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Joyce Black, PhD, RN, DNP (Hon),CWCN, FAAN Associate Professor,

University of Nebraska Medical Center

}  Causes of pressure ulcers ◦  Deep tissue injury etiology ◦  Friction out ◦  Microclimate in

}  Intertriginous Dermatitis }  Deep Tissue Injury ◦  Pathophysiology

}  Biofilms ◦  Silver Resistance?

}  Pressure ◦  Perpendicular force in excess

of capillary flow to tissues, hypoxia develops and tissue dies

}  Shear ◦  Pull and stretch blood vessels

as tangential force is applied to tissue, tissue becomes hypoxic �  Friction is no longer seen as an

etiology �  No pressure component �  Heat builds up and leads to

blistering

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}  Pressure on muscle cell disrupts the cell membrane (Gefen, 2010-2012) ◦  Loss of function ◦  Cell death

}  Historically, part of the extrinsic factors ◦  Measured by Braden “Moisture” Subscale

}  Known association with incontinence ◦  Moist skin does not

tolerate sliding, the tackiness of the skin increases risk of wounds

Skin with severe IAD does not glide on bed linens

}  Sweat gland found in dermis }  Controlled by nerve from

sympathetic nervous system (fight or flight)

}  Body temperature regulation }  Profuse sweating leads to water

and sodium loss

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}  100 mg Hg indenter warmed to 25, 35, 40 and 45 degrees and applied to skin ◦  25 degrees = no skin or muscle damage ◦  35 degrees = moderate muscle damage ◦  40 degrees = skin necrosis and muscle damage ◦  45 degrees = full skin necrosis, deep tissue

damage �  ? Burns at 45 degrees

Kokate, 1995

}  Skin temperature and humidity at the interface between skin and the surface ◦  Relatively ignored until recently

}  As temperature of skin rises, the metabolic needs of the skin for oxygen and glucose rises ◦  10% increased need for each 1 degree ◦  These substrates cannot be delivered if the skin is

under pressure

Dressing Injury

Candidiasis

Deep tissue injury IAD

Zinc oxide

Stool on the skin

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Heat and humidity accumulate between the skin and the surface Low air loss cannot cool those areas unless the patient turns

If LAL could control microclimate, we would have air hockey

}  Sweat produced to cool the body ◦  Obese patients ◦  Febrile (fever) patients

}  Sweat produced due to stress on the sympathetic nervous system ◦  Low Blood Pressures (shock states) ◦  Myocardial Infarction (heart attack) ◦  Shortness of breath/breathlessness ◦  Head injury/Brain bleeds

}  Sweat produced due to lack of control ◦  Neurological disease ◦  Spinal cord injury ◦  Stroke

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}  Or is the damage from moisture?

Presumption was that skin folds would grown Candida

Literature suggests that skin fold can also contain

Pseudomonas Staphyloccus

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}  Patients with skin folds seen on admission

}  History included conditions that could impair skin and increase infection

}  Cultures taken of skin folds before use of InterDry

Pannus:  Staphyoloccus  coag  neg  Proteus  mirabilis  Enterococcus  faecalis  Candida  albicans  Escherichia  coli    

Axilla:  Proteus  mirablilis  Enterococcus  faecalis  Staphlococcus  coag  neg  Candida  albicans  VRE  

Breast:  Proteus  mirabilis  Staphyoloccus  coag  neg  Diphtheroids  

Groin:  Staphyoloccus  coag  neg  Candida  albicans  Diptheroids  Proteus  mirablis  Enterococcus  faecalis    

Knee:  Proteus  mirablilis  Staphylococcus  coag  neg      

}  Incisions placed through skin folds? }  Bathing of skin folds and contamination of

surgical sites? ◦  Bath basins heavily contaminated

}  Pretreatment of surgical sites? ◦  Really unable to clean patients in preop ◦  Unable to use chlorhexidine on open skin

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}  Koziak’s model shows ulcers developing in 2 hours at 600 mmHg pressure

}  And ulcers developing after 10 hours at 200 mg Hg pressure

}  Are these ulcers different?

