Pressure Ulcers: Putting Pressure on Prevention Karen Clay, RN CWOCN

Why are we failing? Insanity –Doing the same thing & expecting different result Changing policy not practices Looking at paper not people

Goals Respond to pressure ulcer needs assessment questionnaire Share prevention “pearls” Identify a variety of prevention possibilities Encourage honest examination of facility practices Plan prevention in the context of each resident’s life, routine and preferences

Questionnaire Results 68% of facilities conduct weekly risk assessment x 4 weeks after admission 85% have process for re-stocking personal care products –44% randomly audit this 52% have process for checking MDS coding accuracy for Section M 31% have “rule” to decrease HOB elevation when picking up meal tray

Questionnaire Results cont’d 55% of weekly skin committees include visual rounds of residents in their seating or bed positioning 78% have permanent assignments for CNAs 68% have PU prevention as part of orientation

Assessing Risk

Other Risk Factors History of pressure ulcers, scarring Medical diagnoses Nutritional deficits - wt loss, low albumin or pre-albumin “Behaviors”: non-compliance, self- destructive behaviors –Do we “create” non-compliance when not including the resident preferences in the plan? –Is the resident REFUSING or CHOOSING?

Complicating Illnesses Impaired cardiovascular or pulmonary function: *Compromise perfusion and oxygenation Conditions with damage to capillary basement membrane - radiation, PVD * Tissue perfusion is restricted Systolic pressure <100 mm Hg and diastolic <60 associated with PU development –may shunt blood flow away from skin to more vital organs…..decreasing skin tolerance by allowing capillaries to close at lower levels of interface pressure

Pain Control Eliminate/control pain –Affects mobility –Affects mental status –Affects motivation –Affects blood flow/perfusion of tissue –Affects nutrition

Sample Protocol “At Risk”Moderate Risk High RiskVery High Risk Turn/reposition every 2 hours (if mobility impaired)  Turn/reposition every 2 hours AND prevent direct contact between bony prominences  Protect heels  If bedfast, provide pressure-reducing support surface  If in wheelchair, provide standard pressure-reducing seat cushion  If appropriate, initiate remobilization program (ambulation, stand-pivot transfers, etc)  Manage moisture (from incontinence)  Manage nutrition  Reduce friction/shear 

Sample Protocol “At Risk”Moderate Risk High RiskVery High Risk Provide wedges/repositioning aids for 30 degree lateral positioning  Supplement turning schedule with small position shifts (hourly)  Obtain rehab assessment to: -determine need for pressure relief cushion -assess correct seat height and w/c positioning  Consider a pressure relieving support surface or powered mattress overlay  Sample risk reduction strategies: Heel Protection – Friction: “gripper” socks, sheepskin at foot of bed, transparent dressings, moisturizers, “bunny” boots Heel Protection – Pressure: elevate lower extremities on pillow, multi-podus boots, heel-lift boots, loosen bed linens at foot of bed, foot cradle Manage Incontinence: initiate bowel/bladder program or scheduled toileting, incontinent care every two hours, incontinence barriers, briefs, absorbent under pads, fecal bag (if frequent stools) Reduce friction/shear: draw sheet or lift pad for bed movement, trapeze, moisturize skin, limit head of bed elevation to 30 degrees (and only as required), long sleeve garments/elbow protectors, careful cleansing during incontinence/hygiene care, gait belt transfers (as appropriate), mechanical lift

Frequency of Assessment Minimally –upon admission –quarterly –upon Significant Change in Condition Ideally –day 7, 14, 21, 28 (post admission) and as above –during acute illness

Risk Assessment Establish guidelines, protocols, algorithms/decision trees based on risk –Low risk does not equal no risk Don’t just treat the conglomerate of score –Intervene based on the risk assessment What risks can you modify?

EXTERNAL FACTORS Pressure Shear Friction Moisture

Manage Moisture B&B programs Briefs Open vs. Closed system at night Cleansing and Moisturizing Moisture barriers Sweat

Fecal Incontinence Maklebust and Magnan (1994) –56.7% of patients with PU were fecally incontinent –22 times more likely to have PU than patients without fecal incontinence

Cleansing & Moisturizing Perineal cleansers better than soap or products for routine skin cleansing –Soap can dry, raise pH and contribute to epidermal erosion Perineal cleansers – most contain humectants –Help replace oils in the skin

Skin Barriers Creams = water based preparations Ointments = oil based, longer lasting (more occlusive) Paste = Ointment with powder; more durability and absorption

SHEAR Tissue layers slide against each other, disrupts or angulates blood vessels

Heels 2 nd most common site Subject to high interface pressures Suspend versus cushion Diligent positioning and assessment –Don’t treat just one heel Be flexible in approach – two hrs in position may not be tolerable

Address Risk Factors Skin care Repositioning –1 hour in chair; 15 minutes in chair by resident; 1-2 hours in bed, lift devices Pressure relief –Cushions, support surfaces, off-load heels Assess/address nutrition, toileting schedule? Rehab? Positioning evaluations?

