Suspected Deep Tissue Injury (sDTI) Challenges and Solutions Introduce self and topic, and objectives-quick overview of sDTI based on current evidence based practice and recent NPUAP sDTI focused conference Karen Zulkowski, DNS, RN,CWS WOCN 2013

sDTI was first introduced as a pressure ulcer concept by NPUAP in 2003 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 A little background to ground us

SUSPECTED DEEP TISSUE INJURY 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 Speaker Notes: Finally, Suspected Deep Tissue Injury or sDTI is another stage of pressure ulcers and was added to the NPUAP classification system in the late1990’s. It may present as a Purple or maroon localized area of discolored intact skin or a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. While what exactly causes a sDTI, how it evolves and treatment is still being researched we do know that: More than 70% of all sDTI pressure ulcers are in the following locations: Heels 41% Sacrum 19% Buttocks 13% 1 Stewart,TP (Magnano, SJ (1988 )Burns or pressure ulcers in the surgical patient Decubitus. 1(1) 36-40 2. Stewart, T, Salcido, R. (2012). Deep tissue injury: 25 years of learning. Advances in Skin and Wound Care. 15(2):59-60.3. Salcido, R. (2007). Muosubcutaneous infarct:deep tissue injury. Advances in Skin and Wound Care. 20:248-50. 4. Black, J (2009) Deep tissue injury an evolving science, Ostomy/Wound Management 55 (2) 4 5. VanGIlder, C, MacFarlane,GD, Harrison, P, Lachenbruch C, Meyer, S. (2010). The demographics of suspected deep tissue injury in the United States; An analysis of the International Pressure Ulcer Prevalence Survey 2006-2009. Advances in Skin and Wound Care. 23(6):254-61 Salcido R, Lee A, Ahn C. Heel pressure ulcers: purple heel and deep tissue injury. Adv Skin Wound Care. Aug 2011;24(8):374-380; quiz 381-372. 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 2006-2009. Adv Skin Wound Care. Jun 2010;23(6):254-261. 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):26-35. NPUAP. Suspected Deep Tissue Injury: State of the Science and Results of the NPUAP Consensus Conference. Paper presented at: SDTI Consensus

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 More facts on sDTI Salcido R, Lee A, Ahn C. Heel pressure ulcers: purple heel and deep tissue injury. Adv Skin Wound Care. Aug 2011;24(8):374-380; quiz 381-372. 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 2006-2009. Adv Skin Wound Care. Jun 2010;23(6):254-261. 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):26-35. NPUAP. Suspected Deep Tissue Injury: State of the Science and Results of the NPUAP Consensus Conference. Paper presented at: SDTI Consensus

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

BACKGROUND: OVERALL IPUP RESULTS The first International Pressure Ulcer Prevalence Survey was performed in 1989, (24 years ago) in response to a request by NPUAP to benchmark pressure ulcer prevalence in the US. Currently it is performed to assist facilities in quality improvement initiatives to enable facilities to benchmark their PU prevalence against other similar facilities and/or units. The survey has grown from the initial 148 facilities (34,987 patients) in 1989 who participated to 983 facilities with 104,913 patients participating in 2012. As you can see OP and FAP are trending down – that’s good news 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

OVERALL PREVALENCE BY US CARE SETTING: Here is a deeper look at OP in the US by care setting. Note the LTACH and Rehab numbers – same trend but higher overall. Any one here work in these areas? Thoughts on why-pt acuity?LOS? If you are wondering about methodology of IPUP, any Facility can choose to participate in the IPUP survey by signing up on the Hill-Rom® website, (http://www.hill-rom.com/ipup/). Registered sites receive study materials consisting of data collection forms, educational materials and general instructions. The goal of the survey is to perform skin assessments and document findings for 100% of admitted patients during a pre-selected 2 to 3 day window. Patient demographics, pressure risk assessment score, age, stage and quantity of pressure ulcers, unit type, etc. are recorded by the site, sent to Hill-Rom, where they are scanned into the database. Participating facilities then receive a detailed benchmarked customized report demonstrating details on individual progress and trends. 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

FA PREVALENCE BY US CARE SETTING: Now lets look at FAP ….range is 3.4 – 4.3% in 2012, down from 4.0 – 9.0% just 6 yrs ago 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

