WHY THE HEEL? Sharon Lucich, PT, CWS. By the end of this session, the learner will be able to:

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1 WHY THE HEEL? Sharon Lucich, PT, CWS Objectives By the end of this session, the learner will be able to: 1. Describe the unique anatomical features that contribute to the development of heel pressure ulcers 2. Understand the relationship between soft tissue distortion and ischemia 3. Recognize the differences between the medical condition and the position of foot drop 4. Understand how heel ulcer prevention and ankle mobility contribute to maximizing a patient s quality of life Copyright EHOB

2 HOW BIG IS THE PROBLEM? CMS no longer reimburses for Hospital Acquired Pressure Injuries (HAPI s) Pressure Injury Prevalence Rates are viewable online by public Hospitals and Staff can and are being sued for development of HAPI s The Impact of Pressure Injuries... To the SYSTEM In 2007 the Center for Medicare Services spent approximately $43,180 on each Stage III & IV Pressure Ulcer In 2007 CMS reimbursed 257,412 Stage III and IV Pressure Ulcers = $11 billion Length of stay may increase 3.5X for people with pressure ulcers To the PATIENT Pressure ulcers predispose patients to: osteomyelitis, septicemia, longer hospital stays (up to 3.5 times) Patients with pressure ulcers have: pain & disfigurement, reduced quality of life, prolonged rehabilitation, 3X increased mortality. Copyright EHOB

So Let s talk about the heel! http://sumerdoc.blogspot.com/2014/11/heel-fat-pad-syndrome.

Long-Term Acute Care facilities for Facility-Acquired pressure ulcers *Courtney B, Ruppman J,

3 So Let s talk about the heel! Heel Statistics Location, location, location: 2 nd Most common site overall #1 Location in Long-Term Acute Care facilities for Facility-Acquired pressure ulcers *Courtney B, Ruppman J, Cooper H. Save our skin: initiative cuts pressure ulcer incidence in half. Nurs Manage Copyright EHOB

4 Heel Statistics Cost to heal: Average cost of treating a stage III/IV pressure ulcer per hospital stay $43,180 (2007 data) Snapshot of a facility: 20 % of HAPI s were at the Heel 2017 HAPI's thru Mid-October Heel 20% Other Sites 80% Copyright EHOB

5 Snapshot of a facility: Cost of Heel HAPI 20 Heel Ulcers X $43,180 = $863,600 YTD 2017 thru Mid-Oct Est. cost for Stage 3 and 4 Hospitals are no longer reimbursed for HAC s How does a HAPI affect Patient Satisfaction scores? AND Hospital reimbursement! Heel pressure injuries are preventable! But here is what was seen: Low compliance in use of heel protection by clinical staff Lack of/or inadequate skin assessment for heels Why? Awareness of risk??? Copyright EHOB

6 If awareness if the issue To get a better understanding of the problem, let s take a closer look at the Heel Structure Of The Skin Epidermis Dermis Subcutaneous What lies beneath? Copyright EHOB

7 Retains fluid Intact SKIN- It does a lot! Contains the body Detects temperature Provides structural strength Provides structural support Provides Nutrients Energy storehouse Collagen, Elastin production Provides cushion Vitamin D Granulation production Protects from UV Radiation Provides insulation Regulates temperature Epidermis Dermis Subcutaneous Detects pain Defends against infection Detects pressure Provides growth factors Provides light touch sensation Sharon Lucich 2017 Anatomy of the Heel Unique features Calcaneus: protruding bony prominence Largest bone in the foot Primary weight-bearing bone Copyright EHOB

body http://kannakyoto.blog106.fc2.com/blog-entry-80.html Poor vascularity!

8 Anatomy of the Heel Unique features Fat pad: adipose tissue Loose connective tissue composed of white adipocytes Cushions and insulates the body Poor vascularity! Copyright EHOB

9 Main Peripheral Arteries in the Legs Main Arteries in the Heel Copyright EHOB

restored; overcompensation Reperfusion injury: tissue damage occurs due to the presence of free radicals, which are toxic to tissue http://blogs.uoregon.

