1. Spotlight Case The Forgotten Turn

2. 2 Source and Credits This presentation is based on the December 2010 AHRQ WebM&M Spotlight Case –See the full article at http://webmm.ahrq.govhttp://webmm.ahrq.gov –CME credit is available Commentary by: Susan Barbour, RN, FNP, University of California San Francisco Medical Center –Editor, AHRQ WebM&M: Robert Wachter, MD –Spotlight Editor: Bradley A. Sharpe, MD –Managing Editor: Erin Hartman, MS

3. 3 Objectives At the conclusion of this educational activity, participants should be able to: Describe the six stages of pressure ulceration per the National Pressure Ulcer Advisory Panel. List risk factors for the development of pressure ulcers in hospitalized patients. Appreciate the importance of early skin assessment and the challenges of pressure ulcer identification. Describe measures that can be implemented early in the hospitalization to prevent pressure ulcer development.

4. 4 Case: Forgotten Turn A 79-year-old woman with mild dementia presented to the emergency department (ED) after sustaining a mechanical fall at home. She was ambulatory with a walker and had slipped on a rug. In the ED, she was found to have right hip and left humerus fractures. Because of her two fractures, she was unable to move in bed without severe pain or without assistance. She was admitted to the hospital for surgical management of her hip fracture..

5. 5 Case: Forgotten Turn (2) Because of a bed shortage, the patient remained in the ED for 8 hours before being transferred to an inpatient room during the change in nursing shifts at 7:00 AM. Due to a mechanical problem with one of the beds, the patient was kept in the same bed she had been in from the ED (a thin and firm mattress).

6. 6 Case: Forgotten Turn (3) The day nurse found the patient to be confused but oriented, pleasant, and clinically stable; the patient complained of pain with any movement. The nurse began his admission assessment but was interrupted multiple times because of acute issues with other patients. He gave the patient her morning medications but was unable to provide any further interventions.

7. 7 Case: Forgotten Turn (4) In mid-afternoon, the nurse and patient care assistant came to turn and bathe the patient, and discovered a moderate-sized stage 2 pressure ulcer (partial thickness skin loss resulting in ulceration) on her left hip.

8. 8 Epidemiology Pressure ulcers common after hip fracture –Rates from 36% to 66% Also common in other hospitalized patients –Rates from 4% to 38% Patients with pressure ulcers are at risk for pain, distress, increased length of stay, infection, death See Notes for references.

9. 9 Regulatory Bodies & Payers In 2007, Centers for Medicare & Medicaid Services (CMS) listed hospital-acquired pressure ulcers as common, costly, and “reasonably preventable” –One of eight conditions given this designation Based on this, CMS stopped reimbursing hospitals for these complications when they occur in the hospital Organizations publish pressure ulcer rates online See Notes for reference.

10. 10 Pressure Ulcer Definition National Pressure Ulcer Advisory Panel (APUP) defines a pressure ulcer as: “A localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.” See Notes for reference.

11. 11 Pressure Ulcer Stages Pressure Ulcer Stages: National Pressure Ulcer Advisory Panel (NPUAP)–2007 Stage IIntact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage IIPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage IIIFull thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IVFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. UnstageableFull thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Suspected deep tissue injury 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. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

12. 12 Pressure Ulcer Risk Factors Multiple known risk factors can contribute to development of pressure ulcers –Immobility –Altered mental status or delirium –Pain –Fecal incontinence –Malnutrition –Peripheral arterial disease/neuropathy (heel ulcers) See Notes for references.

13. 13 Identification of Pressure Ulcers Early identification is essential Most common sites for pressure ulcers are sacrum, coccyx, buttocks, heels Skin changes can mimic other conditions (e.g., bruises, fungal conditions), making diagnosis challenging If uncertainty, suspected pressure ulcers should be treated as such See Notes for references.

14. 14 Identification of Pressure Ulcers (2) Skin changes can appear days after the tissue injury Pressure ulcers often cause pain initially— may be a warning sign Providers should be particularly vigilant in setting of delirium, non–English-speaking patients, or patients with other serious illness (like a hip fracture, as in this case) See Notes for reference.

15. Case: Forgotten Turn (5) Upon review of the records, there was no documentation of a skin assessment at any point in her hospitalization. Furthermore, it became clear the patient had not been moved in her bed since her time in the ED, which likely led to the rapid development of this pressure ulcer. 15

16. 16 Documentation of Pressure Ulcers Appropriate documentation is not just part of the nursing assessment Physicians should document pressure ulcers on admission and throughout the hospital stay CMS denial of reimbursement for pressure ulcers that develop in hospital is based on physician documentation

17. 17 Preventing Pressure Ulcers Bundled interventions including: –Risk assessment –Skin assessment –Support surface assessment –Nutritional screening –Moisture management –Optimizing fluids and hydration –Regular repositioning

18. 18 Regular Repositioning Guidelines suggest high-risk patients be repositioned at least every 2 hours Institutions have tried different cues as reminders for repositioning including: –Specific bedside clocks –Overhead music played at specific intervals –Pagers remind staff to turn patients every 2-4 hours See Notes for reference.

19. 19 Specific Preventive Measures High-risk patients have a SKIN ALERT sticker outside the chart and signs at the bedside At UCSF, all hip fracture patients are immediately placed on a high-level pressure redistribution surface—a type of mattress that uses air or fluid to redistribute the patient’s weight across the entire surface, limiting focal points of pressure

20. 20 Technology or Creative Devices Computerized alerts can remind staff to complete assessments or finish aspects of the bundled intervention Attaching small portable mirrors to the blood pressure machines may facilitate assessing difficult-to-see locations An interdisciplinary team of health care providers focused on identifying and preventing pressure ulcers is optimal approach

21. 21 Take-Home Points Pressure ulcers continue to occur despite national focus on pressure ulcer prevention. To be effective, pressure ulcer prevention programs must involve all departments and staff, including physicians. Pressure ulcers may already be evolving on hospital admission in patients admitted with hip fracture. Place targeted populations of high-risk patients on high-level support redistribution surfaces upon entry into the hospital before skin changes appear.