND TREATMENT STRATEGIES Watch and document the pressure areas carefully (especially important for heels) If wound is on the heels elevate them off the bed Turn the patient off any affected area If wound is on buttocks limit the time in the chair and use a chair pressure redistribution pad Place the person on an appropriate support surface Always remember frequent turning and repositioning based on the patient’s condition in the bed and chair CHECK HEELS AND ELEVATE USE APPROPRIATE SUPPORT SURFACE FOR BED AND CHAIR TURN & REPOSITION

19 19 APPROPRIATE SUPPORT SURFACE HOW DOES A SUPPORT SURFACE HELP OFF LOADING? Design choices to optimize can include Powered, multi-zone surface adjust to separate body areas Surface algorithms tuned to adjust by body weight, and when HOB raised Design choices to optimize can include Conformable, stretchy surface materials Bladder design(horizontal or vertical shape) Fluid support(Air Fluidized) Single zone surface 4 zone surface 1. Immersion: Depth of penetration into Surface2. Envelopment: Contact area of level of immersion Poor Envelopment Conventional Surface Fluid Support

20 20 PREVENTION AND TREATMENT STRATEGIES CONSIDER THE USE OF AIR-FLUIDIZED THERAPY BEDS 1.Allen L. J Wound Ostomy Continence Nurs. 2012;39: Ochs RF, et al. Ostomy Wound Manage. 2005;51: Jackson M, et al. Crit Care Nurse. 2011;31: In a study, 5 patients with sDTIs were placed on AFT within 12 hours of discovery: Patients experienced much less tissue breakdown than expected, sDTIs can rapidly develop into Stage III or IV wounds 4 injuries healed prior to discharge; 4 developed into Stage II ulcers, and 2 remained sDTIs at discharge 1 OTHER AIR FLUIDIZED THERAPY STUDIES In a retrospective review of 664 nursing home patients were placed on 3 groups of surfaces: Those placed on AFT beds experienced significantly faster healing rates and fewer hospitalizations than those patients placed on AIR surfaces (Group 2). 2 In a comparison of post-cardiovascular surgery patients, 27 patients were identified based on common risk characteristics and placed on AFT: The patients remained on AFT until they were extubated, able to bear weight or weaned off vasopressors. These extremely high-risk patients had a 96% reduction in expected ulcers. 3

21 21 If powered, be sure surface is plugged in and working correctly Be sure it is the right size for the patient (especially important for larger persons whose weight may be centered in one area) IN ADDITION…. Document the bed use in the nursing notes daily Be sure the staff knows how the bed works Teach the patient and family how the bed works and how it is helping with skin care Remember… A support surface does not replace good nursing care Patients still need skin checks, and to be turned & repositioned KNOW IF THE BED IS WORKING

22 22 IN SUMMARY Carefully inspect the skin on admission If you are unsure, document exactly what you see Remember long transportation, OR, ER times impact skin Above all, DOCUMENT Use evidence based best practices to monitor, prevent and treat Plan care based on individual patient needs

23 23 (406) QUESTIONS?

24 24 1.Salcido R, Lee A, Ahn C. Heel pressure ulcers: purple heel and deep tissue injury. Adv Skin Wound Care. Aug 2011;24(8): ; quiz VanGilder C, MacFarlane GD, Harrison P, Lachenbruch C, Meyer S. The demographics of suspected deep tissue injury in the United States: an analysis of the International Pressure Ulcer Prevalence Survey Adv Skin Wound Care. Jun 2010;23(6): Gefen A, Farid KJ, Shaywitz I. A review of deep tissue injury development, detection, and prevention: shear savvy. Ostomy Wound Manage. Feb 2013;59(2): NPUAP. Suspected Deep Tissue Injury: State of the Science and Results of the NPUAP Consensus Conference. Paper presented at: SDTI Consensus Conference2013; Houston TX. 5.Catherine VanGilder MBA, BS, MT, CCRA, et al; Prevalence of suspected Deep Tissue Injuries: Analysis of the 2012 International Pressure Ulcer Prevalence™ Survey, 2012 NPUAP Consensus Panel, Biennial meeting, Oral presentation 6.Zulkowski K, Zinnecker P, Blackwell C, et al. Examination of Skin Injuries/Lesions on Admission to an ICU JWCET. 2007;27(1). 7.Davis C, Bullard D, Brothers K, Semich B. Time out! 8.Recognizing caregiver fatigue. Nursing made Incredibly Easy. 2012;10(5): Gorecki C, Nixon J, Madill A, Firth J, Brown J. What influences the impact of pressure ulcers on health- related quality of life? A qualitative patient-focused exploration of contributory factors. Journal of Tissue Viability. 2012;21(1): Baharestani, MM. The lived experience of wives caring for their frail, homebound, elderly husbands with pressure ulcers. Advances in Wound Care. 1994;7: Hospital Acquired Conditions tal-Acquired%20Conditions.asp. Accessed April 11, tal-Acquired%20Conditions.asp 12.MDS 3.0 Manuel V HHS; Patient-Assessment- Instruments/NursingHomeQualityInits/MDS30RAIMa nual.html. Accessed April 16, Patient-Assessment- Instruments/NursingHomeQualityInits/MDS30RAIMa nual.html 13.Allen L. J Wound Ostomy Continence Nurs. 2012;39: Ochs RF, et al. Ostomy Wound Manage. 2005;51: Jackson M, et al. Crit Care Nurse. 2011;31: Additional Resources 1.Gorecki C, Brown JM, Nelson EA, et al. Impact of pressure ulcers on quality of life in older patients: a systematic review. Journal of the American Geriatrics Society. 2009;57(7): Gorecki C, Lamping DL, Brown JM, Madill A, Firth J, Nixon J. Development of a conceptual framework of health-related quality of life in pressure ulcers: a patient-focused approach. International journal of nursing studies. 2010;47(12): Yamamoto Y, Hayashino Y, Higashi T, et al. Keeping vulnerable elderly patients free from pressure ulcer is associated with high caregiver burden in informal caregivers. Journal of Evaluation in Clinical Practice. 2010;16(3): Allen V, Ryan DW, Murray A. Air-fluidized beds and their ability to distribute interface pressures generated between the subject and the bed surface. Physiol Meas. Aug 1993;14(3): Baharestani MM. Quality of life and ethical issues. In: Baranoski S, Ayello EA eds. Wound Care Essentials. 3 rd ed. Wolters Klower;2012;2-20. REFERENCES


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