}  Starts with 3 hours of ischemia ◦  Irreversible after 6

hours }  Elevations in CPK ◦  Variant of

rhabdomyolysis

}  Model of DTI development created from a real patient who was unconscious on a cell phone for 3 days

}  The simulated DTI appeared in muscle tissue in proximity to the bone after approximately 1.5 h, and within less than 10 additional minutes it reached the muscle–fat boundary.

�  Linder-Ganz, 2009

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}  An event of confinement always preceded the first notation of purple skin by 48 hours

}  Within 48 hours of the identification of purple skin, blisters were noted from epidermal sloughing ◦  Thin blisters, not fluid filled ◦  Often called “Stage II” pressure ulcers

Black, Berke, 2005

}  Area sustaining highest pressures is infarcted }  Surrounded by rings of ischemic and injured

tissue that is rescuable } 

}  Pressure creates the injury }  Shear extends it to other tissue ◦  Undermining ◦  Extension

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}  Initial purple area became progressively larger until entire buttock ulcerated

}  Probably most chronic wounds

}  Wounds with slough or eschar ◦  Slough is dried drainage ◦  Eschar is dead tissue

}  Heavily draining wounds ◦  Biofilm promotes

inflammation ◦  Inflammation produces

drainage

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}  Mechanical or sharp debridement }  Antiseptic dressings ◦  Silver dressings �  Silver does not always penetrate thick slough �  Bacterial resistance appears to not be possible ◦  Iodine ◦  Honey

}  Not a good idea to pack with long term plan gauze dressings

Deep Tissue Injury Diagnosis and Treatment Dressings as a Prevention

Medical Device Ulcers OR Pressure Ulcers

Microclimate Management Reducing Injury with Turning and Repositioning

}  Retrospective review of 82 cases of pressure ulcers that began as “purple areas” following a period of immobility

}  Cases were litigants ◦  Sample bias is recognized

}  Demographics ◦  Mean age 70 (range 24-98) ◦  Gender 52% male ◦  Ethnicity (42% Caucasian,

21% Black) ◦  Emergent admission 70%

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Deep tissue injury evolution

Thin blisters as epidermis sloughs

Often develops eschar

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}  Location ◦  Occur on tissue subjected

to pressure ◦  not always bony

prominences }  Timing ◦  Color change is delayed

sometimes after pressure is relieved

}  Color ◦  Purple or maroon, not red

}  Rate of deterioration ◦  Rapid, becoming full

thickness quickly

}  History of trauma }  Fractured pelvis with

pelvic hematoma }  May lead to purple

skin and epidermal slough

}  Morel-Lavallee lesions (internal degloving injury) with pelvic trauma This patient had a history

of fall at high rate of speed onto concrete.

}  Bruising with a history of trauma

}  Often anticoagulated }  Can be difficult to

distinguish from deep tissue injury in the same area

}  Consider Morel-Lavallee lesions

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}  Bruising with a history of trauma

}  Can be difficult to distinguish from deep tissue injury in the same area

}  Consider Morel-Lavallee lesions

}  Rapidly progressive infection ◦  Staphylococcus ◦  Streptococcus ◦  Occ, anaerobes, spores

}  Purple on edge }  Usually not a

pressure area }  Patient is septic

}  Rapidly developing ulcer appearing about 48 hours prior to death

}  Etiology unknown ◦  Low perfusion

during which the skin cannot recover from usual pressures? ◦  Skin infarction? ◦  Variant of DTI?

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}  Seen with prolonged hypotension and Levophed/ Dopamine use

}  Peripheral tissue only, not subjected to pressure

}  Patients with poor perfusion may develop purple skin in dependent tissues

}  Purple color changes with motion

Demarcated tissue of flap used to cover DTI was is cold Patient had multiple infections Contribute to ischemia?

