Pressure Ulcers: Avoidable Or Unavoidable?
SPRING 2011theIn this issue 4678Biennial Conference “Best Posters”New NPUAP DirectorsNew NPUAP Slide Sets Now AvailableNPUAP-Sentara Joint ConferencePRESSURE ULCERPHOTOS ANDNPUAP—EPUAPGUIDELINES NOWAVAILABLE! (see p.3)National Pressure Ulcer Advisory Panel (NPUAP)is the authoritative voice for improved patientoutcomes in pressure ulcer prevention andtreatment through public policy, education andresearch. Learn more about pressure ulcers andNPUAP at www.npuap.orgPressure Ulcers:PRESIDENT’S MESSAGEAvoidableorUnavoidable?Results of the NPUAP Consensus Conferencen 2010 the National Pressure Ulcer Advisory Panel (NPUAP) hosted a multidisciplinary conference to establish consensus on whether there are individuals inwhom pressure ulcer development may be unavoidable and whether a differenceexists between end-of-life skin changes and pressure ulcers.Consensus was achieved for the following statements: most pressure ulcers areavoidable; not all pressure ulcers are avoidable; there are situations that render pressureulcer development unavoidable, including hemodynamic instability that is worsenedwith physical movement and inability to maintain nutrition and hydration status andthe presence of an advanced directive prohibiting artificial nutrition/hydration; pressure redistribution surfaces cannot replace turning and repositioning; and if enoughpressure was removed from the external body the skin cannot always survive.Consensus was not obtained on the practicality or standard of turning patientsevery two hours nor on concerns surrounding the use of medical devices vis-à-vistheir potential to cause skin damage.Research is needed to examine these issues, refine preventive practices in challenging situations, and identify the limits of prevention. Read the entire article: Ostomy Wound Management 2011; 57(2):24–37IAwards Presented at NPUAP Biennial Conferencet its 12th Biennial Conference, NPUAP recognized two individuals and one group byawarding them with the Kosiak, Stewart Founder’sand Roberta Abruzzese awards.AKOSIAK AWARDThis award is presented at each biennial conference to recognize persons making significant contributions to the prevention and/or treatment ofpressure ulcers through their leadership in thefields of, research, education and/or patient care.The 2011 recipient of the Kosiak Award is JanetCuddigan, PhD, RN, CWCN, CCCN. Dr. Cuddigan President McNichol (left) recognizeshas been both an at-large director and an officer of Kosiak Award recipient Dr. JanetContinued on page 2 Cuddigan.NPUAPLaurie McNichol,MSN, RN, GNP, CWOCNreetings! The Panel has been verybusy since the Winter Newsletterwas published! You will read in thisissue about the successful 12th BiennialConference held February 25-26, 2011,at Caesars Palace in Las Vegas, Nevada,and the many activities and awards thatmade that event one of the best educational programs ever offered byNPUAP.My personal thanks to ConferenceChair Dr. Catherine Ratliff, whospearheaded the eighteen-month planning process and whose tireless coordination and attention to detail made thisconference a pleasure to execute. Inaddition to Dr. Ratliff, I would like torecognize the efforts of the Chairs ofthe Best Practice Conference, Dr.Aimée Garcia and Dr. Barbara Pieper,as well as the Chairs of the ConsensusConference, Dr. Janet Cuddigan andDr. Barbara Braden, for their visionand project planning skills. Finally, tothe staff and other volunteers for thePanel, including those representing ourCollaborating, Corporate, Alumni andProvider Advisory Councils, my sincerethanks for your work on behalf ournearly 500 attendees. Plans are alreadyunderway for the 13th BiennialConference to be offered in Houston,TX, February 22-23, 2013. Mark yourcalendars now to attend!In other NPUAP news:Continued on page 2 G
