Proceedings of the Association for the Advancement of Wound Care’s First Annual Pressure Ulcer Summit

Proceedings of the Association for the Advancement of Wound Care’s First Annual Pressure Ulcer Summit
February 9–10, 2018
Atlanta, Georgia

Approximately 2.5 million patients are affected by pressure ulcers (PrU), and each year 60 000 of them die from these ulcers. PrU represent the second-most common hospital billing claim. Among Medicare beneficiaries, PrU add $43 000 to each hospital stay. Thus, PrU represent a high burden not only in terms of suffering, but also with respect to costs. Despite the establishment and implementation of prevention guidelines, PrU continue to occur. Moreover, management is hampered by variations in the descriptions of PrU, with poor reliability between observers.

On February 9–10, 2018, the Association for the Advancement of Wound Care (AAWC), along with several partner organizations, held the first annual AAWC Pressure Ulcer Summit in Atlanta, Georgia. This Summit brought together an international forum of leaders in wound care and PrU prevention and management to better define pressure-related tissue damage and wounds, assess the state of the science, and identify research opportunities, with an emphasis on clinical implementation of the evidence. Ultimately, the AAWC PrU Summit aims to begin a collaborative effort to provide clarity for health care providers and benefit patients. To that end, the following organizations were active participants in the Summit: Academy of Clinical Electrophysiology and Wound Management (ACEWM), American College of Clinical Wound Specialists (ACCWS), American College of Hyperbaric Medicine (ACHM), American Geriatrics Society (AGS), American Professional Wound Care Association (APWCA), Canadian Association of Wound Care (CAWC), Colegio de Profesionales de la Enfermeria de Puerto Rico (CPEPR), European Wound Management Association (EWMA), International Inter-Professional Wound Care Group (IIWCG), Mexican Association for Skin Care and Wound Healing (AMCICHAC), Society for Post-Acute and Long-Term Care Medicine (AMDA), and Wound Healing Society (WHS). This is a summary of the proceedings from this Summit. Each presentation is summarized, and resources and discussion points follow. These proceedings will be incorporated into a white paper to be published in the near future.                 

Setting the Stage Foundation for Paradigm Shift
Stephen Sprigle, PhD, PT; Georgia Institute of Technology

PrU have physiological similarities with other ulcers and wounds but are unique in that external forces are the defining cause. Clinical interventions seeking to reduce the risk of PrU, as well as research to reduce PrU occurrence, must include a focus on this characteristic. Numerous studies have been structured to identify persons at risk and then invoke general processes and procedures; the implication is that invoking a general plan of care is sufficient because it illustrates preventive actions were taken. However, current plans of action do not adequately inform the management of external forces. 

A paradigm shift is needed. PrU research needs to address what’s next — that is,prevention research should aim to define what should followrisk assessment.Specifically, the emphasis should be on understanding external forces in order to ameliorate their effects within clinical interventions. To help accomplish this goal, researchers can:

  • Provide clear guidelines that reflect how to manage external force effects in light of individual differences in biomechanical risk; 
  • Utilize research methodologies consistent with prevention, including big data analysis coupled with sensor data relating to external forces and 
  • Work together to advocate for prevention research, gather data, and develop performance measures for load bearing surfaces.

Resources

Berlowitz D, VanDeusen Lukas C, Parker V et al. Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of CareRockville, MD. Available at: http://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/index.html(accessed 2/4/2018)

Kosiak, M. Etiology and pathology of ischemic ulcers. Arch Phys Med Rehabil. 1959;40(2):62–69.

Haesler E (ed). National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide.Osborne Park, Australia: Cambridge Media;2014.

Discussion points. Assessments of patient biomechanical risk should incorporate not only the external forces applied at the interface between a body and a surface, but also the biomechanics of the body itself. It should be noted that a focus on external forces will provide insight on the effects of physiologic states, such as hydration, nutrition, and inflammation, on biomechanics.

Prevention research traditionally has not specifically addressed the intensity of an intervention or how much needs to be done to achieve the desired outcomes. However, intensity is inherent in the magnitude, duration, and frequency of external forces or the interventions to lessen them.

Use of large datasets will allow researchers to build a common dataset that can be used to describe patients who develop PrU as well as those who do not. However, at present, electronic health record (EHR) systems, and even the definitions of the data (for example, physiologic parameters), differ among institutions. National standards will be needed to enable data-sharing.

To identify models for building stakeholder consensus in defining PrU, leaders in wound care and PrU prevention and management can look to industries outside of health care. The Insurance Institute for Highway Safety is one example.

Stakeholders in Changing the PrU Paradigm Staging Guidelines, Consensus Panels, and Pathophysiologic Models: Historical Context and Notable Changes

Thomas P. Stewart, PhD, SUNY at Buffalo; Lisa Corbett, DNP, APRN, CWOCN, Hartford Healthcare, Hartford, CT; and Nancy Overstreet, DNP, GNP-BC, CWOCN, CDP, Lynchburg College, Lynchburg, VA and AMDA

Through the years, the National Pressure Ulcer Advisory Panel (NPUAP) has periodically updated staging systems for PrU based on the best evidence and consensus development. Beginning in 1987, this process began with the usage of Shea’s classic 4-stage system; subsequently, NPUAP’s leadership provided numerous updates to staging, such as landmark guidance on deep tissue injury (DTI), unstageable PrU, and unavoidable PrU. Various stakeholders affected by the present guidelines include patients, caregivers, hospitals, long-term care (LTC) facilities, legal entities, payers, regulatory professionals and politicians.

The staging systems are generally believed to follow the etiology and pathophysiology of PrU. However, the 4-stage PrU system has always implied a “top-down” progression in the pathophysiology of PrU. Research concerning etiology and pathophysiology also has unveiled substantial evidence to challenge this progression; there is discord between scientific data and what is currently promoted and reinforced for clinical care. Thus, evidence should be examined to determine if the present staging system, pathophysiological models, and assessment tools are still valid.

At a staging consensus conference in 2016, the NPUAP proposed changing the nomenclature from pressure ulcerto pressure injury(PrI). However, the Society for Post-Acute and Long-Term Care Medicine (AMDA/PALTC), while acknowledging the nomenclature changes in their 2017 Revised Clinical Practice Guideline on Pressure Ulcers, continued to support the use of pressure ulcer. The society also passed a resolution opposing nomenclature changes and supporting the term pressure ulcerin the 10th Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) and other diagnostic catalogues and classification systems.

Longstanding inconsistencies exist in PrU risk assessment, staging definitions, classifications for adverse event reporting, and definitions for quality metrics across health care settings. These contradictions place a daily burden on clinical resources in health care organizations and have not significantly advanced the mission of improved patient safety. How recent changes in pressure ulcer staging will cascade to provide clarity, and what alternative approaches can improve this gap, are unclear.