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Outside to Inside with Low Pressure

(Classic) Stage I

Fluid-filled blisters

Stage II

Inside to Outside with High Pressure

DTI Stage II with epidermal loss Unstageable with eschar or blister

Stage III or IV

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}  Relieve pressure completely from areas likely to have DTI ◦  Side to side turning ◦  Support surfaces ◦  Heels in boots

}  Relieve pressure from all purple skin

}  Building evidence for MIST therapy ◦  Honaker, 2011

}  No evidence today to support: ◦  Early debridement ◦  HBO

DEMOGRAPHICS CONTROL GROUP TREATMENT GROUP

NO. OF PATIENTS IN STUDY 42 43 GENDER RATIO – MALE 48% 42% AVERAGE AGE 69 YRS 75 YRS AVG. LENGTH OF STAY 19 DAYS 21 DAYS

DIABETES 48% 60%

ESRD 26% 28%

CHF 24% 19%

COPD 26% 16%

PVD 17% 33%

HTN 71% 79%

ANEMIA 83% 88%

SMOKER 43% 28%

Group Comparisons

}  Retrospective chart review; March 09 - March 10 �  127 sDTI’s �  63 were treated with SoC only �  64 with SoC and MIST®

}  Inclusion consisted of patients identified with sDTI with in 4-5 days of onset. ◦  All patient received standard of care ◦  Treatment group received MIST and standard of care

Honaker, 2011

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SECONDARY CONDITIONS

CONTROL GROUP

TREATMENT GROUP

Low albumin/pre-albumin

67% 70%

Fecal Incontinence 67% 74% Urinary Incontinence 26% 28% End of Life/Palliative care

45% 33%

Operating Room time > 3.5 hr

5% 5%

Vasopressors 36% 35% Vent Support 50% 44%

}  Wound Color/Tissue Assessment 1 = Pink/Normal skin tone 2 = Red wound bed dermal layer

exposure 3 = Maroon Nonblanchable 4 = Purple Nonblanchable 5 = Subcutaneous tissue exposure,

but no bone, muscle, or tendon exposure

6 = Black/Grey/Yellow/Brown Necrotic Tissue

7 = Bone, muscle, and/or tendon exposure

}  Total Surface area Size 1  = 1 cm2 2 = 1.1cm2 – 5cm2 3 = 5.1cm2 – 10cm2 4 = 10.1cm2 – 15cm2 5 = 15.1cm2 – 20cm2 6 = 20.1 cm2 – 35 cm2 7 = 35.1 cm2 – 50 cm2 8 = ≥50.1cm2

}  Skin Integrity 1 = Intact 2 = Blister/Bulla formation 3 = Epidermis broken

Scores can range from 3 to 18

}  Control Group Mean sDTI Score ◦  Time 1 = 9.62 ◦  Final score for Time 2 = 10.68 ◦  Difference = ↑ 1.06

}  Treatment Group Mean sDTI Score ◦  Time 1 = 9 ◦  Final score for Time 2 = 7.55 ◦  Difference = ↓ 1.45

}  Significant Difference = p < .000 ◦  (T = 5.67)

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}  Scott Triggers (Suzie Scott-Williams, 2011) ◦  ASA score 3 or higher ◦  Age over 62 ◦  Albumin less than 2.5

}  Add in length of time planned for surgery over 3 hours (NPUAP, 2009)

}  Evaluate OR table cover ◦  If 2” elastic foam with cover may not be

adequate ◦  Replace with 3-4 inches of visco-elastic foam

}  Consensus Group Examined Literature on Dressings to Reduce Pressure, Shear and Friction

}  Group members from EU, US and Australia }  Examined bench data from Evan Call lab on

dressings reducing �  pressure by dispersing it �  shear by absorbing it into layers of dressing �  friction by slick outer surface �  microclimate by absorbing sweat

}  Brindle: PrU rate lower in OR (2012) Brindle: PrU rate lower in ICU (2010) Chaiken: PrU rate fell from 13.8-1.8 in ICU (2012) Cherry: ICU rate fell to 0 (2012)

September 3 2012

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}  Choose or make a dressing larger than body area at risk ◦  allows pressure and shear forces to be deflected

into tissue outside the area of risk }  Multiple dressings may be needed

September 3 2012

}  Dressing shown to reduce pressure in immobile patients in OR

}  Time to develop OR ulcers is generally greater than 3 hours

September 3 2012

}  Shear injury when HOB elevated can be reduced with layered dressing

}  Sacral DTI with HOB up

September 3 2012

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}  Heels at high risk for pressure ◦  Immobile legs, neuropathy,

arterial disease

September 3 2012

}  Heel at risk for shear injury ◦  Shear forces tear layers of

skin/tissue ◦  Leads to blisters

}  Shear forces best prevented by layered dressings

September 3 2012

}  Comparisons of every 2 and 4 hours done in Belgium ◦  Elders on visco-elastic foam mattresses with intact skin and

nonblanchable erythema (stage I pressure ulcers) assigned to turning groups �  Experimental group (N=122)

