Pressure Ulcers 101 or Hospital Acquired Pressure Ulcers What you need to know

1. Pressure Ulcers 101orHospital Acquired Pressure UlcersWhat you need to know Kristin Moeller, M.D. Contra Costa Regional Medical Center July 2009

2. Learning Objectives • Learn the definition of a Hospital Acquired Pressure Ulcer (HAPU) • Learn the significance of HAPU • Learn how to stage HAPU • Learn who is at risk for HAPU • Learn how to prevent HAPU

3. Pressure Ulcer Definition: Localized skin injury which develops as a result of unrelieved pressure Frequently over a bony prominence Can be as a result of a medical device (Foley) Often is a result of shear or friction forces combined with pressure

4. HAPU(Hospital-acquired pressure ulcer) • HAPU is the new buzz-word: • Prevention of HAPU is key • Preventing Stage 1 and 2 ulcers from progression to Stage 3 or 4 is the next goal

5. HAPU CMS (Medicare/Medicaid) will no longer reimburse for treatment of Stage 3 or 4 pressure ulcers acquired at our hospital • Stage 3 and 4ulcers are reportable events: • If acquired at CCRMC or if present on admission fill out SERS (Safety and Event Reporting System) report on computer • SERS information goes to Hospital Administration and the State!

6. Who’s at risk? Everyone! Well, OK, not everyone but lots of our patients. Risk factors: limited mobility, poor nutrition, critical illness, chronic disease, dehydration, incontinence, fever, infection, poor sensation, obesity, age, medications, and various other medical diagnoses

7. Whose job is it to prevent Pressure Ulcers? Everyone’s! Look at the skin, especially in high risk patients Document what you see Ulcer, no ulcer/intact skin, color changes If Stage 3 or 4, document in H & P and fill out SERS or bring to attention of the Charge Nurse If you can stage the ulcer, great; if not, talk to an attending or the nurses to help you

8. Why???? Good, complete patient care If no ulcer on admission, prevent one If there is an ulcer, heal it & prevent worsening Money $$$ CMS is one of our main sources of reimbursement – we are charged with caring for some of the most vulnerable members of the population

9. What do I have to do? We all need to Look and Document Document skin exam on H & P Check the skin regularly, especially in high risk patients and document updated exams Request help from Attending Staff or Nursing regarding staging and treatment If nursing brings an ulcer to your attention – see it and document it a.s.a.p.

10. What if I identify a Pressure Ulcer? Put it in your H & P (or Progress Note) Put it in your orders as an admit diagnosis, either as a primary or secondary diagnosis Write orders for wound care Notify the Charge Nurse and fill out a SERS report Not sure? Ask a Staff member for help (Attending M.D. or Charge Nurse)

11. Staging Basics • Don’t be intimidated, the rules are easy • ONLY Pressure Ulcers are stageable • Other wounds (surgical, venous stasis, neuropathic/diabetic ulcers) are not • A wound never “regresses” in stage • A Stage 2 is always a Stage 2 • As it heals, it becomes a “healing Stage 2 ulcer”

13. Stage 1 Pressure Ulcer Non-blanching erythema over a pressure point; area may be painful, firm, soft, warm or cool. • Note: the skin is intact

14. Stage 2 Pressure Ulcer Partial thickness disruption of the dermis with shallow red/pink wound bed without slough; no undermining or tunneling. • Note: this includes blisters

15. Skin Tears • Do not confuse a Stage 2 Pressure Ulcer with a skin tear.

16. Stage 3 Pressure Ulcer Full thickness tissue loss with disruption of the dermis and into SubQ; may have slough, tunneling,undermining. No muscle, tendon or bone is exposed.

17. Stage 4 Pressure Ulcer Any deeper disruption, which disrupts the fascia and may or may not involve muscle, bone, tendon or ligament. • Note: does not necessarily go to bone but be suspicious for osteomyelitis

18. Deep Tissue Injury I Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage to underlying soft tissue from pressure.

19. Deep Tissue Injury II The area may be preceded by tissue that is painful, firm, boggy, warmer or cooler as compared to adjacent tissue. Evolution may be rapid exposing additional layers of tissue even with treatment.

20. Unstageable I Full thickness tissue injury in which the base of the ulcer is covered by slough (yellow, tan, gray, green, brown) or eschar (tan, brown, black).

21. Unstageable II • * Special care must be taken with heel ulcers. Do NOT unroof unless aided by an experienced physician. They may be better left intact.

23. Treatment I Keep wounds moist but not too moist. Debride any necrotic or excess fibrinous tissue Sharp, chemical or autolytic debridement. If you are getting near bone, tendon or ligament, STOP until you have more experienced hands & eyes with you. Unless the wound is a Stage 4 or causing sepsis, this can all be done slowly and cautiously. Damp to dry dressing with Saline will get you through the night. If you are the new primary team in the AM, look at the identified wound a.s.a.p. and begin to formulate a treatment plan.

24. Treatment II • Initiate/reassess prevention strategies: • Pressure reducing mattress • Maximize mobility • Maximize Nutrition • Minimize devices • Good skin hygiene • Be sure to communicate with your patient & caregiver in his/her native language Empower your patient to partake in his/her care

26. Wound Care Team“Wound Wednesdays” Goal 1: Educate! Goal 2: Prevent Pressure Ulcers Goal 3: Prevent worsening of Pressure Ulcers (avoid progression to Stage 3 or 4) Goal 4: Help guide treatment via interdisciplinary team approach Goal 5: Planned Obsolescence!

27. Forms – more paperwork! Yes, they are coming. Initial Documentation and order form Follow-up documentation form Q week or for any significant change of status

28. Forms – Initial Documentation

29. Photo – op? • All Pressure Ulcers must be documented with photos • Upon diagnosis and Q week on Wednesdays • Photos are uploaded in PACS (yup, with the Xrays) • Other wounds may be documented with photos to document wound progression

30. In Brief • Documentation is key • Physician must be part of documentation of HAPU • Must be documented on admit H & P to document that it was not caused at our facility • Prevention is key • Ask for help as we are all learning this new system