Resources

Shea JD. Pressure sores: classification and management. Clin Orthop Relat Res. 1975;112:89–100. 

International Association of Enterostomal Therapy. Dermal wound: pressure sores. Philosophy of the IAET. J Enterostomal Ther. 1988;15(1):4–17.

Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. J Wound Ostomy Continence Nurs. 2016;43(6):585–597. 

AMDA. The Society for Post-Acute and Long-Term Care Medicine Pressure Ulcers and Other Wounds Clinical Practice Guideline. Columbia, MD. 2017. Available at: https://paltc.org/product-store/pressure-ulcers-other-wounds-cpg(accessed 1/20/2018)

Bauer K, Rock K, Nazzal M, Jones O, Qu W. Pressure ulcers in the United States' inpatient population from 2008 to 2012: Results of a retrospective nationwide study. Ostomy Wound Manage. 2016;62(11):30–38. 

Padula WV, Valuck RJ, Makic MB, Wald HL. Factors influencing adoption of hospital-acquired pressure ulcer prevention programs in US academic medical centers. J Wound Ostomy Continence Nurs. 2015;42(4):327–330.

Ankrom MA, Bennett RG, Sprigle S, et al. Pressure-related deep tissue injury under intact skin and the current pressure ulcer staging systems. Adv Skin Wound Care.2005;18(1):35–42. 

Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System. J Wound Ostomy Continence Nurs. 2016;43(6):585–597. 

Discussion points. Although the development of PrU staging systems is driven primarily by science, PrU staging in clinical practice tends to be driven more by regulatory and legal forces. For example, slough is an indication of inflammation, which is an internal process, and the established definition for Stage 2 PrU has no slough. However, clinicians tend to classify PrU with slough as Stage 2 because of concerns about regulatory or legal consequences. There is also some debate as to whether wounds containing slough at the base could be classified scientifically as Stage 2 PrU.

Definitions and reporting tend to differ across stakeholders. For example, PrU might be defined differently among an oncologic population than among a long-term care population, or different consensus panels can develop different definitions based on the same or similar information. In addition, several organizations tend to track PrU incidence, but regulatory agencies such as the Centers for Medicare and Medicaid Services (CMS) emphasize prevalence. How to change the paradigm toward an emphasis on incidence is not clear.

The environment for reporting PrU is highly punitive. For example, even when clinicians and staff undergo training and implement prevention practices, they still must report PrU occurrences. An estimated 35% of PrU are caused by medical devices. Separating these ulcers from overall reporting could aid researchers and clinicians in working with manufacturers to innovate in interventions.

Perspectives from Capitol Hill

Representative Karen Handel (R-GA, 6th District)

As Congress continues to grapple with the escalating costs of health care, it is clear that costs associated with PrU are a large part of the equation. The CMS estimates that PrU account for an additional cost of $43 000 for each hospital stay and that 5% of all hospital patients experience some type of PrU. If these numbers are extrapolated to the United States population, they translate to a high burden of suffering. It is clear that prevention and better management of PrU are imperative. Although the CMS is working to provide guidance on indicators and tips for prevention, no objective monitoring tools or uniform system for reporting and tracking PrU exist. Clinicians know about the issues related to PrU because they work on the front lines and live it, but more quantifiable data are needed to support policy solutions. Researchers, manufacturers, and clinicians are making a difference, but they do not receive as much recognition as they should.

Congress likely will focus on health care again, this time issue by issue. If policymakers want to address this concern and ultimately reduce costs, they will need to work with researchers, clinicians, patients, and advocates to improve their awareness and understanding of PrU. In Congress, Representatives Karen Handel, Doug Collins, and Rob Woodall, all of Georgia, are leading efforts to raise awareness of PrU and working with public and private agencies to address prevention and management. 

Representative Handel serves on the Joint Economic Committee, which might serve as a nexus through which Congress can work with clinicians, researchers, and the AAWC and its partner organizations. She has learned about and become interested in PrU through a visit with a partner organization and through personal experience with a friend who suffered from a PrU while fighting cancer. She calls upon stakeholders to bring their perspectives to Congress and help policymakers understand what they do, why it is important, and what solutions should be considered. She also encourages organizations such as the AAWC to visit Capitol Hill and engage with Congress and the Joint Economic Commission.

Discussion points. Researchers and organizations such as the AAWC can increase engagement with their representatives in Congress through annual fly-ins, where they can meet with individual representatives and members of the Ways and Means and Energy and Commerce committees. Researchers also can keep Congress informed of new developments such as new findings or new clinical trials.

Some companies have reached out to Congress and found an enormous amount of interest in PrU prevention, which can create a large amount of employment, not only in research but in new types of interventions. PrU prevention is of particular interest in the Department of Veterans Affairs (VA), whose efforts include the development of an interactive app focused primarily on prevention.

Clinical Considerations Mechanisms of Pressure-Induced Tissue Damage. A Historical Perspective

Ruth Bryant, PhD, RN, CWOCN, Abbott Northwestern Hospital, Minneapolis, MN

Pressure-induced tissue damage affects an estimated 2.5 million patients every year and results in 60 000 deaths per year. By conservative estimates, a hospital-acquired PrU will add $40 000 to the hospital stay. Despite the many years of research, including studies of risk factors, risk assessment, and bundled approaches to prevention of this multifactorial complex phenomenon, the problem of pressure-induced tissue damage persists. Today, we still find ourselves asking fundamental questions about the mechanisms of pressure-induced tissue damage and the histopathology of this condition. Is it a cone-shaped pressure gradient at the bone-soft tissue interface? Can pressure-induced tissue damage also be expressed at the epidermal and dermal layers through changes in dermal papillae and collagen fibers? Or is that a different condition that co-occurs? Conceptual frameworks proposing the etiology of PrU identify 2 key concepts: pressure and tissue tolerance. Although these models have been used traditionally to guide patient care, are they current and do they address tissue deformation? Where is the model to convey the series of events at the microscopic scale of the various histological and cellular responses of tissue to tissue deformation and pressure such as vessel occlusion, thrombosis, tissue hypoxia/ischemia, metabolic accumulation of wastes, interstitial fluid accumulation, and reperfusion injury, among other factors?

Resources

Brooks G, Duncan GW. Effects of pressure on tissues. Arch Surgery. 1940;40:696–709. 

Husain T. An experimental study of some pressure effects on tissues with reference to the bed-sore problem. J Pathol Bacteriol.1953;66:347–358. 

Reichel SM. Shearing forces as a factor in decubitus ulcers in paraplegics. J Am Med Assoc.1958;166:762–763. 

Kosiak M. Etiology and pathology of ischemic ulcers. Arch Phys Med Rehabil.1959;40:62–68. 

