They’re Not Called Mystery

Ulcers.

Stop Pressure Injuries Now!

Speaker

Disclosure

Karen A. Lerner, RN, MSN, ATP, CWS

Regional VP, Clinical

Drive DeVilbiss Healthcare

NPIAP.ORG

Skin

Largest organ in the body

15% of total body weight

21 square feet

9 lbs.

11 miles of blood vessels

300 million skin cells

Renews itself every 28 days

½ dust in your home is dead skin

No extra holes

Pressure Injury

Semantics and Acronyms

6

• Bedsore

• Decubitus

• Decubitus Ulcer

• Pressure Sore

• Pressure Damage

• Pressure Lesion

• Pressure Ulcer, PU

• Pressure Injury, PI

• Stage 1, 2, 3 and 4

• Stage I, II, III or IV

• Deep Tissue Injury (DTI)

• Suspected Deep Tissue Injury (sDTI)

• Group 1 and Group 2 Support Surfaces

• Group I and Group II Support Surfaces

• Pressure Reducing Support Surfaces - PRSS

60K # of Pressure

Injury Hospital Acquired

Conditions (HACs)as cause of death

17KPressure Injury related lawsuits/yr

Wheelchair users who develop Pressure Injuries within 1st year

2.5 million annual # of Americans who

get Pressure Injuries

Health Care Facilities

Health Care Facilities

https://www.ahrq.gov/sites/default/files/wysiwyg/professiona

ls/quality-patient-safety/pfp/pfphac.pdf

Society

Medical errors – 3rd4th*

leading cause of death

in US

* Covid-19 has taken over

the 3rd spot

Society• Pressure Injury prevalence predicts whether a nursing home

will readmit residents to hospitals (HSR- Health Services Research).

• Pressure Injury prevention is used as quality of care indicator

• Pressure Injury prevention is top priority for ALL health care facilities

Society

Who gets pressure injuries?

Who gets pressure injuries?

• Spinal Cord Injuries -

25% - 85%

• Elderly with Femoral

Fractures - 66%

• Quadriplegics - 60%

• Skilled Nursing

Facilities - 23%

• 66% of pressure

ulcers develop in

pelvic region

Who gets pressure injuries?Describe your typical your clients

Top Pressure Injury Intrinsic Risk Factors

• Immobile and partially immobile

• Incontinent

• Insensate

• Heavily medicated

• Nutritional impairment

• Weight loss

• Elderly

• Excess moisture or dryness

• Medical conditions affecting blood flow

• Smoking

• Limited alertness

• Muscle spasms

Who gets pressure injuries?

• Spinal cord injury

• Traumatic brain injury

• Cerebral palsy

• Muscular dystrophy

• Spina bifida

• Osteogenesis imperfecta

• Arthrogryposis

• Amyotrophic lateral sclerosis

• Multiple sclerosis

• Paralysis or paresis

Who gets pressure injuries?

• Alzheimer’s & Non-Alzheimer’s Dementia

• Parkinson’s

• Debility

• Cancers

• Chronic Kidney/ESRD

• CVA/Stroke

• Congestive Heart Failure (CHF) & other heart diseases

• Failure to Thrive

• Liver failure

• Pneumonia & non-infectious respiratory

Who gets pressure injuries?

Kids

• 27% PICU patients

• 0.47% - 13% Non-critical hospitalized pediatric patients

• 20% - 43% Spina Bifida

Definition

Localized damage to skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device.

Intact skin or an open ulcer and may be painful

Result of intense and/or prolonged pressure or pressure in combination with shear

Microclimate, nutrition, perfusion, co-morbidities and soft tissue condition affects tolerance

Stages

Defined in 1975

Changed in 2007; updated in 2016 (6 stages)

Provides a name to the amount of anatomical tissue loss

Confusing to many clinicians

Inaccurate staging

Normal, Healthy Skin

Epidermis Epidermis

Dermis

Adipose

Muscle & Tendons

Bone

Medical Device Related

Describes an etiology

Covid Mask

• Do not use petroleum jelly or mineral oil

• Do not use thin prophylactic dressing

• Remove the mask Q2 for 15 minutes

• Treat abrasions

https://cdn.ymaws.com/npiap.com/resource/resmgr/position_statements/Mask_Position_Paper_FINAL

_fo.pdf

Stage 1

Intact skin: Non-blanchable erythema or redness

Stage 1

Stage 2

Partial-thickness skin loss with exposed dermis

ITD

MASD

IAD

Does Not Include:

MARSI

Trauma

Stage 3

Full thickness tissue loss• Adipose (fat)

• Granulation tissue

• Epibole (rolled wound edges)

• Undermining & Tunneling

• Slough & Eschar

Stage 4

Full-thickness skin and tissue loss with

exposed or directly palpable

• Fascia

• Muscle

• Tendon or Ligament

• Cartilage or Bone

Deep Tissue Injury

Persistent non-blanchable deep red, maroon

or purple discoloration

Unstageable

Obscured full thickness tissue loss

• Slough Eschar

Implications• Q: If a beneficiary has an unstageable ulcer

on the buttocks, does the beneficiary qualify for a pressure reducing mattress? We receive referrals from licensed clinical medical professionals, but they are unable to give a stage on the ulcers. They just state that they are unstageable.A: The beneficiary would not qualify for a Group 2 until the ulcer is able to be staged.

3 Legged Stool

Support SurfacesSupport surfaces are (were?) considered

adjunctive treatment for pain management

& comfort

Pressure Redistribution

What caused this?They’re not called Mystery Ulcers or Injuries

PressureShear and Friction

Moisture

CMS LCD

CMS (TPE, RAC, CERT, SMC)

Changes

– ICD-10s

• L89 Pressure Ulcer Diagnosis code

– Includes body location and stage

Not qualifying

Qualifying

• L89 Pressure Ulcer

Diagnosis code

• Includes body location

and stage

ICD 10s

Initial Qualifications -

Option #1

andPatient has been on a comprehensive

ulcer

treatment program for at least the past

month

which has included:

• use of an appropriate Group 1 Support

Surface

• regular assessment

• appropriate turning

• positioning and wound care

• moisture and incontinence management

• nutritional assessment and intervention

Multiple Stage II pressure ulcers located on the trunk

or pelvis that have failed to improve over the last

month

38

Initial Qualifications -

Option #2

Large or multiple stage III, IV or unstageable

pressure ulcer(s) located on the trunk or pelvis

Unstageable Pressure Injury

39

Initial Qualifications -

Option #3

Recent myocutaneous flap or skin graft

for a pressure ulcer on the trunk or pelvis

(surgery within the past 60 days)

and Patient has been on a Group 2 or 3

support surface immediately prior to a

recent discharge from a hospital or

nursing facility (discharge within the past

30 days).

40

Myocutaneous

flap

Skin Graft

Progression

No Reverse Staging

42

Support Surface Standards

Initiative (S3I) History

42

2001

National Pressure Ulcer Activity Panel

20152007 2011 2014

NPUAP established Support Surface Standards Initiative (S3I) as a task force

First 4 standards are approved by ANSI

S3I is sanctioned by American National Standards Institute (ANSI) through RESNA to develop technical standards for support surfaces

International Organization of Standards (ISO) creates committee to develop international standards for support surfaces

Terms and Definitions developed and validated

2019

Standards published for manufacturers

and suppliers of full body support surfaces

who wish to provide consistent, quality

information to clinicians about their

products

S3I 2017 Update

Characteristics of “high specification foam”

• Mattress height or depth: 6”

• Density: 35- 130 Kg/M2

• IFD: 1.75- 2.4

• MVTR of cover: >300g/m2/24 hours

S3I 2018 Update

S3I 2019 UpdatesS3I Subcommittee of the NPUAP Approves New Support

Surface Standards Tests

S3I 2018

Update

S3I Updates

S3I 2018

Update

S3I Updates

S3I 2018

Update

S3I Updates

S3I 2018

Update

S3I Updates

S3I- How Do You Use This

Information?Which Support Surface is Better?

• Peak Sacral Pressure: 39.5 mmHg or 26.4 mmHg?

• Shear: 22.3 N or 1.8 N?

• Evaporative Capacity: 17.4 g/m2-hr or 1080 g/m2/hr?

• Heat Dissipation: 120 W/m2 or 53 W/m2?

• IFD: 1.0 or 5.0 pcf?

• Density: 25 or 150 Kg/m2

• Regression graphs and regression analysis, P Value?