INSIDEthe NPUAPPRESIDENT’S MESSAGEContinued from page 1 The Panel is beginning work on anupdated Monograph, PressureUlcers in America: Prevalence,Incidence and Implications for theFuture, under the direction ofEditor in Chief, Barbara Pieper,PhD, RN, CWOCN. The Executive Committee is working on some process and infrastructure improvements that include,but are not limited to, the reviewand revision of our Bylaws, Policiesand Procedures and meeting materials, implementing the use of project planning concepts andtimelines in our subgroup activitiesand exploring methods forimproved communication to ensureour ability to be nimble. The Education Committee will behosting our first educational webinar this spring on the topic ofAvoidable vs. Unavoidable PressureUlcers. Our website is undergoing someupdating of content and cosmeticchanges under the direction of PastPresident Laura Edsberg, PhD. The Board is preparing for theirnext strategic planning session (tobe held in August), which willdirect our activities for the next twoyears.In short, there is a steady stream ofactivity. I am invigorated and inspired bymy association with this dedicated groupof volunteer leaders in the field of pressure ulcers. I look forward to providingyou another update on their activities inthe next issue of this publication. Laurie McNichol, MSN, RN, GNP, CWOCNNPUAP President1025 Thomas Jefferson Street NWSuite 500 EastWashington, DC 20007202 521 6789 Fax 202 833 3636E-mail: npuap@npuap.orgwww.npuap.orgSPRING 2011NPUAP BIENNIAL CONFERENCE AWARDSContinued from page 1the Board of Directors of the NPUAP. As an officer, she served as both Treasurer andVice President. She was the project manager for the AHCPR’s Pressure Ulcer ClinicalPractice Guidelines, served as Editor in Chief of the NPUAP Monograph, PressureUlcers in America: Prevalence, Incidence and Implications for the Future and was amember of the NPUAP task force that developed the PUSH tool. Dr. Cuddigan hasworked with others to execute several of the NPUAP Biennial Conferences and has over15 articles on pressure ulcers published in peer-reviewed journals. Her most recentachievement has been to serve as Co-Chair and Editor-in-Chief of theNPUAP/EPUAP International Guideline on Pressure Ulcer Prevention and Treatment.Dr. Cuddigan epitomizes the health care professional for whom the Kosiak Awardwas designed. Her dedication to increasing the knowledge and increasing the evidenced based care provided to patients with pressure ulcers have been long-standingand far-reaching.STEWART FOUNDER’S AWARDThis award is presented at each biennial conference to honor persons who have made significant contributions to the field of pressureulcer prevention and treatment, particularlyrelating to public policy. This prestigious awardreflects NPUAP’s ongoing commitment topositively impact public policy to improve pressure ulcer prevention, treatment, education andpatient care.The 2011 recipient of the Stewart Founder’sAward is the CMS MDS 3.0 Team, guided byPresident McNichol (at left )Shari M. Ling, MD, Medical Officer, CMS. Therecognizes Stewart Founder’s Awardteam’s ceaseless energy around revising the prerecipient CMS MDS 3.0 Team,vious data collection tool used in the long-termrepresented by Ellen Berry.care setting will improve care for millions ofbeneficiaries. The Panel applauds the team’swillingness to collaborate with others and to review evidence based materials from manysources so that the revised tool reflects the most recent evidence and terminology.Continued on next page Save the date!2NPUAP 13th NationalBiennial Conference2013February 22–23, 2013 Houston, TexasWe look forward to seeing you there!