% BY WORST STAGE – PATIENT LEVEL ANALYSIS We’ve looked at the big picture of OP and FAP digging a little deeper as we go. Now lets introduce sDTI into the picture with this slide. When did sDTI start showing up in the IPUP survey-2003 is when it was added and you can see the steady increase from almost negligible to 11.3% in 2012. Look at the decrease in Stage I PUs at the same time. But note that Stage III-IV have not changed much-work to do here 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

2012 US DATA: OP AND FA BY STAGE (ALL ULCERS) 9.5% 13.4% Further analysis of sDTi 2012 data by Facility type gives us more clarity : 9.5 % and 13.4% OP/FAP respectively. Buried in the downward trends we saw in earlier slides are some pretty startling FA sDTI numbers 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

2012 US ACUTE CARE sDTI BY UNIT TYPE sDTI AS A PERCENT OF ULCERS Can you take one more slide? If we dig down again into unit type within AC facilities, the data indicates we need to look seriously at adult ICUs to impact the sDTI trends we ‘ve reviewed To wrap up the challenge of sDTI with IPUP data conclusions: sDTI’s are more likely to be facility acquired than present on admission 9.5% of all ulcers identified 13.4% of FA ulcers Patient level analysis: sDTI’s represent 11.3% of worst stage ulcers They are commonly found in high acuity care settings and unit types: -LTAC (10% of all ulcers & 18% of FA ulcers) -ICU (14% of all ulcers & 20% of FA 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

Ischemia—Reperfusion Injury WHAT CAUSES sDTI? Pressure/shear Deep muscle that covers bony prominences may have higher overall pressure Shear lowers the ulceration threshold 6-fold1 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 tissue2 Persons with DM are higher risk for reperfusion injury3 Long transportation, OR, ER times4 Here are some thoughts on causes of SDTI Salcido R, Lee A, Ahn C. Heel pressure ulcers: purple heel and deep tissue injury. Adv Skin Wound Care. Aug 2011;24(8):374-380; quiz 381-372. 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):26-35. NPUAP. Suspected Deep Tissue Injury: State of the Science and Results of the NPUAP Consensus Conference. Paper presented at: SDTI Consensus Conference2013; Houston TX Zulkowski K, Zinnecker P, Blackwell C, et al. Examination of Skin Injuries/Lesions on Admission to an ICU JWCET. 2007;27(1). .

IMPACT ON CAREGIVER AND PATIENT Caregiver—Stress is problematic for caregivers with many situations1 Patient—Anxiety is less if the wound is healing but patients expressed disgust with the wound on their body and dependence on others2 Pressure ulcers can have a negative impact on Caregivers and patients alike. caregiver strain resulted in a 23% increased risk of stroke. Elevated stress levels will also suppress the caregiver's immune response, placing him or her at increased risk for infections. Research conducted with heterosexual couples has proven that a caregiver wife's hospitalization increased her chronically ill husband's chances of dying within a month by 35%, and a caregiver husband's hospitalization increased his chronically ill wife's mortality risk by 44%. ipt here 2 Davis C, Bullard D, Brothers K, Semich B. Time out! Recognizing caregiver fatigue. Nursing made Incredibly Easy. 2012;10(5):45-49. 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):3-12.

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 Impact—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 Speaker Notes: We’ve looked at how many are affected but we sometimes don’t think about how pressure ulcers affect the person’s quality of life. The impact is immense. Obviously at the physical level, there is pain and discomfort which may lead to reluctance to move and reposition, diminished activities of daily living and even social isolation. The unpleasant odor from a pressure ulcer may also cause a person to restrict their social interactions. There is also the emotional and financial toll. The meaning of the wound to the person may vary and may include perceptions of betrayal of their own body that can conjure up images of horror movies or shameful repulsive beliefs. In addition, unlike some other medical conditions, pressure ulcers sometimes carry the additional stigma of healthcare professionals assigning blame to patients and caregivers for the development and reoccurrence of pressure ulcers. 1. Baharestani, MM. Advances in Wound Care. 1994;7:40-52.

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 Read slide Hospital Acquired Conditions. 2008. http://www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acquired%20Conditions.asp. Accessed May 16, 2013. MDS 3.0 Manuel V01 07. HHS; 2011. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html. Accessed April 16, 2013.