Dinsdale SM. Decubitus ulcers: role of pressure and friction in causation. Arch Phys Med Rehabil. 1974;55:147–152. 

Shea JD. Pressure sores: classification and management. Clin Orthop Relat Res. 1975;112:89–100. 

Reddy, NP, Cochran GVB, Krouskop TA. Interstitial fluid flow as a factor in decubitus ulcer formation. J Biomechanics. 1981;14:879–881.

Witkowski JA, Parish LC. Histopathology of the decubitus ulcer. J Am Acad Dermatol. 1982;6: 1014–1021. 

Krouskop, TA. A synthesis of the factors that contribute to pressure sore formation. Med Hypotheses. 1983;II:255–267. 

Parish LC, Witkowski JA, Crissey JT. The Decubitus Ulcer. Chicago, IL: Year Book Medical Publishers, Inc;1983. 

Edsberg LE. Pressure ulcer tissue histology: an appraisal of current knowledge. Ostomy Wound Manage. 2007;53(10):40–49. 

Gefen A. Bioengineering models of deep tissue injury. Adv Skin Wound Care. 2008;21(1):30–36.

Cells Put to the Torture Rack: Why Is Sustained Deformation Lethal to Tissues?

Amit Gefen, PhD, MSc, BSc, Tel Aviv University

Experimental mechanobiological modeling research has revealed that sustained deformations, whether associated with bodyweight loads and gravity or related to medical devices, inflict the primary cell and tissue damage that results in PrU. In both cases, sustained deformations, which arise from hard tissue elements concentrating mechanical stresses in adjacent soft tissues or from a stiff medical device transferring forces to nearby tissues, cause prolonged cell and tissue distortions. Within seconds to minutes, if these forces are not relieved, these distortions will affect cytoskeletal integrity and cause plasma membrane poration, leading to transport abnormalities through the plasma membrane. Loss of homeostasis in the distorted cells eventually follows, occursen masse, and triggers a necrotic-apoptotic cascade of cell death in the affected tissues, leading to inflammation, edema, and a macroscopic spread of the damage. The expected cell response to and likelihood of damage from the sustained mechanical loads delivered to cells and tissues likely vary by the intensity (ie, low, intermediate, or high) of these loads.

With respect to translation of these basic science findings to bioengineering technologies, devices, and practice, the findings from these studies point to a key design requirement for medical devices geared toward PrU prevention or for any device that applies loads on soft tissues or may be intentionally or accidently positioned under the weight-bearing body: alleviation of both skin and deeper-tissue deformations and concentrated mechanical stresses. This requirement has implications for support surfaces and devices and ultimately for effective PrU prevention.

Resources

Slomka N, Gefen A. Relationship between strain levels and permeability of the plasma membrane in statically stretched myoblasts. Ann Biomed Eng. 2012;40(3):606–618. 

Gefen A, Weihs D. Cytoskeleton and plasma-membrane damage resulting from exposure to sustained deformations: a review of the mechanobiology of chronic wounds. Med Eng Phys. 2016;38(9):828–833. 

Levy A, Kopplin K, Gefen A. Device-related pressure ulcers from a biomechanical perspective. J Tissue Viability. 2017;26(1):57–68.

What Lies Beneath: Tissue Biomarkers Indicate Why Pressure Mapping Alone Cannot Tell the Whole Story

Kath Bogie, PhD, Case Western Reserve University, Cleveland, OH

PrU development continues to have a devastating impact on quality of life for too many people with reduced mobility, particularly older adults and persons with spinal cord injury. Many people with long-standing neurological impairment experience a continuous cycle of recurring PrU, whereas others remain free from PrU free for years. It is well established that interface pressure alone cannot account for differences between frequent tissue breakdown and maintenance of tissue health. The impact of pressure and time are related to the quality or resilience of the soft tissues under load. Current studies are identifying correlations between tissue health biomarkers, muscle quality, and PrU development, with the overall goal of developing a user-centered tool to determine an individual’s risk for PrU.

A repeated measures study design has used an established, noninvasive methodology, the Tissue Health Evaluation Toolbox, to assess relationships between muscle quality and tissue resilience under applied loads in a cohort of 40 individuals with SCI. The study employs transcutaneous oxygen and laser Doppler flowmetry to monitor tissue oxygenation and skin blood flow and near infrared sensing to monitor muscle blood flow. The study monitors tissue health bilaterally over the ischia when unloaded and when the individual is sitting. The study also includes contrast-enhanced supine pelvic computed tomography scans. Preliminary findings suggest that detailed analysis of muscle characteristics and tissue resilience can provide personalized indications of risk for PrU. Muscle quality appears to be a key biomarker that differentiates between individuals who develop severe and recurrent PrU and those who do not. These findings suggest that more reliable indicators than pressure mapping risk are needed.

Biomechanics and Age in Pressure Ulcers: The Inflammasome Role

Olivera Stojadinovic, MD, University of Miami, Miami, FL

Mortality of patients with Stage PrU is high, but very little is known regarding molecular mechanisms that participate in the development of these ulcers. Both young and older bed- or wheelchair-bound individuals develop PrU, but these ulcers are more prevalent among older adult patients.

Inflammasomes are large intracellular multiprotein complexes that play a central role in innate immunity and participate in the development of several inflammatory diseases. It is possible, then, that both age and mechanical load will affect inflammasome activation and contribute to its deregulation thus affecting skin inflammatory response in respect to load and age. 

Stojadinovic et al have developed a biomechanical model in which human skin specimens were subjected to a confined compression load of 300 KPa. This load was identified by pressure-plate measurements as the highest load measured on sacral skin when a person is lying on the back. The specimens were subjected to this load for 0.5, 1, 2, and 4 hours, and inflammasome components were quantified by immunoblotting. Skin specimens also were analyzed by histology, and collagen orientation was assessed by using polarized light. Skin from younger (29 to 35 years) and older (54 to 60 years) Caucasian female patients was tested to assess the contribution of age.

In this model, loaded skin shows marked changes in both morphology and inflammasome activation. Focal disruptions along the epidermal-dermal junction and altered orientation of collagen fibers in dermis appear in aged skin after 2 hours of loading. Loaded skin also shows lower levels of inflammasome proteins, caspase-1, and IL-1β, compared with unloaded skin. Interestingly, loaded young skin showed significantly higher levels of inflammasome proteins than elderly skin did. These findings confirm that aging contributes to both morphological changes and decreased inflammasome activation in response to load, suggesting that declines in the innate inflammatory response among older adults may contribute to PrU pathogenesis.

Resources

Eming SA, Martin P, Tomic-Canic M. Wound repair and regeneration: mechanisms, signaling, and translation. Sci Transl Med. 2014;6(265):265–266. 

