Current Status of Pressure Ulcer Management in the US Geriatric Population Gregory A Bohn, MD MAPWCA, ABPM/UHMS

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1 Current Status of Pressure Ulcer Management in the US Geriatric Population Gregory A Bohn, MD MAPWCA, ABPM/UHMS Department of Surgery Central Michigan School of Medicine Tawas, Michigan

2 Disclosures Medical/Scientific Boards: Medline Convatec Acelity ULURU Consultant: ULURU Activities: President American Board of Wound Healing Past President: Association for the Advancement of Wound Care (AAWC)

3 HAPU and Value of Prevention HAPUs affect over 2.5million patients annually 60,000 deaths Develop from sequelae of inpatient therapy Widely used as an indicator of Hospital Quality HAPUs cost hospitals $9.1 to $11.6 billion annually Padula WV, et al. Value of hospital resources for effective pressure injury prevention: a cost-effectiveness analysis. BMJ Qual Saf 2018;0:1 10

4 Preventions / Interventions Value of hospital resources for effective pressure injury prevention: a cost-effectiveness analysis Prevention guidelines applied to all patients daily Risk-stratified prevention only to patients below certain categorical Braden score thresholds Standard care for all patients in which compliance is variable Padula WV, et al. Value of hospital resources for effective pressure injury prevention: a cost-effectiveness analysis. BMJ Qual Saf 2018;0:1 10

5 Preventions / Interventions Skin and Tissue Assessment Risk Assessment (Braden) Preventative Skin Care Skin Clean and Dry Barrier Moisturizer Nutritional Assessment Padula WV, et al. Value of hospital resources for effective pressure injury prevention: a cost-effectiveness analysis. BMJ Qual Saf 2018;0:1 10

6 Value of Preventative Measures Nursing best practices for HAPU prevention (risk assessment Braden Scale) Time-consuming and complex tasks that require nursing diligence in order to be completed Compliance with best practices may therefore be lower when patients have acute needs or require other procedural interventions for which nursing time is reimbursed. There is little research on the comparative effectiveness on value of repeated Braden Scale completion. Padula WV, et al. Value of hospital resources for effective pressure injury prevention: a cost-effectiveness analysis. BMJ Qual Saf 2018;0:1 10

7 Value of Preventative Measures Most cost-effective strategy remained prevention-for-all Risk stratifying patients and providing pressure-injury prevention only to patients with Braden scores <15 was both less costly and more effective than standard care. Remaining diligent to perform follow-up risk assessment in all hospitalized patients appears to be of good value and improve quality compared with providing risk-stratified prevention to only higher-risk patients. Padula WV, et al. Value of hospital resources for effective pressure injury prevention: a cost-effectiveness analysis. BMJ Qual Saf 2018;0:1 10

8 Conclusions on Prevention Pressure ulcer prevention in all hospitalized patients remains the highest value alternative Requires investment in a quality-improvement infrastructure of nursing time and technology to remain compliant. Hospitals can little afford this investment to improve if constantly being penalized Payment system reform in the US that supports hospitals to invest and apply prevention guidelines could be more beneficial to patients. Padula WV, et al. Value of hospital resources for effective pressure injury prevention: a cost-effectiveness analysis. BMJ Qual Saf 2018;0:1 10

9 Value cost Analysis of Prevention Administrators may find themselves in a financial predicament 500-bed hospital International Guidelines represent over 150 nursing hours per day Pressure-distributing beds cost $10000 each Skin care and moisture management cost $30 50 per patient-day. Startup costs in the first month $250,000 One HAPU out of 100 inpatients, offset cost of prevention for a cost of 500-bed hospital Cost of Prevention $99.44/Pt/day Assuming a health system has 500,000 covered lives Cost 24 per day in an infrastructure to prevent HAPUs is good value considering the morbidity these conditions cause.

10 AGING SKIN Multiple Contributing Factors in Aging: Changes in body composition Skin thinning Muscle loss Bone demineralization Energy imbalance Malnutrition Protein Malnutrition Strength Neurodegeneration Neuropathy Balance Dementia Gould LJ, Fulton AT; Wound Healing in Older Adults Rhode Island Medical Journal 2016 Feb p

11 Elderly and Aging Skin Loss of protective functions Decreased SQ fat, Sweat Glands, Pilosebacous Glands Reduced Sebum Production Diminished sensation, light touch and pressure Preventative Skin Care Skin Clean and Dry Barrier Moisturizer Gould LJ, Fulton AT; Wound Healing in Older Adults Rhode Island Medical Journal 2016 Feb p

12 Healing in the Elderly Co Morbid Conditions Affect Healing Renal failure Peripheral vascular disease Diabetes Malnutrition Altered hormone levels (Estrogen, Testosterone, GH) Anemia changes CHF, Venous stasis, and hypoalbuminemia Gould LJ, Fulton AT; Wound Healing in Older Adults Rhode Island Medical Journal 2016 Feb p Levine,J. Pressure Ulcers and Wound Care Geriatrics Review Syllabus. Ed. Samuel C. Durso, Ed.Gail M Sullivan. American Geriatrics Society, 2016

13 Aging Skin Loss of Rete Ridges Skin separates easily Dermal Thickness Decreased Macrophages Fibroblasts, Langerhans Cells Reduced ECM components, Collagen, Glycosaminoglycan, Elastin Changes in Aging Skin 3 19 yo 74 yo