Evidence

“Currently, it is impossible to determine the most effective surface for either prevention or treatment.” (Guidance, 2001)

“Selection of a support surface plays a major role in preventing pressure ulcers.” (CMS 2007)

“Many specialized beds appear to be effective in reducing the development of pressure ulcers when compared to standard mattresses.” (Agnostini et all, 2001)

“The occurrence of pressure sores and their severity can be significantly reduced when patients at risk receive an interface pressure decreasing mattress.” Hofmann et all. Lancet, 1994)

Evidence

Outcomes Matter

Our health care system moves from the fee-

for-service model to collaborative care model

• Patient Driven Payment Model (PDPM)

• Patient Driven Groupings Model (PDGM)

• Accountable Care Organizations (ACOs)

National Pressure Injury Advisory Panel (NPIAP)

• Survive COVID and die from a pressure injury?

• 2019 guidelines include Support Surfaces

They’re not called “Mystery

Injuries”

Increased # of Pressure Injuries

Covid and Pressure Injuries

Support SurfacesSupport surfaces are (were?) considered

adjunctive treatment for pain management

& comfort

Group 2 Support Surfaces are

not just for Pressure Injuries• Enhancing quality of life

• Sleep

• Pain & comfort

• Respiratory conditions

• Reduce turning & repositioning

• Reduce falls

Shift the Focus

Shift the Focus

• Support surfaces help care giving

– Turning and repositioning

(autofirm feature) are easier

and less painful to the client

– Turning often hurts.

Patients MAY go to every or

q4 or q6 hours turn

schedule rather than q2

hour turning

• Enhance comfort so patients may

require fewer pain meds (narcotic

analgesics) and complain to DME

Provider less frequently

– “Classics”• Local Physicians and Hospitals

• Wound Healing Clinics

• Sub-acute/Short Term Rehab Facilities

– Other Channels• Home Health Agencies (HHAs)

• Long Term Care/Skilled Nursing Facilities

• Assisted Living Facilities

• Outpatient therapy

• Hospice

• Retail/Ecommerce

Who treats Pressure

Injuries?

3 Legged Stool

Intrinsic Risk Factors

• Nutrition

• Demographics

• 02 delivery system

• Chronic Illness

• Medications

• Pain

Nutrition

Don’t miss:• Losing weight

• Won’t or can’t eat

• Too tired to eat

• Non-healing pressure injury

Medicare adults ≥ 65 yo at risk for pressure injury- 76% were malnourished

Low BMI, reduced food intake, impaired ability to eat – 4x higher risk

Nutrition

• Valid Screening Tools (to determine who’s at risk for malnutrition)

• Mini Nutrition Assessment (MNA)

• Malnutrition Universal Screening Tool (MUST)

• Nutrition Risk Screening (NRS-2002)

• Short Nutrition Assessment Questionnaire (SNAQ)

• Encourage

• Hydration

• Protein

• Vitamins and Minerals

Nutrition

• Punitive damages of $92 million, later lowered to $11,855,000, were imposed where malnutrition and dehydration were proven against a nursing home.1

• A dietary manager for a nursing home told state surveyors that her nursing home had "dropped the ball" on a resident's nutrition needs when that resident had lost 17 pounds in 75 days; a $1,385,000 settlement was reached.2

• Malnutrition with a loss of 27% of body weight in 15 months led to a $380,000 settlement just before trial.3

3 Legged Stool

World Union of Wound

Healing Societies

Dressings

• Get rid of dead tissue

• Identify and eliminate infection

• Obliterate dead space

• Absorb excess exudate

• Maintain a moist wound surface

• Provide thermal insulation

• Protect from trauma or bacterial invasion

CMS’ Comprehensive Wound

Treatment Plan

• Regular assessment

• Appropriate turning

• Positioning and wound care

• Moisture and incontinence management

• Nutritional assessment and intervention

Pressure Injuries:

Clinical Education

Part 2

68

Drainage and Odor

• Exudate: Fluid from wound

• Amount, type and odor

• Light, moderate, heavy

• Drainage

• Clear

• Sanguineous (bloody)

• Serosanguineous (blood-tinged)

• Purulent (cloudy, pus-yellow, green)

• Odor: Most wounds have an odor

• Faint, moderate, strong

Debridement

Removal of necrotic tissue

• Mechanical

• Enzymatic or Chemical

• Sharp

• Autolytic

• Biosurgical

Unstageables qualify for group 2 support surfaces

Tissue Type% of each type• Granulation tissue: Red, cobblestone appearance

• Necrotic: Slough, Devitalized, Eschar

• Additional Tissue Damage

Undermining Tunneling

Shear

Pressure Injuries are a

Patient Safety Issue• Timeliness: Pressure Injury can occur in 2 hours

• ID at Risk– Braden Scale (<18)