Kurose T, Hashimoto M, Ozawa J, Kawamata S. Analysis of gene expression in experimental pressure ulcers in the rat with special reference to inflammatory cytokines. PLoS One. 2015;10(7):e0132622 

Stojadinovic O, Minkiewicz J, Sawaya A, et al. Deep tissue injury in development of pressure ulcers: a decrease of inflammasome activation and changes in human skin morphology in response to aging and mechanical load. PLoS One. 2013;8(8):e69223. 

Strbo N, Yin N, Stojadinovic O. Innate and adaptive immune responses in wound epithelialization. Adv Wound Care. 2014;3(7):492–-501.

A Murine Model for Pressure-Induced Tissue Damage

Seok Jong Hong, PhD, Northwestern University Feinberg School of Medicine, Chicago, IL

The causes of nonhealing wounds are often multifactorial, making management quite challenging. Ischemia-reperfusion injury (IRI) has been increasingly recognized as a major factor in the pathogenesis of chronic skin wounds. Repetitive IRI stems from positional changes and/or mechanical loading and unloading of the affected areas and their associated effects on blood flow. IRI is a complex molecular process that can occur in nearly every physiologic system in response to cyclical changes in local oxygen tension. It has been studied extensively in the heart, brain, kidney, and liver, but few studies have been conducted in cutaneous tissues. Furthermore, the differential tolerance of the components of subcutaneous tissues, adipose and dermis, is poorly understood. A delineation of the distinct role of adipose and dermis in the pathogenesis of nonhealing wounds such as PrU could yield significant insight into their treatment and prevention.

In several studies, Hong et al identified factors underlying tissue responses to IRI using a cyclical murine IRI injury model in which wild-type C57BL/6 mice were subjected to IRI cycles that varied in number (1 to 4 cycles) and duration of ischemia (1 to 2 hours). Increases in both IRI cycle number and ischemia duration correlated with increased areas of epithelial necrosis, both grossly and histologically, and with an increase in cellularity and neutrophil density. Increased inflammatory infiltrate and a significant increase in the expression of pro-inflammatory markers was observed in adipose tissue subjected to IRI, but not in dermis. These findings indicate an active role of adipose tissue in the stress response to IRI, although adipose tissue has traditionally been considered a passive bystander in IRI.

Resources

Gust MJ, Hong SJ, Fang RC, et al. Adipose tissue drives response to ischemia-reperfusion injury in a murine pressure sore model. Plast Reconstr Surg. 2017;139(5):1128e–1138e.

Hong SJ, Jin DP, Buck DW 2nd, Galiano RD, Mustoe TA. Impaired response of mature adipocytes of diabetic mice to hypoxia. Exp Cell Res. 2011;317(16):2299–2307.

Hong SJ, Park E, Xu W, Jia S, Galiano RD, Mustoe TA. Response of human mature adipocytes to hypoxia-reoxygenation. Cytotherapy. 2014;16(12):1656–1665. 

Mustoe TA, O'Shaughnessy K, Kloeters O. Chronic wound pathogenesis and current treatment strategies: a unifying hypothesis. Plast Reconstr Surg. 2006;117(7 suppl):35S–41S.

Steinberg JP, Gurjala AN, Jia S, Hong SJ, Galiano RD, Mustoe TA. Evaluating the effects of subclinical, cyclic ischemia-reperfusion injury on wound healing using a novel device in the rabbit ear. Ann Plast Surg. 2014;72(6):698–705.

Discussion points. At first glance, the evidence suggesting sustained tissue deformation gives rise to the damage that eventually leads to PrU appears to conflict with evidence that negative pressure therapy facilitates wound healing through cell deformation. However, the localized tissue distortions seen in negative pressure wound therapy protocols are not as profound as those seen in the interaction between soft tissues and sharp bony areas or medical devices. 

The markers upregulated in the model presented by Hong also appear to be upregulated in muscle tissue that has become fatty, as shown by Polymerase Chain Reaction (PCR) on muscle biopsy samples. It is possible (eg, among patients with SCI) persons who develop PrU might have a more active inflammatory response. At first glance, this might contradict with Stojadinovic’s data suggesting that PrU development might be associated with a lower inflammatory response. However, the model used by Stojadinovic et al focuses on inflammation primarily seen from keratinocytes and cannot answer questions about muscle or fat involvement.

Damaged skin that can no longer redistribute is more susceptible to the substantial damage that leads to PrU. Factors such as urinary or fecal incontinence alter skin integrity. Moisture changes the topography of the skin, and this change alters the coefficient of friction and other mechanics of the skin. At the same time, wet skin loses stiffness and strength. Thus, incontinence or other factors creating moisture can create conditions where the skin is weakened and tear more easily, at a time when a region might be subjected to higher forces. However, it is not clear that incontinence and other factors necessarily lead to PrU; other comorbidities might contribute as well. It will be important to distinguish and treat the different individual causes of PrU and other skin conditions.

One question to consider is whether turning patients every 2 hours recreates IRI. Hong’s model creates IRI under anoxic conditions, whereas another model creates ischemia at a level similar to that experienced by patients lying on one side. More understanding is needed of the level of injury patients experience, so that these conditions can be re-created in the laboratory.

Some data suggest that African American race might be a protective factor with respect to PrU. However, more studies of age, load, biomechanics, muscle composition, and other factors contributing to PrU are needed in persons of color.

Drive for Evidence/Quality Metrics We Use Today

Matthew Scanlon, MD, Medical College of Wisconsin, Milwaukee, WI; and Holly Kirkland-Kyhn, PhD, FNP-c, GNP-c, CWCN, University of California Davis Medical Center, Sacramento, CA

PrU occur in all settings and can result in significant harm, including wound-related pain, uncomfortable treatments, increased length of hospital stays, increased costs, and significant patient functional disability. Although many entities are collecting quality and safety metrics to compare outcomes on hospital-acquired PrU in acute and long-term care, no metrics have been used to measure PrU that may occur during transport, to describe PrU that are present on admission, or to identify mixed-origin wounds in patients with limited mobility. 

This presentation provided information on tools and metrics used through ICD-9 and ICD-10 coding, EHRs, National Nursing Quality Indicator surveys, Collaborative Alliance for Nursing Outcomes surveys, and local incident reports. Although these quality metrics may be useful, they lack validity, and more data analysis is needed to define which factors are truly related to nursing quality. In addition, the comparative analysis of quality metrics should be used to drive future policy in the identification and prevention of PrU in all settings, rather than focusing on hospital-acquired PrU and assigning the occurrence as a Nursing Quality Indicator.

Resources

Agency for Healthcare Research and Quality (AHRQ). 2000. Reducing Errors in Health Care: Translating Research into Practice.Available at:  http://www.ahrq.gov/qual/errors.htm(accessed 2/4/2018).

