Team-Centered Wound Care: Making Your Wound Care Safe and Simple Again

Transcription

1 Team-Centered Wound Care: Making Your Wound Care Safe and Simple Again October 4 th, 2017 Ryan P. Dirks PA-C Founder and CEO

2 Road to success Detailed Wound Assessment/Risk Assessment External Support Individualized Care Planning Documentation Evidence-Based Treatment Documentation

3 TOPICS WOUND ASSESSMENT 101 PRESSURE INJURY DOCUMENTATION KENNEDY ULCERS MEDICAL DEVICE PRESSURE INJURY

4 Wound Assessment Washington and Idaho Health Care Association

5 Wound Assessment Location Etiology Size: Length x width x depth Wound base Wound margins Drainage color Undermining Tunneling/sinus tracks

6 Wound Measurement Measure the greatest length (head to toe) Measure the greatest width (side to side) Describe the wound as the face to a clock Head in 12 o clock Feet are 6 o clock Side to side is 3 o clock to 9 o clock

7 Wound Measurement Measure depth use a cotton tipped applicator to measure the vertical distance to the deepest area in the wound bed. Tunneling= channel that extends in any direction Undermining= tissue destruction underlying intact skin along wound margins

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9 Wound Assessment Location Etiology Size: Length x width x depth Wound base Wound margins Drainage color Undermining Tunneling/sinus tracks

10 Wound Assessment Wound base or wound bed identify color(s) Granulating tissue (red) Slough (yellow) Infected tissue (green) Necrotic tissue (black) Epithelializing (pink) Tissue Hypergranulation Muscle, Tendon, Fascia, Bone

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13 Wound Assessment Wound Edges Intact Irregular Well defined Calloused, fibrotic, firm Macerated, soft Epibole ( Epiboly ) rolled under edges

14 Wound Assessment Drainage Serous, Sanguineous serosanguinous, purulent Amount Odor Strong Foul Musty Mild Sweet Periwound Erythema Induration Texture Scar tissue Lesions/Rashes Edema Temperature Color Ecchymosis Maceration

15 Most Common Chronic Wound Etiologies Pressure Injury/Ulcer Venous Stasis Ulcer Arterial Insufficiency Ulcer Diabetic-Neuropathic Ulcer

16 Pressure Injury

17 Definition of Pressure Injury Localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. (NPUAP, 2016)

18 High Risk Elderly with hip fractures Spinal cord injuries Critical care >70 years of age

19 Pathogenesis of Pressure Injury Stuck between a rock and a hard place Capillary closing pressure generally considered to be 32 mmhg Venous/lymphatic outflow ceases Increased hydrostatic pressure reduces arterial inflow (Bryant, R.A. & Nix, D.P.,2007)

20 Pathogenesis of Pressure Injury Within 2-9 hours of sustained pressure tissue ischemia can occur. (Bryant, R.A. & Nix, D.P.,2007)

21 Sites for Pressure Injury Development

22 Pathogenesis of Pressure Injury INTRINSIC FACTORS Nutritional Debilitation Advanced Age Low Blood Pressure Stress Smoking Elevated Body Temperatures EXTRINSIC FACTORS SHEARING, FRICTION, MOISTURE

23 Moisture Associated Skin Damage NOT a pressure injury Top down mechanism vs. bottom up

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25 How would you stage these?

26 Stage 1 Pressure Injury

27 Stage 1 pressure Injury Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. (NPUAP2016)

28 How would you stage these?

29 Stage 2 Pressure Injury

30 STAGE 2

31 Stage 2 Pressure Injury Partial Thickness Skin loss with exposed dermis Wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). (NPUAP2016)

32 How would you stage this?

33 Stage 3 Pressure injury

34 Stage 3 Pressure Injury Full Thickness Skin Loss Granulation tissue and adipose tissue often visible Slough and/or eschar may be visible Depth of the tissue damage varies depending on anatomical location (no stage 3 on nose and ear) Undermining and tunneling may occur Fascia, Muscle and tendon ligaments, cartilage, and bone are not exposed If slough or eschar obscures the extent of the tissue loss the wound be considered Unstageable. (NPUAP2016)

35 STAGE 3

36 Stage 4 Pressure Injury

37 Stage 4 Pressure Injury Full Thickness and Tissue Loss exposed WITH directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer Slough and/or eschar may be visible undermining and/or tunneling often occur Depth varies by anatomical location If slough or eschar obscures----still A STAGE 4! (NPUAP2016)

38 Unstageable Pressure Injury Full thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be removed. (NPUAP2016)

39 Unstagable Pressure Injury

40 Deep Tissue Pressure Injury

41 Deep Tissue Injury Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin or blood filled blister Pain and temperature change often can precede a skin color change Discoloration may appear differently in darkly pigmented skin DTPI results from intense and/or prolonged pressure and shear forces at the bone-muscle interfaces Can evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4) (NPUAP2016)

42 DEEP TISSUE PRESSURE INJURY

43 Trials, Tribulations and Institutional Risk Centers for Medicare & Medicaid services refuse to reimburse hospitals for hospital acquired wounds at a stage 3/4. (2007) F-Tag 314 Facility must ensure a resident doesn t develop pressure injuries unless the clinical condition demonstrates they were unavoidable. This places more emphasis on documentation and ensuring that appropriate assessments, treatment plans and wound care is reordered Having an advanced provider to assess and order wound care treatments is a major benefit

