SACS 2.0a review of the original SACS scale

and a proposal of a new classification

ANTONINI MarioOstomy and Wound Care Specialist – Local Healthcare Toscana Centro - Empoli

Professor at University of Florencemantonini11@alice.it

“The Peristomal skin should be

intact with no evidence of

redness, loss of epidermis or

sensations such as itchiness,

warmth or pain ”

Colwell J, Beitz J. Survey of wound ostomy and continence (WOC) nurse clinicians on stomal and peristomal complications: A content validation study. J Wound Ostomy Continence Nurs.

2007;34(1):57-69.

WHAT IS A PERISTOMAL SKIN DISORDERS?

- Any compromise in the integrity of peristomal skin (definition)- Wide range of incidence rates:

- 10,2 – 40% (review of 7 studies)1

- 18 – 55%2

- Lack of consensus concerning stomal and peristomal complications does not allow for comparison of prevalence rates

1. Salvadalena G. Incidence of complications of the stoma and peristomal skin among individuals with colostomy, ileostomy, and urostomy: a systematic review. J Wound Ostomy Continence Nurs. 2008;35(6):596-607.

2. Bosio G, Pisani F, Lucibello L, Fonti A, Scrocca A, Morandell C, Anselmi L, Antonini M, Militello G, Mastronicola D, Gasperini S. A proposal for classifying peristomal skin disorders: results of a multicenterobservational study. Ostomy Wound Manage. 2007;53(9):38-43.

3. Colwell J, Beitz J. Survey of wound ostomy and continence (WOC) nurse clinicians on stomal and peristomal complications: A content validation study. J Wound Ostomy Continence Nurs. 2007;34(1):57-69.

ST. CYR ET AL. (2012)

An evaluation of the canadian assessment guide

44%

BOSIO ET AL. (2007)

A proposal for classifying peristomal skindisorders: results of a multicenter

observational study

52%

COLWELL ET AL. (2001)

The state of the sandard diversion

56%

ANTONINI M, MILITELLO G (2013)

The incidence of Stomal and PeristomalComplications in Italy: results of a pilot study

56%

SCARPA ET AL (2007)

Rod in loop ileostomy: just aninsignificant detail for ileostomy-

related complications?

61%

REVIEW OF THE LITERATURE

Incidence of complications of the stoma and peristomal skin

among individuals with colostomy, ileostomy, and

urostomy: a systematic review.

Salvadalena G. Journal Wound Ostomy Continence Nurs. 2008

Nov-Dec;35(6):596-607; quiz 608-9.

Number of participants in each phase of the analysis.

Different length of the studies.NO DEFINITIONS OF SKIN DISORDERS.

NO DESCRIPTION OF THE ASSESSMENT OF

THE SKIN LESIONS.

Complications

Time OSTOMY COMPLICATIONS PERISTOMAL COMPLICATIONS Cutaneous signs

Immediate post-operative complications (0 – 72 hrs)

Oedema Contact Allergic Dermatitis (CAD) Cutaneous alterations

Ischaemia and necrosis Candidiasis Infection

Intra and peristomal haemorrage Folliculitis or other bacteria

Malpositioning Pseudo-verrocous lesion Proliferation

Poor creation of a stoma Oxalates deposit

Late post-operative complications Retraction Neoplasia

Prolapse Mucocutaneous detachment Ulcer

Fistula Pressure Ulcers

Stenosis Contact Irritative Dermatitis (CID)

Hernia Pyoderma Gangrenosum

Trauma Trauma

Pseudo-inflammatory polypse Dermatitis Artefact

Psoriasis Dermatological disease

Eczema

Seborrheic dermatitis

WHAT IS THE SACS INSTRUMENT?