Cafardi S, Coomer NM. 2012. Examination of the accuracy of coding pressure ulcer stages. Final Report. Available at:  https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Downloads/Accuracy-of-Coding-Pr-Ulcers.pdf(accessed 2/4/2018).

Healy DA, Spain PC, Cromwell J. Examination of Spillover Effects and Unintended Consequences of Medicare HAC-POA Program(CMS Contract No. HHSM-500-2005-00029I). Prepared for Centers for Medicare and Medicaid Services, September 2011. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Downloads/HAC-SpilloverEffects.pdf(accessed 1/30/2018).

National Database of Nursing Quality Indicators (NDNQI). Available at: https://nursingandndnqi.weebly.com/ndnqi-indicators.html(accessed 2/4/2018).

National Database of Nursing Quality Indicators (NDNQI). NDNQI: Transforming Data into Quality Care[brochure]. 2010. Available at:  https://www.nursingquality.org/(accessed 2/4/2018)

Discussion points. Health care providers are concerned primarily with caring for their patients, but they must balance this with meeting the requirements of regulatory agencies that oversee their care. In many cases, accountability measures are established by regulatory agencies in a way that makes it difficult to avoid judgment and blame. Constant conversations are necessary so that clinicians will know what they are held accountable for. Blame can be minimized by establishing automated systems that prod practitioners to document, describe, and stage what they see as PrU. For example, systems described by Kirkland-Kyhn include a function that provides a definition and photograph for each stage and thus increases confidence in staging. Hiring more wound ostomy nurses, educating all staff on risk, implementing Braden interventions, and daily safety briefings are additional suggestions for ensuring excellence in practice. Administrative pushback on fully documenting PrU in the health record can be addressed by discussing the downsides of incident reports.

PrU Risk Assessment

E. Foy White-Chu, MD, CWSP, AGSF, VA Portland Healthcare System, Portland, OR; Sunniva Zaratkiewics, PhD, RN, CWOCN, University of Washington, Seattle, WA; Gail Powell-Cope, PhD, ARNP, FAAN, VA HSR&D Center of Innovation on Disability and Rehabilitation Research, Tampa, FL; and Jeanine Maguire, PT, CWS, Genesis HealthCare, Kennett Square, PA

PrU risk assessment traditionally has been done through standardized tools. In the era of electronic health records, the tendency of clinicians to copy and paste information for the sake of efficiency, the accuracy of existing tools and their use in a variety of settings, and research indicating multiple risk factors that are not currently included in existing tools, offer opportunities for improvement. This session reviewed risk assessment in patients with SCI and in different venues such as acute care and post-acute care, as well as regulation updates in various venues, in the context of 2 cases:1 patient with SCI and 1 frail older adult, who both develop a PrU/I despite the use of risk assessment tools. Both the speakers and audience were challenged to identify gaps in care, pose research questions to improve the evidence, and identify ways to change their practice at their home institutions.

Resources

Alderden J, Whitney J, Taylor S, Zaratkiewicz S. Risk profile characteristics associated with outcomes of hospital acquired pressure ulcers: a retrospective review. Crit Care Nurse. 2011;31(4):30–43. 

Rondinelli J, Zuniga S, Kipnis P, Kawar L, Liu V, Escobar G. Hospital-acquired pressure injury: risk-adjusted comparisons in an integrated healthcare delivery system. Nursing Research. 2018;67(1):16–25. 

Tescher A, Branda M, Byrne T, Naessens J. All at-risk patients are not created equal: analysis of Braden Pressure Ulcer Risk scores to identify specific risks. J Wound Ostomy Continence Nurs. 2012;39(3):282–291. 

Varghese J, Kleine M, Gessner S, Sandmann S, Dugas M. Effects of computerized decision support system implementations on patient outcomes in inpatient care: a systematic review. J Am Med Inform Assoc. 2017;Epub ahead of print.

Discussion points. Front-line nurses serve as the true protectors of patients, but they are overburdened with various tasks. If the Braden Scale is implemented correctly, approximately 82% of patients would be classified as “at risk.” Thus, instead of asking nurses to assess PrU risk for each individual patient, creating a standard algorithm to be used with most, if not all, patients might be more useful. Yet PrU still occur in institutions where universal interventions have been implemented. The health care industry should define which interventions should be included in a universal algorithm and assess regularly to ensure the correct combination of algorithms is used. Other suggestions for improving PrU risk assessment include removing from nurses’ workloads the tasks that do not add value and stratifying patients with SCI by age and length of injury.

Pressure-Induced Tissue Damage: Science of Detection and Describing Early Identification of Deep Tissue Injury (DTI) Using Long-Wave Infrared Thermography 

Richard Simman, MD, FACS, FACCWS, Jobst Vascular Institute/ Wright State Boonshoft School of Medicine, Toledo, OH

Timely and accurate assessment of skin and underlying tissue is crucial for making informed decisions relating to DTI and the ultimate development of PrU. Unfortunately, the current gold standard (visual assessment) is limited mostly to what clinicians can see, which often reflects what has already happened. The soft-tissue damage and distortion brought on by DTI results from a combination of pressure and frictional and shear forces. These forces lead to reduction of blood flow to an area in the form of ischemia, cell distortion, impaired lymphatic drainage, impaired interstitial fluid flow, or reperfusion injury. These pathophysiological events lead to changes in the temperature of the affected tissue and are manifested in the form of a previsual ischemic and inflammatory phase. 

Long-wave infrared thermography (LWIT) has been identified as a tool that provides an objective, noninvasive, and quantitative means of early DTI diagnosis. Simman et al conducted a study using an FDA-approved LWIT device to measure at-risk areas, regardless of whether they showed visual changes, to assess temperature change as an early, previsual indicator for the development of DTI. LWIT was used to scan the sacral/coccyx and bilateral heels of 70 patients at risk for DTI/PrU development upon admission to and throughout their stay at a long-term acute-care hospital (LTACH). Preliminary data suggest utility and added advantage of LWIT to document and screen patients for previsual signs and symptoms of DTI development. These data add to the existing body of evidence of differences in heat between DTI and surrounding tissue. By integrating LWIT with head-to-toe skin assessment, providers may be able to improve outcomes through targeted interventions and preserve revenue through avoidance of litigation and reimbursement loss. 

Resources

Stekelenburg A, Gawlitta D, Bader D, Clemens C. Deep tissue injury: how deep is our understanding? Arch Phys Med Rehabil. 2008;89(7):1410–1413. 

Bhargava A, Chanmugam A, Herman C. Heat transfer model for deep tissue injury: a step towards an early thermographic diagnostic capability.Diagn Pathol. 2014;9:36. 

Judy D, Brooks B, Fennie K, Lyder C, Burton C. Improving the detection of pressure ulcers using the TMI ImageMed System. Adv Skin Wound Care. 2011;24(1):18–24.