Support Surfaces Pressure reducing/relief devices –foam, static air, alternating pressure, low air loss, air, gel, etc. –If foam is used it should measure 3-4” in thickness –Egg-crate foam overlays are inadequate –Sheepskin booties do not relieve pressure –Need to learn properties

Rule of 30 Head of bed is elevated to 30 degrees or less Body is placed in a 30-degree laterally inclined position - when repositioned to either side –Hips and shoulders tilted 30 degrees from supine –Pillows or wedges to keep position without pressure over trochanter or sacrum

Repositioning Every 1-2 hours in bed –Pros/Cons of facility-wide “clocks” Positioning devices –No direct contact of bony prominences –MPB and stablizing bars –Individualized w/c “accessories” Encourage mobility CREATE A CULTURE OF MOVEMENT

Tissue Tolerance Deep tissue ischemia can occur without observable changes in skin but it can “sensitize” the skin. After that small increments of pressure may result in breakdown Husain (1953) research with rat muscle pressure of 100 mm Hg 2 hours Three days later: 50 mm Hg pressure to same tissue caused muscle degeneration in only 1 hour

Skin Check To be completed during the resident’s 1st bath of the week. Please check the appropriate box and indicate the location..  Skin tear _____________________________  Bruise _______________________________  Open area ____________________________  Reddened area_________________________  Rash_________________________________  Blister_______________________________  No skin concern  Resident refused shower or bath Comment:_______________________________________________________ _______________________________________________________________ The Charge Nurse will notify the DON when there is a pattern of resident refusals. Charge Nurse Signature______________________________ Date__________

Competencies Have staff been taught how to conduct a skin assessment Competency testing initially and annually –Follow-up when a “necrotic” area is discovered If skin check during shower…..how can we do a complete assessment if resident sitting on a shower chair?

Recurrent PU – Why? Decreased tensile strength of skin Characteristics of scar tissue –Difficulties in assessment Higher level of prevention strategies stopped when wound closes Weekly assessments by team stop when wound closes –Analogy of active rehab and “functional maintenance” programs

Wound Care Teams ?Focus wound progress vs. prevention –Wound characteristics assessed Cushions may/may not be assessed –Presence, condition Heel off-loading devices may/may not be assessed –Is there foot drop/deformity, condition of device, any evidence of pressure from device Posture in chair –Feet firmly planted (on floor or foot rest) –How is position overall? Need therapy?

Mini-Focus Studies Check all residents requiring mechanical lifts –What time does the person get up in a.m.? –What time does the person go back to bed If interval greater than two hours – how is pressure relieved? How is incontinence care given? –Have we worked with the resident to design a schedule that honors their preferences and protects skin Discussing benefit vs. risk with residents

Assignments & Appointments Many facilities have 11-7 assist a group of residents up in a.m. –What is criteria for developing this list –Is skin risk considered If high risk resident assisted by 11-7 resident may be ready for position change, incontinent care/ toileting or back-to-bed at the beginning of 7-3 shift How are routines altered if it is hairdresser day? Podiatry visits? –Potential for prolonged waiting times

Facility Patterns and PU Retrospective review of residents using restraint –How many restrained residents had any stage PU in the past 3 or 6 months? Referrals to therapy for bed mobility? Any program to teach/encourage resident(s) how to use chair rail to stand up?

Wheelchair: Standard Issue How is it decided who “keeps” a w/c at all times? –Versus out of room storage for those requiring for long distances Honest evaluation –Is there a culture of mobility or immobility Wheelchairs for mobility –Not used as “furniture”

Pondering Points…… When folding bedcovers back and putting extra blankets at the end of the bed –Where is the weight? When we remove pillows from under the heels to “boost” the resident –What happens? When we don’t use foot rests on wheelchairs when needed –What happens?

Involving Residents & Families Education in Resident Council Educating families –Ways they can help –Prohibiting family-provided devices unless assessed by the team (cushions from home, etc.) Encouraging culture of mobility

Involve Everyone! “Adopt a Resident” program Every two hour “theme” music/signal “Rounds” aligning with area of expertise –Therapy random rounds for positioning –CNA cross-audits of another unit for presence of skin care supplies at bedside (if appropriate) –SDC random competency check of skin assessment –Any employee: walk thru after b’fast/meals to confirm HOB has been lowered (unless clinically contraindicated) –Activities: who needs more movement incorporated into activities program

“Super CNA” or “Lead CNA” Lighter assignment –Enhance skin prevention role –Verifying position changes, presence/use of devices –Work with nurse to modify resident schedules –Participate in rounds –Update peers weekly on progress

Care Plans Identify modifiable and non-modifiable risks Link assessment with interventions Understand rationales for care Continually re-assess and update Weigh benefit versus risk –Document

Quality Improvement Look for problems that exist in the delivery of care –Systems versus individuals How will you identify the problem(s)? What steps will you take to correct them? How will you measure your success?

Reality Check Check the budget for treatment supply allocations Then…………….. Check the budget for prevention supplies, pillows, positioning devices, cushions What does it show?

Incentives and/or Recognition When goal is reducing staff sick time –Incentives often provided When goal is reducing worker’s comp –Incentives often provided Staffing shortages and recruitment plans –Incentives often provided When goal is reducing PU –“I wish our numbers would come down”

The Devil is in the Details Communication to staff Equipment provision and condition Resident and facility routines Availability of positioning devices Willingness/commitment to have a living, breathing, changing POC Improving one step at a time –Don’t try to solve everything – pick one and start

QI Lessons Learned Systems improvement does not happen from –Writing a new program –Providing education one time –Having “weekly measurements” –Good intentions

MOST IMPORTANT The resident WILL get your time…… Either proactively with PREVENTION Or Reactively with TREATMENT

My Challenge to You For the State that has the greatest decline in pressure ulcers in the next measurement period……….. –I will provide a complimentary four hour educational presentation on any pressure ulcer or wound care topic chosen by that State –The facility within that State with the greatest improvement will be honored at that presentation

Thank you for your time & attention! Karen Clay, RN, BSN, CWCN Clay & Associates (formerly Kare N’ Consulting)