14 Pressure Ulcer Development Changes occur more rapidly in aged skin are contributing factors to wounding: Alterations in collagen fibers orientation : susceptible to tear? Thinning of dermis : easily damaged? Reduced collagen production : Slower healing? Increased MMP-1 : ECM breakdown Chronicity? Slow proliferation of fibroblast : Slower repair? Stojadinovic O, Minkiewicz J, Sawaya A, Bourne JW, Torzilli P, et al. (2013) Deep Tissue Injury in Development of Pressure Ulcers: A Decrease of Inflammasome Activation and Changes in Human Skin Morphology in Response to Aging and Mechanical Load. PLoS ONE 8(8): e69223

15 Pressure Ulcer Development Recent ex-vivo Study with application of a compressive load to ischemic aged skin resulted in : Sub-epidermal separation Altered orientation of the collagen fibers similar to that seen in patients with pressure ulcers Changes occur more rapidly in aged skin and alterations in collagen fibers orientation are feature of aged skin. Thinning of dermis, reduced collagen production, increased MMP-1 and slow proliferation of fibroblast in aged skin are contributing factors. Stojadinovic O, Minkiewicz J, Sawaya A, Bourne JW, Torzilli P, et al. (2013) Deep Tissue Injury in Development of Pressure Ulcers: A Decrease of Inflammasome Activation and Changes in Human Skin Morphology in Response to Aging and Mechanical Load. PLoS ONE 8(8): e69223

16 Pressure Damage in Aged Skin We report that a continuous load of 300 kpa leads to subepidermal separation in ex vivo human skin upon loading for 4 hrs in both, aged and young ischemic skin, suggesting that tissue damage may not be entirely preventable. Changes occur more rapidly in aged skin and alterations in collagen fibers orientation are feature of aged skin ( 2 hrs vs 4 hrs ). Stojadinovic O, Minkiewicz J, Sawaya A, Bourne JW, Torzilli P, et al. (2013) Deep Tissue Injury in Development of Pressure Ulcers: A Decrease of Inflammasome Activation and Changes in Human Skin Morphology in Response to Aging and Mechanical Load. PLoS ONE 8(8): e69223

17 Biomechanics and Age: Inflammasome Role Stojadinovic Olivera, MD Department of Dermatology & Cutaneous Surgery University of Miami Miller School of Medicine Jackson Memorial Hospital Focal disruptions along basement membrane in elderly skin together with change in orientation of collagen fibers may identify initial changes that lead to development of pressure ulcers in elderly population. Inflammasome is multiprotein complex Expressed in keratinocytes Component of Innate immune system Responsible for activation of inflammatory processes - IL1 IL1 suppressed in aged and loaded skin Inflammasome components are suppressed in elderly indicating greater risk for PrUs

18 Aging Skin and Healing Multiple Contributing Factors in Aging: Changes in body composition Skin Thinning Loss of Elasticity Keratinocyte dysfunction Muscle loss Bone demineralization Energy imbalance Malnutrition Protein Malnutrition Strength Neurodegeneration Neuropathy Balance Dementia Gould LJ, Fulton AT; Wound Healing in Older Adults Rhode Island Medical Journal 2016 Feb p

19 Deep Tissue Injury in Development of Pressure Ulcers: Skin Morphology of Aging Skin Changes occur more rapidly in aged skin: Alterations in collagen fibers orientation are feature of aged skin. Thinning of dermis Reduced collagen production Increased MMP-1 Slow proliferation of fibroblast in aged skin Loss of Langerhans Cells Stojadinovic O, Minkiewicz J, Sawaya A, Bourne JW, Torzilli P, et al. (2013) Deep Tissue Injury in Development of Pressure Ulcers: A Decrease of Inflammasome Activation and Changes in Human Skin Morphology in Response to Aging and Mechanical Load. PLoS ONE 8(8): e69223

20 Tissue Biomarkers: Pressure Mapping Not Enough Kath Bogie, PhD Case Western Reserve University Cleveland, OH Muscle quality, specifically fat infiltration, impacts local tissue quality and resilience Muscle composition impacted skin blood flow component with significant correlations with gluteal intramuscular fat Muscle quality A Missing Key Factor? Normal muscle Fat infiltrated muscle

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22 Early Detection: Recall the Paradigm of Pressure Induced Tissue Damage How Can We Detect the Damage occurring before we can see it a the skin level?

23 Early Detection: DTI Richard Simman, MD, FACS, FACCWS

24 The cascade from microscopic to macroscopic edema Sub-epidermal moisture (SEM), which cannot be detected through visual skin assessment, is the early sign of macroscopic edema Pending FDA decision, not for sale in the US

25 Treatment Often Ineffective Pressure relief Nutrition Mobility Healing defects Growth factors Osteomyelitis Infection ECM devices NPWT Surgical Flaps Harder to treat than Prevent? Focus on Prevention May well provide most immediate Benefit!

26 Certification Path to Fellowship Become Wound Care Certified

27 Current Status of Pressure Ulcer Management in the US Geriatric Population Gregory A Bohn, MD MAPWCA, ABPM/UHMS Department of Surgery Central Michigan School of Medicine Tawas, Michigan