INSIDE the NPUAPSome of the significant revisions include: Reverse staging is now prohibited Risk assessment is not required (M0100, M0150) Present on admission pressure ulcer data is now captured for all stages Pressure ulcer staging is now consistent with the 2007 NPUAP staging definitions,as, in addition to stages I-IV (M0300A-D), there is now a separate coding sectionfor Unstageable pressure ulcers due to eschar (M0300G). Pressure ulcers that present as blisters are in accordance with NPUAP staging definitions as those filledwith serum are coded as Stage II and those with blood are now coded as deep tissue injury. Important characteristics of pressure ulcers that NPUAP pioneered on the PUSHtool are now mandatory. There is a subsection for the measurement of the largestpressure ulcer that follows NPUAP recommendations. The scale for the tissue typeis exactly the same as that found in the PUSH tool.Work of this scope and magnitude is recognized and deeply appreciated by all thewound care community.SPRING2011NOW AVAILABLE AT THENPUAP ONLINE STOREPressure Ulcer Photo GalleryHigh-resolution pressure ulcer photosare now available at the NPUAP OnlineStore! Images from the NPUAP PhotoGallery may be purchased for 5 each forpersonal or self-presentation use; or 25each for professional use, such as textbooks, saleable presentations or industry.These photographs are reprinted withpermission of the copyright holder,Gordian Medical, Inc. dba AmericanMedical Technologies. www.npuap.orgROBERTA ABRUZZESE AWARDThis award provides biennial conference travelfunds to a student showing interest and promise in the field of pressure ulcer research, treatment and prevention or education. The award,sponsored by Stryker, is named in honor of Dr.Roberta Abruzzese for her vision, leadership,and support in promoting educational endeavors in relation to pressure ulcer management.This year’s recipient, Yi-Ting Tzen, PhD,impressed the selection committee with herimpressive vitae; she has seven publications inPresident McNichol (at left)peer reviewed journals, five podium presentarecognizes Abruzzese Awardtions and numerous awards, including being arecipient Dr. Yi-Ting Tzen.poster finalist at the NPUAP’s 2009 BiennialConference. Her 2010 dissertation work, entitled “Effectiveness of local cooling on enhancing tissue ischemia tolerance in people with spinal cord injury”, has great implicationsfor people with spinal cord injuries in the prevention of pressure ulcers.Dr. Tzen has served as a Graduate Mentor and a Teaching Assistant at theUniversity of Pittsburg since 2008, and has been continuously certified inRehabilitation Technology since 2006. We look forward to the continued scientificcontributions of this fine recipient. NPUAP-EPUAP InternationalPressure Ulcer Guidelines Learn about the latest in pressureulcer prevention & care. Join an international community ofclinicians & researchers. For best evidence-based practicesfrom around the world buy theinternational pressure ulcerguidelines today!PRESSURE ULCER PREVENTION & TREATMENTQUICK REFERENCE GUIDE(QRG): 25 S&HThis document provides evidence-basedrecommendations on a full range oftopics related to pressure ulcers.PRESSURE ULCER PREVENTION & TREATMENTCLINICAL PRACTICEGUIDELINE (CPG): 85 S&HThis larger document expands on the QRGby providing a summary of the researchsupporting each recommendation.AHRQ Introduces New Pressure UlcerPrevention Toolkiteed help in improving your pressure ulcer preventive practices? Guidelines onbest practices for pressure ulcer prevention have long been available and havebeen updated by NPUAP in 2009. Yet implementing these best practices in the hospital environment can often be difficult. A new toolkit that can guide you throughthe step-by-step process of a quality improvement initiative has just been released byAHRQ. The toolkit, Preventing Pressure Ulcers in Hospitals, has been developed bypast NPUAP members under the auspices of AHRQ and is available atwww.ahrq.gov/research/ltc/pressureulcertoolkit/. N BULK DISCOUNT Receive 10% OFF the regular price whenyou order 20 or more copies or either book!The NPUAP Online Store is atwww.npuap.org3