Farid K, Winkelman C, Rizkala A, Jones K. Using temperature of pressure-related intact discolored areas of skin to detect deep tissue injury: an observational, retrospective, correlational study. Ostomy Wound Manage. 2012;58(8):20–31. 

Use of Subepidermal Moisture To Detect Pressure Damage

Barbara Bates-Jensen, PhD, RN, FAAN, UCLA School of Nursing & David Geffen School of Medicine, Los Angeles, CA

Devices using surface electrical capacitance methods detect and measure subepidermal moisture (SEM) or water below the stratum corneum within the tissues. By using dielectric parameters, high-frequency, low-power electromagnetic waves 300 MHz or less are transmitted via an open-ended coaxial wand/device that is manually placed on the skin surface. In the skin, the induced electrical field interacts with water molecules, with the depth of interaction (typically 2.5 mm) depending on the diameter of the circular electrode on the device. The electromagnetic energy that is not absorbed by tissue water is reflected and measured and displayed in the measuring unit. This technology is not new; it has been used to examine post-treatment erythema in dermatology, to quantify epidermal healing in premature infants and among burn patients, and to quantify lymphedema in patients with breast cancer. Two (2) devices, the MoistureMeter D (Delfin Technologies Ltd, Kuopio, Finland) and the SEM Scanner (Bruin Biometrics, LLC, Los Angeles, CA), have been studied for use in detecting PrU damage. 

Over the past 12 years, research has consistently demonstrated a relationship between SEM and PrU development across multiple populations, various instruments, and various anatomic locations. Multiple studies now demonstrate that a hand-held device for SEM measurement can identify and predict early skin damage at the sacrum and buttocks locations in nursing home residents, persons with dark skin tones, and persons with SCI; can detect and predict heel pressure damage; and differentiate DTI that resolves versus that that deteriorates among nursing home residents. SEM is correlated with ultrasonography of pressure damage, and it demonstrates beginning of validity for pediatric orthopedic patients. Further, recent clinical evidence from the United Kingdom and Ireland shows a reduced incidence of hospital-acquired PrU when SEM measurement is part of a PrU prevention program. Thus, technology to measure SEM may be useful for identifying early skin injury that can benefit from intervention. 

Resources

Bates-Jensen BM, McCreath HE, Nakagami G. Patlan A. Subepidermal moisture detection of heel pressure injury: the Pressure Ulcer Detection study outcomes. Int Wound J.2017 Dec 17. Epub ahead of print.

Bates-Jensen BM, McCreath HE, Patlan A. Subepidermal moisture detection of pressure induced tissue damage on the trunk: the Pressure Ulcer Detection study outcomes. Wound Repair Reg. 2017;25:502–511. 

Bates-Jensen BM, McCreath HE, Kono A, Apeles NC, Howell L, Alessi C. Subepidermal moisture predicts erythema and stage I pressure ulcers in nursing home residents: a pilot study. J Am Geriatr Soc. 2007;55:1199–1205.

Bates-Jensen BM, McCreath H, Pongquan V. Apeles NCR. Subepidermal moisture differentiates erythema and stage I pressure ulcers in nursing home residents. Wound Repair Regen.2008;16:189–197. 

Bates-Jensen BM, McCreath HE, Pongquan V. Subepidermal moisture is associated with early pressure ulcer damage in nursing home residents with dark skin tones: pilot findings. J Wound Ostomy Continence Nurs. 2009;36(3):277–284. 

Clendenin M, Jaradeh K., Shamirian A, Rhodes SL. Inter-operator and inter-device agreement and reliability of the SEM scanner. J Tissue Viability. 2015;24(1):17–23.

Ching CT, Chou MY, Jiang SJ, et al. Tissue electrical properties monitoring for the prevention of pressure sore. Prosthet Orthot Int. 2011;35(4):386–394. 

Harrow JJ, Mayrovitz HN. Subepidermal moisture surrounding pressure ulcers in persons with a spinal cord injury: a pilot study. J Spinal Cord Med. 2014;37(6):719–728.

Goretsky MJ, Supp AP, Greenhalgh DG, et al. Surface electrical capacitance as an index of epidermal barrier properties of composite skin substitutes and skin autografts. Wound Repair Regen. 1995;3:419–425.

Guihan M, Bates-Jensen BM, Chun S, Parachuri R, Chin AS, McCreath H. Assessing the feasibility of subepidermal moisture to predict erythema and stage 1 pressure ulcers in persons with spinal cord injury: a pilot study. J Spinal Cord Med. 2012;35(1):46–52. 

Mayrovitz, HN. Assessing local tissue edema in postmastectomy lymphedema. Lymphology. 2007;40(2):87–94. 

Mayrovitz HN, McClymont A, Pandya N. Skin tissue water assessed via tissue dielectric constant measurements in persons with and without diabetes mellitus. Diabetes Technol Ther. 2013;15(1):60–65. 

Mayrovitz HN, Guo X, Salmon M, Uhde M. Forearm skin tissue dielectric constant measured at 300 MHz: effect of changes in skin vascular volume and blood flow. Clin Physiol Funct Imaging. 2013;33(1):55–61. 

Palenske J, Morhenn VB. Changes in the skin’s capacitance after damage to the stratum corneum in humans. J Cutan Med Surg. 1999;3(3):127–131.

Visualizing Tissue Deformation and Biomechanical Risk

Sharon Sonenblum, PhD, Georgia Institute of Technology, Atlanta, GA

Because the arrangement of human soft tissue is so specific to posture, loading should be studied in the actual posture with respect to gravity, such as sitting upright, lying supine, or lying with the head of the bed elevated. Studying tissue in these postures is possible in the FONAR upright magnetic resonance imager (MRI). Images collected in situ can be used to understand tissue deformation in response to sitting and lying down.

The human body is mostly water, and therefore it does not compress under load. Where the water-filled tissue goes when loaded by sitting or lying supine is not clear. Three-dimensional data and analysis provide some insight into where tissue displaces under load. Some image analysis techniques are available to track tissue displacement and distortion, but innovation and improvement are needed. Imaging also can be used to identify differences in tissue characteristics and deformation across individuals with SCI, who are diagnostically similar but present with very different tissue responses. Moreover, imaging can be used to determine how cushion design, including materials and shape, influences deformation. 

Resources

Al-Dirini RM, Reed MP, Thewlis D. Deformation of the gluteal soft tissues during sitting. Clin Biomech (Bristol, Avon). 2015;30(7):662–668.

Gefen A. The Compression Intensity Index: a practical anatomical estimate of the biomechanical risk for a deep tissue injury. Technol Health Care. 2008;16(2):141–149.