- An evidence-based instrument developed out of a clinical need

- A systematic literature review revealed that no universal system existed to objectively classify peristomallesions according to type and location

- The SACS™ Instrument was developed to help establish a standard language for the assessment and classification of peristomal lesions

- Provides operational definitions for the consistent interpretation of peristomal skin lesions

- An objective classification system to document the incidence of peristomal skin lesions

L1 – Erythematous lesion(peristomal erytheme withoutloss of substance

L2 – Erosive lesion with loss of substance as far as and non beyond the basal membrane

L3 – Ulcerative lesion beyondthe basal membrane

L4 – Ulcerative fibrinous/necrotic lesion

LX – Proliferative lesion(neplasia, granulomas, osalatedeposit)

ORIGINAL SACS CLASSIFICATION

The SACS 2.0 Study: objectives

1. Completion of the classification to include an additionallevel of severity (L5)

2. Classification of all types of peristomal skin changespresent, eliminating the notion of «most serious lesion»

Empoli

Prato

Rimini

Catania

Beginning of the SACS 2.0 Study

(January 2013)

End of the SACS 2.0 Study

(December 2014)

Coming soon…..

WCET Journal

Ostomy Patient

S.A.C.S. 2.0 Study

ENROLLMENT

Time frames

T0 T1 T2 T6T5T4T3

ASSESSMENT

7 DAYS

14 DAYS

1 MONTH 2 MONTHS

3 MONTHS

6 MONTHS

Consensus Conference

SACS 2.0 Classification

The SACS 2.0 Study: Results

PATIENTS ENROLLED

Skin Integrity

171

Peristomal SkinDisorders

255

Incidence

59,86%

47%53%

Gender

Males ♂ Females ♀

43%

40%

17%

Ostomy Types

Colostomy Ileostomy Urostomy

61

74

23

66

13

18

0 10 20 30 40 50 60 70 80

L1: Erythematous lesion

L2: Erosive lesion

L3: Ulcerative lesion

L4: Ulcerative with fibrin/necrotic lesion

L5: Ulcerative involving planes beyond thefascia

LX: Proliferative lesion

Peristomal Skin Disorders

L1 – Erythematous lesion(peristomal erytheme withoutloss of substance

L2 – Erosive lesion with loss of substance as far as and non beyond the basal membrane

L3 – Ulcerative lesion beyondthe basal membrane

L4 – Ulcerative fibrinous/necrotic lesion

L5 – ULCERATIVE LESION INVOLVING

PLANES BEYOND THE MUSCOLAR

FASCIA (WITH OR WITHOUT FIBRIN, NECROSIS, PUS OR FISTULA)

LX – Proliferative lesion(neplasia, granulomas, osalatedeposit)

SACS CLASSIFICATION 2.0

Objective n.1: Completion of the classification to include an additional level of severity (L5)

THE SACS STUDY: TOPOGRAPHY (T)

TOPOGRAPHY (T)

Perspective of the HCP

- I = Upper Left Quadrant

- II = Upper Right Quadrant

- III = Lower Right Quadrant

- IV = Lower Left Quadrant

- V = All the Quadrants

Patient standing in front of the

HCP

The order of the quadrants around the stoma

starts in the Upper Left corner (TI) and ends

in the Lower Left corner (TIV) clockwise.

Objective n.1: Completion of the classification to include an additional level of severity (L5)

L5 – ULCERATIVE LESION INVOLVING PLANES BEYOND THE

MUSCOLAR FASCIA (WITH OR WITHOUT FIBRIN, NECROSIS, PUS OR

FISTULA)

We therefore proposed the sole inclusion of the condition relating to the detection of a new non-classifiable lesion (L5) — even though it has a low presence in our study (5%)

4. Sandy-Hodgetts K, Carville K, Leslie GD. Determining risk factors for surgical wound dehiscence: a literature review. Int Wound J 2015;12:265-75.5. Dealey C. The management of patients with acute wounds. In: Dealey C. The Care of Wounds: A Guide for Nurses. Fourth edition. Hoboken, NJ: John Wiley & Sons; 2012.

