Team-Centered Wound Care: Making Your Wound Care Safe and Simple Again October 4 th, 2017 Ryan P. Dirks PA-C Founder and CEO
Road to success Detailed Wound Assessment/Risk Assessment External Support Individualized Care Planning Documentation Evidence-Based Treatment Documentation
TOPICS WOUND ASSESSMENT 101 PRESSURE INJURY DOCUMENTATION KENNEDY ULCERS MEDICAL DEVICE PRESSURE INJURY
Wound Assessment Washington and Idaho Health Care Association
Wound Assessment Location Etiology Size: Length x width x depth Wound base Wound margins Drainage color Undermining Tunneling/sinus tracks
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
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
Wound Assessment Location Etiology Size: Length x width x depth Wound base Wound margins Drainage color Undermining Tunneling/sinus tracks
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
Wound Assessment Wound Edges Intact Irregular Well defined Calloused, fibrotic, firm Macerated, soft Epibole ( Epiboly ) rolled under edges
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
Most Common Chronic Wound Etiologies Pressure Injury/Ulcer Venous Stasis Ulcer Arterial Insufficiency Ulcer Diabetic-Neuropathic Ulcer
Pressure Injury
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)
High Risk Elderly with hip fractures Spinal cord injuries Critical care >70 years of age
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)
Pathogenesis of Pressure Injury Within 2-9 hours of sustained pressure tissue ischemia can occur. (Bryant, R.A. & Nix, D.P.,2007)
Sites for Pressure Injury Development
Pathogenesis of Pressure Injury INTRINSIC FACTORS Nutritional Debilitation Advanced Age Low Blood Pressure Stress Smoking Elevated Body Temperatures EXTRINSIC FACTORS SHEARING, FRICTION, MOISTURE
Moisture Associated Skin Damage NOT a pressure injury Top down mechanism vs. bottom up
How would you stage these?
Stage 1 Pressure Injury
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)
How would you stage these?
Stage 2 Pressure Injury
STAGE 2
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)
How would you stage this?
Stage 3 Pressure injury
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)
STAGE 3
Stage 4 Pressure Injury
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)
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)
Unstagable Pressure Injury
Deep Tissue Pressure Injury
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)
DEEP TISSUE PRESSURE INJURY
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
What is a Kennedy Terminal Ulcer A Kennedy Terminal Ulcer is a pressure ulcer some people develop as they are dying
First described NPUAP 1989. 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
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
KENNEDY ULCER
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.
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
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.
Best Treatment Treatment is the same for other PI. What you see is what you treat.
MEDICAL DEVICE PRESSURE INJURY
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
MEDICAL DEVICE PRESSURE INJURY
MEDICAL DEVICE PRESSURE INJURY
INCREASED RISK WITH: Impaired sensation Moisture under the device Poor perfusion Altered tissue tolerance Poor nutritional status Edema
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
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
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
Road to success Detailed Wound Assessment/Risk Assessment External Support Individualized Care Planning Documentation Evidence-Based Treatment Documentation
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Kick-Off To Team-Centered Wound Care
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.
Winning Components of Weekly Wound Rounds Consistent Team members Organized Approach Accurate Wound Assessments Evidence-Based Treatments Infection Prevention Consistent Documentation Routine
Wound Rounds Flow Huddle Dressing Position Wound Bed Prep Assess
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
Internally vs. Externally Led Wound Care 115 average treatment days 0.21% re-hospitalizations/day due to wound complications $354.26 per resident day (did not include outside transportation) 94 average treatment days 0.08%/day $229.07 per resident day
Internal group wound care costs $40,678.63 Externally led costs $21,449.00 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.
50+ Skilled Nursing Facilities King Peirce Skagit Gray s Harbor Thurston
United Wound Healing Washington Data Wound Type Facility Average National Average Arterial Ulcer 40 81 Dermatologic / Rash 24 42 Diabetic Ulcer 40 83 Other 32 57 Pressure Ulcer 33 71 Skin Tear 15 30 Surgical Wound 30 67 Venous Ulcer 53 69 Total Average Days To Heal 35 69 Total Wounds Included 1326 266222 Facilities Included 84 803
IDT Skin Review IDT Team Members Present DNS/ADON Dietary Manager/RD Therapist SDC CNA/NAC (new regs) Unit Manager/RCM s MDS nurse
Mrs. Jones 86yof Admitted after recent hospitalization Hip fracture requiring surgical intervention ICU stay
Mrs. Jones What s next? Admission to Discharge
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