Sacks AH. Theoretical prediction of a time-at-pressure curve for avoiding pressure sores. J Rehabil Res Dev. 1989;26(3):27–34. 

Sonenblum SE, Sprigle SH, Cathcart JM, Winder RJ. 3D anatomy and deformation of the seated buttocks. J Tissue Viability. 2015;24(2):51–61.

Discussion points. The terminology in the field of PrU research must be reconciled with that used in engineering. Whereas deformation and displacementare terms used by engineers, distortionis a more descriptive term. These differences should be considered when developing equations to describe tissue displacement and biomechanical risk. What is more important is an intuitive understanding of the relocation and shape changes that occur when a load is applied.

The study population described by Bates-Jensen was reflective of the general nursing home population, and studies are under way to incorporate SEM measurement into existing practice in nursing homes. Readings were taken more quickly in a critical care population. In both populations, it is possible that within the week in the study, some pressure-induced damage was missed, and some damage might have resolved because of prevention interventions.

SEM also is known as subepidermal edema. One must take care in measuring SEM in patients with a high level of edema, such as persons with SCI or those with high cervical injury. To begin to define some standards, other studies have assessed other factors, such as blood perfusion, blood flow, or even gender, that might contribute to increased subepidermal edema.

Pressure Ulcer (Description) Tool (PUDT): An Interactive Discussion

Ruth Bryant, PhD, RN, CWOCN, Abbott Northwestern Hospital, Minneapolis, MN; Tim Paine, PT, Litchfield Hills Orthopedic Associates, Torrington, CT; and Donna Cartwright, MPA, RHIA, CCS, RAC, FAHIMA, Integra LifeSciences Corporation, Plainsboro, NJ

There is a critical need for the PrU label to be assigned reliably to true pressure-induced tissue damage. However, considerable confusion occurs when one attempts to distinguish pressure-induced tissue damage from other sources of skin damage such as shear, moisture, friction, or viral infections. The process of delineating pressure and non-pressure related etiologies of ulcerations in the perirectal, fleshy buttocks, and gluteal cleft areas is complex and requires consideration of many factors: ulcer or lesion presentation, condition of the surrounding skin, distribution of ulcer or lesions, location of the ulcer, immune status, nutritional status, medication history, co-existing diseases, and bowel and/or bladder control.

Evidence suggests this confusion results in the misclassification of nonpressure-related ulcerations as Stage 2 and Stage 3 PrU. One (1) study reported that among 100 nurses who specialize in wound care, agreement of 75% or higher on the etiology of buttock ulcerations was obtained in only 3 of the 9 color wound photographs. Thus, a new method to accurately identify a PrU and its severity is needed and desirable. 

The Pressure Ulcer Description Tool (PUDT) is designed to quickly guide clinicians at all levels of care through the assessments necessary to determine the most likely etiology (such as PrU, incontinence-associated dermatitis, virus) of the current skin condition in the perirectal and fleshy buttocks area. The items included in this tool are key assessment parameters derived by a multidisciplinary group of clinical experts after an extensive review of the literature. The PUDT contains 3 domains: skin damage without open ulcer, blisters, and skin damage with open ulcer. Each domain has 2 to 5 subcategories.

This session described the current status of this tool, its clinical utility, anticipated linkage with CMS documentation, and next steps. Clinical experts attending the Summit were asked to provide feedback, via the PollEverywhere app, on the clinical relevance of the items to PrU detection. Immediately apparent from participant responses was the need to improve descriptions regarding the intent of the PUDT and to clearly define the terminology used.

Resources

Beeckman D, Schoonhoven L, Fletcher J, et al. EPUAP classification system for pressure ulcers: European reliability study. J Adv Nurs. 2007;60(6):682–691. 

Beeckman D, Schoonhoven L, Fletcher J, et al. Pressure ulcers and incontinence-associated dermatitis: effectiveness of the Pressure Ulcer Classification Education Tool on classification by nurses. Qual Saf Health Care. 2010;19(5):e3–e3.

Briggs SL. Pressure ulcers. How accurate are RGNs in grading pressure ulcers? Br J Nurs. 2006;15(22):1230–1234. 

Bruce TA, Shever LL, Tschannen D, Gombert J. Reliability of pressure ulcer staging. A review of literature and 1 institution's strategy. Crit Care Nurs Q. 2012;35(1):85–101.

Defloor T, Schoonhoven L, Katrien V, Weststrate J, Myny D. Reliability of the European Pressure Ulcer Advisory Panel classification system. J Adv Nurs. 2006;54(2):189–198.

Nix DP, Mackey DM. Support surfaces. In: Bryant R, Nix D (eds).Acute and Chronic Wounds: Current Management Concepts,5th ed. St. Louis, MO: Elsevier;2016.

Mahoney M, Rozenboom B, Doughty D, Smith H. Issues related to accurate classification of buttocks wounds. J Wound Ostomy Continence Nurs. 2011;38(6):635–642.

Prevention Interventions Prevention of Pressure Ulcers: Tools for Risk Reduction

Rummana Aslam, MD, Rutgers New Jersey Medical School

Successful PrU prevention is achievable by utilizing a multidisciplinary, multimodality, and multidimensional plan of care. All major hospitals and rehabilitation facilities have protocols and education in place for PrU prevention based on evidence-based guidelines. Despite the existence of these protocols, policies and procedures, PrU prevention and management remains a very challenging problem. Successful outcomes might require a different overall approach to this problem. 

Most cases of failure to prevent PrU exhibit 3 characteristics: lack of ownership, lack of role specification, and lack of communication. One (1) care team member, preferably the physician or lead nurse, should be responsible for steering the ongoing care of the health of the skin as an organ system and making sure all protocols are followed. Everyone taking care of the patient, including family members and the patient, should have their role and contribution to the care plan specified. Communication between all care team members, family, and the patient should be frequent and ongoing, especially when the medical condition of the patient changes.

Importantly, this is not a one-size-fits-all issue. Successful outcomes are possible if the care plan to reduce PrU risk is individualized and goal-directed, taking into consideration all the barriers, facilitators, and resources available. Everyone should approach this problem by taking ownership and playing a specific role in the care given, and the process must emphasize constant communication, collaboration, and coordination.

Complex Rehab Technology

Karen Whitesell, PT, DPT, NCS, ATP, George Washington University Hospital, Washington, DC

An optimally configured manual or power wheelchair and a high-quality skin-protection cushion are essential for a person with a mobility impairment. In addition to offering independent mobility, this equipment assists in PrU prevention. New complex rehab technology to assist in PrU prevention includes power tilt-in-space and recline functions with tracking and memory capability assist greatly with patient adherence to pressure reliefs. However, many barriers interfere with access to this necessary equipment. Health care providers, patients and families lack knowledge of complex rehab technology. Medicare requirements create barriers to obtaining optimal skin-protection cushions and wheelchairs, and they indirectly affect all persons requiring complex rehab equipment.