L5 – ULCERATIVE LESION INVOLVING PLANES

BEYOND THE MUSCOLAR FASCIA (WITH OR

WITHOUT FIBRIN, NECROSIS, PUS OR

FISTULA)

L5, TI-III-IV

Objective n.2: Classification of all types of peristomal skin changes present, eliminating the notion of «mostserious lesion»

L2, TV: EROSIVE LESION WITH SUPERFICIAL LOSS OF SUBSTANCE

(LESIONS 1, 2 AND 3); L4, TII-III-IV – FIBRINOUS/NECROTIC

ULCERATIVE LESION (LESIONS 5 AND 6); LX, TIII-IV -PROLIFERATIVE LESION (LESION 4)

WHEN USING THE SACS 2.0 INSTRUMENT:

- Document each lesion observed

- Document the topographical location(s) for each lesion observed

The sole classification of the prevailing sign (most serious lesion) is reductive in most cases and not explanatory for the health professional. For example, ‘redness’ may exist as a single lesion (simple redness - L1) or co-exist together with an ulcerative fibrinous/necrotic lesion (L4) as a sign of inflammation/infection, but may also not be present in an ulcerative lesion (L3) as it is in the healing phase. In literature such situations may be referred to as primary skin lesions present at the onset of the disorder or as secondary skin lesions as a result of modifications over time caused by the progression of the disorder, manipulation, medications or the healing process5. During the course of the development of consensus it was thus decided that each lesion present in the peristomalquadrant should be classified.

5. Dealey C. The management of patients with acute wounds. In: Dealey C. The Care of Wounds: A Guide for Nurses. Fourth edition. Hoboken, NJ: John Wiley & Sons; 2012.

CLASSIFICATION OF THE LESIONS IN THE PHOTO (EXAMPLE):

- L2, TV (lesions 1,2 and 3)

- L4, TII-III-IV (lesions 5 and 6)

- LX, TIII-IV (lesion 4)

L2, TV: erosive lesion with superficial lossof substance

L4, TII-III-IV –fibrinous/necrotic ulcerative lesion

LX, TIII-IV -proliferative lesion

L2, TV: EROSIVE LESION WITH SUPERFICIAL LOSS OF SUBSTANCE

L4, TII-III-IV – FIBRINOUS/NECROTIC ULCERATIVE LESION

LX, TIII-IV - PROLIFERATIVE LESION

CO

NC

LUSI

ON

The inclusion of an additional descriptive clinical picture of a lesion such as L5 and the possibility to classify any lesion present in the peristomalquadrant makes the classification more precise for the health professional.

We have maintained the basic characteristics of the original SACS Study, on the basis of which it is objective, reproducible and easy to use.

This upgrade tool offers, at all clinicians, a complete guideline for a correct interpretation and diagnosis of skin disorders, characteristics not present in other types of classification.

The use of the SACS instrument is important in terms of determining and documenting skin lesions, that it would contribute to the exact measurement of the prevalence and incidence of skin lesions, and that it would provide assistance in clinical decision making.

The low rate of lesion L5 is a limitation of this study, but only for the numerosity of the sample. However, the numerosity of this type of lesion is strongly influenced by risk factors such as: Abdominal operative procedure, operative time, emergency procedure and clean wound classification.Consequently the need to implement the existing classification with a type of clinical picture that interested the abdominal structures beyond the dermis.

FUTURE STEPS

• The study group is currently working on a NEW

DIAGNOSTIC PROPOSAL FOR EACH ‘L’ CONDITION, which, in all likelihood, we will refer to as ‘LD’ (LESION DIAGNOSIS) and to which will necessarily correspond a TOPICAL OR SYSTEMIC THERAPEUTIC

PROPOSAL referred to as ‘R’ (RESOLUTION).

THANK YOU FOR YOUR

ATTENTION

ANTONINI MarioOstomy and Wound Care Specialist – Local Healthcare Toscana Centro - Empoli

Professor at University of Florencemantonini11@alice.it