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 Not a lot is yet published on sDTI-these studies were reviewed at the recent sDTI NPUAP conference

An sDTI can precede admission to a health care facility SDTI STATE OF THE SCIENCE; KEY CONSENSUS POINTS FROM NPUAP BIENNIAL CONFERENCE 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 Read slide

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 TURN & REPOSITION USE APPROPRIATE SUPPORT SURFACE FOR BED AND CHAIR

1. Immersion: Depth of penetration into Surface APPROPRIATE SUPPORT SURFACE HOW DOES A SUPPORT SURFACE HELP OFF LOADING? 1. Immersion: Depth of penetration into Surface 2. Envelopment: Contact area of level of immersion Poor Envelopment Conventional Surface Fluid Support 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 Conformable, stretchy surface materials Bladder design(horizontal or vertical shape) Fluid support(Air Fluidized) Single zone surface 4 zone surface Speakers notes: Looking at the illustration1, Immersion is simply the depth that a load sinks into a surface. All else being equal, the deeper the immersion, the more spreading of load there is, and the lower Pressure But all else is not always equal and we need to include another physical concept – envelopment, which is the ability to conform to irregularities and is shown in illustration 2 The surface that can provide immersion and envelopment, will optimize pressure redistribution: We need to have both Immersion and Envelopment are used along with other support surface design choices to redistribute pressure, such as zoned surfaces, weight based pressure redistribution, and materials that together, minimize pressure points

OTHER AIR FLUIDIZED THERAPY STUDIES PREVENTION AND TREATMENT STRATEGIES CONSIDER THE USE OF AIR-FLUIDIZED THERAPY BEDS 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 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 discharge1 Again, not a lot of published works in the literature. Air Fluidized therapy may have a role to play in preventing and facilitating healing of sDTIs. These were reviewed at the recent NPUAP conference on sDTI Allen L. J Wound Ostomy Continence Nurs. 2012;39:555-561. Ochs RF, et al. Ostomy Wound Manage. 2005;51:38-68. Jackson M, et al. Crit Care Nurse. 2011;31:44-53.

If powered, be sure surface is plugged in and working correctly KNOW IF THE BED IS WORKING 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 Speaker Notes; Remember after a bed with the appropriate support surface is placed, it is everyone’s responsibility to be sure the bed is working properly. Some patients like traumatic brain injury or any patient that can’t communicate is unable to tell you there is a problem. Document the support surface in the plan of care Teach the staff and patient how the product works and why we are using it And above all remember any product does not replace good nursing care

Carefully inspect the skin on admission 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 Read slide

QUESTIONS? drkarenz@aol.com karenz@montana.edu (406)671-2909

REFERENCES Salcido R, Lee A, Ahn C. Heel pressure ulcers: purple heel and deep tissue injury. Adv Skin Wound Care. Aug 2011;24(8):374-380; quiz 381-372. Recognizing caregiver fatigue. Nursing made Incredibly Easy. 2012;10(5):45-49. Additional Resources 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):1175-1183. 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):3-12. 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 2006-2009. Adv Skin Wound Care. Jun 2010;23(6):254-261. 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):1525-1534. Baharestani, MM. The lived experience of wives caring for their frail, homebound, elderly husbands with pressure ulcers. Advances in Wound Care. 1994;7:40-52. 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):26-35. 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):585-589. Hospital Acquired Conditions. 2008. http://www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acquired%20Conditions.asp. Accessed April 11, 2008. NPUAP. Suspected Deep Tissue Injury: State of the Science and Results of the NPUAP Consensus Conference. Paper presented at: SDTI Consensus Conference2013; Houston TX. MDS 3.0 Manuel V01 07. HHS; 2011. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html. Accessed April 16, 2013. 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):359-364. 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 Baharestani MM. Quality of life and ethical issues. In: Baranoski S, Ayello EA eds. Wound Care Essentials. 3rd ed. Wolters Klower;2012;2-20. Allen L. J Wound Ostomy Continence Nurs. 2012;39:555-561. Zulkowski K, Zinnecker P, Blackwell C, et al. Examination of Skin Injuries/Lesions on Admission to an ICU JWCET. 2007;27(1). Ochs RF, et al. Ostomy Wound Manage. 2005;51:38-68. Jackson M, et al. Crit Care Nurse. 2011;31:44-53. Davis C, Bullard D, Brothers K, Semich B. Time out!