4INSIDEthe NPUAPSPRING 2011Three Researchers Receive “Best Poster” Prizesat NPUAP’s Biennial Conference in Las Vegasesearch and Development are the lifeblood of our progresstoward improving pressure ulcer prevention and care. In aneffort to promote the work and recognize the people behind itNPUAP sponsors a poster abstract award competition at itsBiennial Conference. This year a total of 136 abstracts werepresented at the conference. A panel of judges reviewed theposters and selected the best submissions in each of three categories. The winners are Jeremy Honaker for best contributionto the field; Gina Berg for best submission from a new investigator; and Matthew Peterson for best submission from a younginvestigator. They each received a 500 prize from NPUAP.RDavid Brienza(pictured atright) recognizesJeremy Honakerfor BestContributionto the FieldPosterEffect of Non-Contact Low FrequencyUltrasound Treatment on Suspected DeepTissue Injury HealingJeremy HonakerCentral Baptist Hospital, Lexington, KYPURPOSEThe purpose of this study was to assess the effectiveness ofnon-contact low frequency ultrasound (NLFU) on the healingof Suspected Deep Tissue Injury (SDTI). Participants wereadults ranging in age from 28 to 93, with multiple diagnosesincluding anemia, diabetes mellitus, and hypertension. Giventhe dearth of literature on SDTI, evidence regarding optimaltreatment is not available.1,2,3METHODSData were examined retrospectively on 85 patients (intervention group 43, non-intervention group 42) with 127 SDTIs(intervention group 63, non-intervention group 64).Participants in both groups received standard of care for treating pressure ulcers. The Honaker Severity Scale was used toassess SDTI severity before treatment and healing/progressionafter treatment. This scale measures surface area, woundcolor/tissue assessment, and skin integrity with potential scoresof 3 to 18 (higher scores indicate greater severity). Inferentialand descriptive statistics were used to describe the populationand examine the effect of the intervention.RESULTSResults showed that NLFU was effective in promoting healingof SDTIs. A significant difference in changes in wound severitywas found (t 5.67, p .000). Difference in mean changescores was 2.52 on the 3–18 severity scale. The decrease inwound severity for the intervention group was 1.06. Severity inthe non-intervention group increased by 1.45.The final pressure ulcer stage after the SDTI %Stage 42%1%Stage 36%5%SDTI30%5%Stage 221%62%Spontaneously Resolved2%18%CONCLUSIONThis exploratory study of the effect of the NLFU provides initial findings that support its use with SDTIs. A fundedprospective study is planned to add to the body of knowledgeregarding this intervention.1. Berlowitz D, Brienza D. Are all pressure ulcers the result of deep tissueinjury? Ostomy Wound Management. 2007; 53(10):34-38.2. Black J. Deep tissue injury: an evolving science. Ostomy Wound Management.2009; 55(2):4.3. Fleck, C. Suspected deep tissue injury. Advances in Skin and Wound Care.2007; 20(7):413-415.Near Infrared Spectroscopy Measurementof Sacral Tissue Oxygen Saturation(STO2) in Healthy Volunteers Immobilizedon Rigid Spine BoardsGina M. Berg, PhD 1,3; Sue Nyberg, MHS, PA-C 2;Jessica Baumchen, MPA, PA-C 2; Erin Gurss, MPA, PA-C 2;Emily Hennes, MPA, PA-C 2; Paul Harrison, MD 31-KU School of Medicine-Wichita;2-Wichita State University;3Wesley Medical CenterINTRODUCTIONImmobilization of patients utilizing rigid spine boards (RSB) isstandard practice in the management of trauma patients.Pressure ulcers (PU) have been associated with prolongedimmobilization and the possibility exists that formation maybegin when the patient is initially immobilized on the RSB.The effects may not be fully recognized because of limitedresearch on the direct tissue effects of prolonged immobiliza-
INSIDE the NPUAPSPRINGtion. Near-infrared spectroscopy is an emerging tool to measureperipheral tissue oxygenation (StO2). The purpose of thisresearch was to study the effects of prolonged spinal immobilization on an RSB on sacral tissue oxygenation of healthy volunteers.METHODSThis cross-sectional study measured StO2 in healthy volunteersat baseline and again after 30 minutes of immobilization on anRSB at two sites: sacral area (intervention) and 8-10 cm abovesacral area (control). Tissue oxygenation was measured with theInSpectra Tissue Oxygenation Monitor (HutchinsonTechnology ) by placing the probe at the measurement site andwaiting for 15 seconds for equilibration prior to recordingStO2. Data were analyzed utilizing mixed-model and withinsubjects ANOVA, chi-square, and t-tests.RESULTSSeventy-three participants were included in the analysis.Participants were primarily female (55%), average age 38 years,average height 170 cm, and average weight 81 kg. There was asignificant increase in the StO2 percentage at the sacral (intervention) area following immobilization, p .001, rpb .48.Significant changes in oxygenation were not noted at the control site.CONCLUSIONAn increase in sacral tissue oxygenation following immobilization was a finding consistent with other research. This is likelya result of initial, rapid tissue reperfusion at the time of pressurerelease. Rapid reperfusion indicates that a period of