– Norton Scale (<14)

• Adhere to your institution’s Pressure Injury Prevention Guidelines

– Inspect skin (thoroughly and often)

– Document all efforts

• Work together (interdisciplinary)

– Continuity of care

• Use prevention dressings on bony prominences

PeriwoundTissue around wound• Viable, macerated, inflamed

• Color

• Erythematous

• Pale

• Texture

• Dry or moist

• Boggy (soft)

• Indurated (firm)

• Macerated (white, soggy appearance)

• Edematous (swollen with watery fluid)

• Temperature

• Cool or warm

• Skin integrity

• Lesions, excoriation, maceration, denuded (loss of epidermis)

Infection

• Contamination-microorganisms on wound surface

• Colonization-bacteria growing in wound bed without signs or symptoms of infection

• Critical Colonization-bacterial growth causes delayed wound healing, but has not invaded the tissue

Infection

Bacteria invade soft tissue, cause systemic response

• Inflammation

• Pus

• Increase/change in exudate

• Fever

• Pain

• Delirium in elderly

Measurements

Length x Width x Depth in cm

Stage and Anatomical location

What is a large pressure ulcer? (stage III or IV pressure ulcer criterion for Medicare group 2 support surface coverage)

➢ No standard definition

➢ 8cm? (Length X Width X Depth)

➢ Q: What is considered a large stage III or IV ulcer?

A: There is not a standard definition of 'large stage III or IV’ ulcer. There are things that can be helpful in

determining the size of the ulcer and they include information such as the beneficiary's height, weight,

measurements of the ulcer(s) and any undermining and/or tunneling

Flaps and Grafts

Total 60 days of Group 2 or Group 3 Support Surface

Movement Monitors

Display patient movement data:

• Identify patients who were

self‐turning & patients in need of

assisted turns

Potential benefits:

• Prevention of falls & pressure

injuries

• More accurate triaging of patient

care needs with regard to patient

turning

Inside Out

It detects changes in the sub-epidermal moisture, which

can indicate localized edema and tissue fluid related

inflammation days before visually discernible skin damage.

Portable thermal sensor for spotting

elevated temperature on the skin, a

parameter that can point to infection or

active healing, depending on where the

heat around the wound is produced

Pressure Injury Best Practices

• National Pressure Ulcer Advisory Panel, European Pressure Ulcer

Advisory Panel and Pan Pacific Pressure Injury Alliance. (2014).

Prevention and Treatment of Pressure Ulcers: Quick Reference Guide.

• Agency for Healthcare Research and Quality (AHRQ). (2011). Preventing

Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care.

Rockville, MD: U.S. Department of Health and Human Services.

• Veterans Health Administration. (2011). VHA Handbook 1180.02

Prevention of Pressure Ulcers.

• Institute for Healthcare Improvement (IHI). (2011). How-to Guide: Prevent

Pressure Ulcers. Cambridge, MA: Institute for Healthcare

Improvement.

NPIAP

NPIAP

NPIAP

NPIAP

NPIAP

NPIAP

NPIAP

NPIAP

NPIAP

NPIAP

NPIAP

Resources

NPIAP

NPIAP

NPIAP

NPIAP

Hospice Hospice patients are at greater risk of pressure injury development than most patients

Wound Pain

• May be indicator of inadequate wound management, untreated underlying cause and/or infection.

• Frequently happens during dressing change, debridement, from the pressure of exudate, around wound edges, and in the infected wound.

• 50% of patients with pressure injuries have pain, particularly those with Stages 3 and 4 injuries.

• Regardless of support surface in use, each patient should be assessed periodically for comfort.

Hospice• Protect wound edges with barrier cream or hydrocolloid wafer

cut to fit around wound.

• Allow patients to do their own dressing change if possible.

• Allow patients to call time out.

• Let patients know that there are “no points for bravery”; blood flow can decrease during episodes of pain.

• Pre-medicate prior to dressing change and debridement..

• Encourage the use of compression bandages, hose and binders to decrease swelling and thereby decrease pain.

• Consider the use of dressings least likely to adhere and cause pain like hydrogels, hydrofibers, alginates, and soft silicones.

• Dressings such as gauze and others that can dry out can cause tremendous pain, especially when removed.

• Limit tape; try tubular net bandages

Recap

• They’re NOT Mystery

Injuries

Thank you!

Questions?

Anything you’d like to discuss?

Future topics?

Karen LernerKlerner@drivemedical.com

Drive Medical

516-998-4600