10 What happens with Stretching or Crimping of vessels from pressure and/or shear*?? Decreased blood supply (ischemia) and decreased oxygen to the cells (hypoxia); release of free radicals Reactive hyperemia: blood supply and oxygen restored; overcompensation Reperfusion injury: tissue damage occurs due to the presence of free radicals, which are toxic to tissue *The Science of Pressure Ulcer Development, Prevention and Treatment with a View of New Approaches to Predict and Model - White Paper James G. Spahn, MD, FACS Reactive Hyperemia? Lucich Copyright EHOB

female, African American; DTPI Left Heel

11 Why are these different? Lucich Direct pressure WITH soft tissue distortion (shear) Thermal Imaging Using Digital And Infrared Cameras 74 years old, female, African American; DTPI Left Heel -7C -6C -5C -4C -3C -2C -1C 0 1 C 2C 3C 4C 5C 6C 7C Copyright EHOB

Relative Skin Temperature From Reference Point Recommendations from the

Ensure that the heels are free of the surface of the bed Prevention and

completely in such a way as to distribute the weight of the leg along

12 Relative Skin Temperature From Reference Point Recommendations from the National Pressure Ulcer Advisory Panel 1. Ensure that the heels are free of the surface of the bed Prevention and 1.1 Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf without Treatment! placing pressure on the Achilles tendon. COPYRIGHT EHOB 2016 Copyright EHOB

Paper test If you can slide a piece of paper under the heel It s off loaded Raising heels too high, without calf support, can cause

13 Remember Assess the Heels (at least) q shift Are there any signs of pressure injury? Use of a mirror can help, but you still have to remove heel offloading device to inspect fully Are the heels offloaded? Paper test If you can slide a piece of paper under the heel It s off loaded Raising heels too high, without calf support, can cause knee hyperextension SCD Tubing placement- Avoid device related injury Monitor mobility status changes Heel protection should not be the only goal: Preserve ankle mobility and function! Copyright EHOB

14 Let s talk about Foot Drop What is it??? Confusing terminology The Position of Foot Drop The Medical Condition of Foot Drop But first, let s understand Neutral Ankle position- -when the foot is at a right angle (90 ) to the lower leg Not in Dorsiflection Not in Plantarflextion Copyright EHOB

15 What is: The Position Of Foot Drop? The normal, relaxed position of the ankle when at rest (i.e. lying in bed) Foot is pointed in a downward direction, away from the body The Position Of Foot Drop If the foot/ankle is in plantarflexion for an extended period of time, the calf muscle and/or Achilles tendon group can shorten and/or develop scar tissue. Permanent tightness can occur and affect ankle mobility. Leads to a plantarflexion contracture Aka: foot drop Aka: heel cord tightness Copyright EHOB

16 Why avoid ankle contractures? Plantarflexion contractures lead to functional impairments that adversely affect daily living activities.* *Clavet H, Hébert PC, Fergusson D, Doucette S, Trudel G. Joint contracture following prolonged stay in the intensive care unit. Can Med Assoc J. 2008;178(6): What can you do to avoid ankle contractures? ROM! Copyright EHOB

What else can you do? Proper positioning in bed!

Consult rehab if spasticity or contractures present What else can you do?

34% of patients with prolonged immobility due to critical illness

and most persisted until the time of discharge.

17 What else can you do? Proper positioning in bed! Consider heel offloading devices that help control ankle positioning Consult rehab if spasticity or contractures present What else can you do? Early mobilization! 34% of patients with prolonged immobility due to critical illness developed a joint contracture that impaired heel mobility after 14 days, and most persisted until the time of discharge.* *Clavet H, Hébert PC, Fergusson D, Doucette S, Trudel G. Joint contracture following prolonged stay in the intensive care unit. Can Med Assoc J. 2008;178(6): Copyright EHOB

normal motion BUT Specific muscles in the anterior leg no longer

18 What else can you do? Early mobilization! But watch the heels!! The Medical Condition Of Foot Drop Calf muscle and ankle joint have normal motion BUT Specific muscles in the anterior leg no longer function DUE TO Failure of the nerve that signals the muscle Copyright EHOB

conditions, *Ludwig LM. Preventing footdrop when your patient's on the mend. Nursing. Aug 1995;25(8):32C-32D, 32F, 32J.

19 Causes of the Medical Condition Of Foot Drop The most common cause of this condition is due to the compression of the peroneal nerve* The most vulnerable aspect of the nerve is located 1-2 cm distal to the fibular head x Can also be caused by spinal disorders or other neurological conditions, *Ludwig LM. Preventing footdrop when your patient's on the mend. Nursing. Aug 1995;25(8):32C-32D, 32F, 32J. such as a stroke or spinal tumor The peroneal nerve can get damaged while in bed. Can also get damaged by tightly applied compression wraps or short leg casts Copyright EHOB

20 In The Medical Condition Of Foot Drop You may notice the patient trip or stumble when they are walking They cannot raise their foot to clear the floor when taking the next step Or the patient compensates: Raising their affected leg unusually high Circumduction What can you do? Rehab Consult: Consider Ankle Foot Orthosis (AFO) Copyright EHOB

21 Quality of life isn t that what it s all about? Questions?? THANK YOU!! Copyright EHOB

22 Copyright EHOB

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