�  2 hours in lateral positions �  4 hours in supine positions

�  Control group (N=113) �  Repositioned every 4 hours

◦  Outcomes �  Pressure ulcers in experimental group=16.4% (stage II, III, IV) �  Pressure ulcers in control group=21.2% (stage II, III, IV) �  Different not statistically significant

}  Are these outcomes adequate to change practice? Vanderwee K, et al. J Adv Nurs. 2008;57(1): 59-68

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}  Back injury very common in healthcare workers ◦  1/3 of back injuries are due to moving patients

�  Nurses aides, orderlies and attendants are number 2 in the top 10 occupations for back injury

◦  In 2009, there were 25,160 on-the-job injuries �  60% required 5 days off; 12% required 8 days off

�  Nurses use 30% more sick leave annually due to back pain

}  The cost of on-the-job musculoskeletal injury is high ◦  $20 billion on worker’s compensation ◦  $100 billion on indirect costs

American Nursing Association. http://www.anasafepatienthandling.org/Main-Menu/SPH-Background /Background.aspx. Accessed May 15. Bureau of Labor and Statistics. http://www.bls.gov/news.release /archives/osh2_11202008.pdf. Accessed May 15. Bureau of Labor and Statistics. http://www.bls.gov/news. release/archives/osh2_11092010.pdf. Accessed May 15. Occupational Safety and Health Administration. http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=205&p_table=SPEECHES. Accessed May 16.

}  If turning takes 5 minutes per turn x 12 turns per day =1 hr ◦  In acute care, RN=$38 per day per patient ◦  In a 200 bed hospital, turning half the patients=$3800

for salary if alone �  How many patients can be turned alone? �  How many patients can be turned in 5 minutes?

}  Considered a pressure ulcer

}  If cartilage is visible or palpable }  Stage IV

}  Mucous membrane ulcers are not staged

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}  General care items ◦  Bedpans ◦  Foley tubing ◦  NG tubes ◦  Bed trash ◦  Suture

}  Bedpans left under patients can create intense pressure ◦  Fatal wounds

}  Strap injury from boots

}  Injury to “other leg” when patient on his side

}  Nerve/tendon injury when leg not maintained in neutral alignment

Prevents leg rotation

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}  Elastic devices can impair blood flow to the legs ◦  “TED sores”? ◦  Ulcers on shin, toes,

calf }  Must be removed

daily to inspect the skin

}  Fit the device to the patient ◦  Measure TEDs ◦  Use proper sized boots

}  Be aware of edema }  Devices can be “lost”

in bariatric patient skin folds

}  Remove or move device on each shift }  Examine skin beneath device and do not

replace device back onto injured tissues ◦  Move ET tubes ◦  Do not tighten O2 cannulas �  Secure to face ◦  Move pulse oximetry probes ◦  Splint NG tubes ◦  Remove TEDs BID

}  Return devices that are defective!!

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}  Litigation risk ◦  Increasing numbers of cases �  “Never event” setting the stage for plaintiffs �  Skin failure and skin changes at life’s end helping the

defense }  Reducing your risk --- nothing new here ◦  Skin assessment on admission with proper

classification of wounds found ◦  Accurate risk assessment with linked interventions ◦  Assignment of upscaled beds or turning ◦  Documentation

A sloth in the wound? 3 toed?

}  Check the credentials of providers }  Be aware of a tendency to debride every

wound ◦  Often with a curette and topical Lidocaine �  No bleeding from wound �  No removal of necrotic tissue, in that healing is not

promote }  CMS aware of rising charges for

débridements ◦  Some states limiting coverage

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}  Call for podium presentations on DTI ◦  Do you have data?

Your participation in advancing the science and practice remains important

for quality patient outcomes