44 What is a Kennedy Terminal Ulcer A Kennedy Terminal Ulcer is a pressure ulcer some people develop as they are dying

45 First described NPUAP Named after a NP in Fort Wayne Indiana Later found to be described in 1877 Decubitus Acutus by Dr Jean- Martin Charcot. Controversy: is this a symptom of death or a cause of death? Lawyers say categorizing KTU as unavoidable is irresponsible 62 % of patients in hospice develop pressure ulcers in their final 2 weeks of life

46 What does a KU look like It usually presents on the sacrum or buttocks. It can be shaped like a pear, butterfly or horseshoe. It can be red, yellow, black or purple. The borders are usually irregular Sudden onset Common statements: Oh my gosh that was not there the other day

47 KENNEDY ULCER

48 How does a KU progress It usually starts out as a blister or a Stage II and can rapidly progress to a Stage III or IV. May initially look like an abrasion.

49 Cause More research needed Skin utilizes 25-30% of the total cardiac output to maintain perfusion. Probably end of life organ failure of skin. Usually part of multi-organ failure It seems that skin over bony prominences in particular starts to show effects of pressure of a much shorter time frame

50 How are they different from other PI They start our larger that other PI s, and may be more superficial initially. Then develop rapidly in size, depth, and color.

51 Best Treatment Treatment is the same for other PI. What you see is what you treat.

52 MEDICAL DEVICE PRESSURE INJURY

53 DEFINITION Pressure ulcers that result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure ulcer generally closely conforms to the pattern or shape of the device. EPUAP, NPUAP, and Pan Pacific Pressure Ulcer Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guidelines. Second Edition 2014, page 119

54 MEDICAL DEVICE PRESSURE INJURY

55 MEDICAL DEVICE PRESSURE INJURY

56 INCREASED RISK WITH: Impaired sensation Moisture under the device Poor perfusion Altered tissue tolerance Poor nutritional status Edema

57 Common devices Nasogastric tubes Feeding tubes Endotracheal tubes Tracheostomy tubes/collars/straps Oxygen delivery Mask Nasal cannula IV/PICC line/central lines Anti-Embolic stockings bedpans

58 UNAVOIDABLE? When it is medically contraindicated to adjust, relocate, or pad underneath a therapeutic device When a life sustaining vascular access or other medical device precludes turning and positioning When underlying edema or uncontrollable moisture under device compromises tissue tolerance to pressure/shear forces

59 STRATEGIES FOR PREVENTION Proper selection and fitting of device Communicate with patient if possible Close observation Extensive care plan Education Consistent reassessment/re-evaluation Team involvement (PT/OT) Follow manufacturers specifications Secure device properly

60 Road to success Detailed Wound Assessment/Risk Assessment External Support Individualized Care Planning Documentation Evidence-Based Treatment Documentation

61 Learn More!

62 Kick-Off To Team-Centered Wound Care

63 What Makes a Winning Team? Focusing on patient care Willing to discuss ideas and challenge each other in a positive way while always moving to a solution. Understanding that together we are better than if we worked independently: Bringing different treatment ideas together to find the best treatment Serving each other to provide care that would be extremely difficult for one person (one person treats, one positions, one charts) Daily care combined with weekly consulting with an expert can produce faster/more complete healing.

64 Winning Components of Weekly Wound Rounds Consistent Team members Organized Approach Accurate Wound Assessments Evidence-Based Treatments Infection Prevention Consistent Documentation Routine

65 Wound Rounds Flow Huddle Dressing Position Wound Bed Prep Assess

66 Team-Centered Wound Care 2 cohorts of skilled patients with all major types of chronic wounds 311 had standard nursing care (internally led) 372 had multidisciplinary team led by an external wound management group 10 month study 3 primary outcomes Days to heal Wound related re-hospitalizations Cost DeZanzo et al. 2011

67 Internally vs. Externally Led Wound Care 115 average treatment days 0.21% re-hospitalizations/day due to wound complications $ per resident day (did not include outside transportation) 94 average treatment days 0.08%/day $ per resident day

68 Internal group wound care costs $40, Externally led costs $21, Wounds healed faster Less wound related complications/hospitalization I would venture that the quality of care in other non-wound related areas increased although this was not studied. Simply because of less effort and energy spent on wound management.

69 50+ Skilled Nursing Facilities King Peirce Skagit Gray s Harbor Thurston

70 United Wound Healing Washington Data Wound Type Facility Average National Average Arterial Ulcer Dermatologic / Rash Diabetic Ulcer Other Pressure Ulcer Skin Tear Surgical Wound Venous Ulcer Total Average Days To Heal Total Wounds Included Facilities Included

71 IDT Skin Review IDT Team Members Present DNS/ADON Dietary Manager/RD Therapist SDC CNA/NAC (new regs) Unit Manager/RCM s MDS nurse

72 Mrs. Jones 86yof Admitted after recent hospitalization Hip fracture requiring surgical intervention ICU stay

73 Mrs. Jones What s next? Admission to Discharge

74 Questions? Learn More!