previoushypoperfusion has occurred. This suggests that pressure ulcerformation may begin prior to hospital admission with immobilization on an RSB.2011Patient Repositioning and Pressure UlcerRisk: Monitoring Interface PressuresMatthew J. Peterson, PhD; Nikolaus Gravenstein, MD;Wilhelm K. Schwab, PhD; Johannes H. van Oostrom, PhD;Lawrence J. Caruso, MDHSR&D/RR&D Center of Excellence: MaximizingRehabilitation Outcomes, James A. Haley VA Medical Center,Tampa, Florida; Department of Anesthesiology, University ofFlorida College of Medicine, Gainesville, Florida; J. CraytonPruitt Family Department of Biomedical Engineering,University of Florida College of Engineering, Gainesville,FloridaPURPOSETurning patients regularly to prevent pressure ulcers and reduceinterface pressures is a standard of care; yet, this practice hasfailed to decrease the incidence of pressure ulcers in severalstudies. Our prior work revealed that standard, lateral turningdid not unload all areas of high, peri-sacral, skin-bed interfacepressures in healthy volunteers. Therefore, this study was conducted to assess the effect of routine repositioning on the perisacral skin-bed interface pressures and its effectiveness inrelieving at-risk tissue of patients at-risk for pressure ulcer formation.METHODSA descriptive, observational study was conducted at a university-affiliated hospital. A convenience sample of 23 bedridden,predominantly ICU patients at risk for pressure ulcer formation(Braden score 18) provided informed consent. Peri-sacralskin-bed interface pressure measurements were recorded frompatients receiving routine repositioning care for 4-6 hours.Interface pressures were recorded every 30 seconds using anXSENSOR pressure-mapping system.RESULTSDavid Brienza (atright) recognizesMatthewPeterson forBest Posterfrom a YoungInvestigatorLaurie McNichol(left) recognizesGina Berg forBest Posterfrom a NewInvestigatorAll 23 patients exhibited specific areas of skin (206 182 cm2)that were subjected to interface pressures 32 mmHg for 95%of the total observation period. Of the 13 patients observed inall 3 positions (supine, turned left, turned right), all exhibitedspecific areas of skin (166 184 cm2) 32 mmHg for 95% ofthe total observation period.CONCLUSIONBedridden patients at risk for pressure ulcers exhibit areas ofskin that always appear at risk throughout the duration of theirhospital stay despite routine repositioning care. Healthcareproviders are unaware of the actual tissue-relieving effectiveness(or lack thereof ) of their repositioning interventions, whichmay help explain why pressure ulcer mitigation strategies arenot as successful as one might imagine. Additionally, ICUpatients experienced higher peak interface pressures and largerskin areas subjected to pressures 32 mmHg than previouslystudied healthy adults. Further study is needed in patient repositioning techniques to improve skin-bed interface pressurerelief. 5
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sure redistribution surfaces cannot replace turning and repositioning; and if enough pressure was removed from the external body the skin cannot always survive. Consensus was not obtained on the practicality or standard of turning patients every two hours nor on concerns surrounding the use of medical devices vis-à-vis
Aug 09, 2016 · Wound Incidence/Prevalence About 2% of the U.S. adult population has a chronic wound. Chronic wounds are considered: pressure ulcers/injuries lower extremity ulcers diabetic foot ulcers venous ulcers and arterial ulcers Prevalence is measured by the number of cases of pressure ulcers at a specific time. Incidence measures the number of new pressure ulcers without
11. Cox J. Predictors od Pressure Ulcers in Adult Critical Care Patients. Amer J Crit Care 2011;20(5):364-374. 12. Delmore B, Cox J, Rolnitzky L, Chu A, Stolfi A. Differentiating Pressure Ulcers from Acute Skin Failure in the Adult CriticalCa re Patie
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developed and provide specific treatment recommendations for stage 2 or higher pressure ulcers, including proper wound care (5). This Data Brief presents the most recent national estimates of pressure ulcer prevalence, resident characteristics associated with pressure ulcers, and the use of wound care services in U.S. nursing homes.
The goal of this guideline is to provide evidence based recommendations for the prevention and treatment of pressure ulcers that can be used by health professionals throughout the world. The purpose of the prevention recommendations is to guide evidence based care to prevent the development of pressure ulcers and the purpose of the treatment
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