Pressure mapping assists in obtaining the most appropriate skin protection cushion to prevent PrU. Use of the pressure-mapping system as an education tool for patients and family can strengthen patient education. Physical and occupational therapy, including functional mobility training, can also assist in PrU prevention. A comprehensive seating assessment from a seating and mobility clinic in conjunction with a comprehensive Face-to-Face Mobility Assessment is necessary to obtain the most appropriate, optimally configured wheelchair and skin-protection cushion. An electronic medical record Face-to-Face template assists in successful equipment procurement. Physician education with respect to correct documentation will greatly increase access, and denials can be addressed through peer-to-peer appeals. Stakeholders in PrU prevention also can work to effect change at the national level by contacting Congressional representatives and senators to protect access to complex rehab technology.

Resources

Coleman S, Nixon J, Keen J, et al. A new pressure ulcer conceptual framework. J Adv Nurs. 2014;70(10):2222–2234.

Dicianno BE, Margaria E, Arva J, et al. RESNA Position on the Application of Tilt, Recline, and Elevating Leg Rests for Wheelchairs. Rehabilitation Engineering and Assistive Technology Society of North America, 2008. Available at: http://www.rstce.pitt.edu/RSTCE_Resources/Resna_Position_on_Tilt_Recline_Elevat_Legrest.pdf. Accessed February 19, 2018.

Levy A, Kopplin K, Gefen A. An air-cell-based cushion for pressure ulcer protection remarkably reduces tissue stresses in the seated buttocks with respect to foams: finite element studies. J Tissue Viability. 2014;23(1):13–23.

Medicare Learning Network Power Mobility Devices. October, 2017. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/pmd_DocCvg_FactSheet_ICN905063.pdf. Accessed February 19, 2018.

Shoham N, Levy A, Kopplin K, Gefen A. Contoured foam cushions cannot provide long-term protection against pressure-ulcers for individuals with a spinal cord injury: modeling studies. Adv Skin Wound Care. 2015;28(7):303-316.

Discussion points. Fall prevention protocols dictate that patients in intensive care units not be moved until a physical therapist has seen them. Because of inadequate staffing in physical therapy departments, patients often wait for a long time before they are assessed. Physical therapists should be involved early and quickly in patient wound care. In the acute care setting, physical therapists can conduct seating assessments and teach other staff about transfer and bed mobility. To address delays in assessments, more physical therapists can be educated regarding spinal cord injury and seating mobility, institutions can advocate to include seating specialists in physical therapy departments, and nurses can be trained to conduct mobility assessments. Nursing staff also should be increased.

Clinical Implementation: Translating the Science into Action Factors Affecting Implementation of a Pressure Ulcer Monitoring Tool (PUMT) in Spinal Cord Injury

MaryLou Guihan, PhD, Edward Hines Jr VA, Hines, IL

PrU are a significant source of morbidity, mortality, and diminished quality of life for veterans with SCI, and treatment is expensive (more than $100,000 annually). The SCI Pressure Ulcer Monitoring Tool (SCI-PUMT) was developed to evaluate PrU in SCI. Although a multifaceted strategy was used to implement the SCI-PUMT, only about 50% of 24 VA SCI centers reported consistent use of the SCI-PUMT at 1 year following implementation.

A study was conducted to identify barriers and facilitators to SCI-PUMT implementation, as well as best practices to be evaluated in future studies. Facilitators of implementation included presence of an experienced and dedicated interdisciplinary wound care team and strong staff and leadership support. Barriers included time and staffing constraints, lack of training, and lack of leadership. Standardized documentation was reported by some sites as a facilitator, because it provided a common language. Other sites cited it as a barrier because they were documenting multiple PrU in up to 3 different places (bedside, chart, and stand-alone database). Chart reviews identified 72 unique veterans with 206 PrU (mean = 2.9 ulcers/veteran); only 25% had a weekly SCI-PUMT score documented. More severe PrU (Stage 3 to Stage 4) were twice as likely to be documented as less severe PrU (Stage 2) (mean = 40% vs. 19%, range 15%–66%).

These findings show that implementation is influenced by the characteristics of interventions and inner settings reflecting organizational and unit-level factors. The study further identified high- and moderate-adopting centers as potential targets for increased implementation and improved sustainability.

Resources

Thomason SS, Powell-Cope G, Peterson MJ, et al. A multisite quality improvement project to standardize the assessment of pressure ulcer healing in veterans with spinal cord injuries/disorders. Adv Skin Wound Care. 2016;29(6):269–276. 

Thomason SS, Luther SL, Powell-Cope GM, Harrow JJ, Palacios P. Validity and reliability of a pressure ulcer monitoring tool for persons with SCI. J Spinal Cord Med.2014;37(3):317–327.

Thomason SS, Graves BA, Madaris L. A pilot study to evaluate the role of the Spinal Cord Impairment Pressure Ulcer Monitoring Tool (SCI-PUMT) in clinical decisions for pressure ulcer treatment. Ostomy Wound Manage.2014;60(12):28–36.

Translating Science into Practice

Kathleen Borchert, MS, RN, ACNS-BC, CWOCN, CFCN, University of Minnesota Medical Center, Minneapolis, MN

This presentation described a project to critically review current practices and guidelines for PrU prevention and to implement a nursing-improvement plan to reduce hospital-acquired PrU in adult ICU populations. Specifically, the project aimed to identify strategies that had been shown to be effective prevention strategies but were not used in ICUs at the University of Minnesota Medical Center by having a wound, ostomy, and continence (WOC) nurse observe ICU staff nurses and documenting the care they delivered.

Followinga thorough literature review, the WOC nurse and project staff determined the ICUs lacked 2 evidence-based interventions: prophylactic use of silicone dressings and staff nurse knowledge of PrI prevention strategies. Many staff who thought they were following prevention strategies did not know the difference between the institution’s 2 offloading mattresses. This lack of knowledge resulted in incorrect documentation of interventions by staff. 

Resources

Balzer K, Kottner J. Evidence-based practice in pressure ulcer prevention: lost in implementation? Int J Nurs Stud. 2012;52(11):1655–1658. 

Elliott R, McKinley S, Fox V. Quality improvement program to reduce the prevalence of pressure ulcers in an intensive care unit. Am J Crit Care. 2008;17(4):328–334.

Minnesota Hospital Association Safe Skin Toolkit. Available at: http://www.mnhospitals.org/pressure-ulcers#/videos/listAccessed January 15, 2018.

Discussion points. Padula et al published studies on the optimal number of WOC nurses (~5.5) per PrU event. The University of Minnesota began with 4.9 full-time WOC employees and has managed to increase this by 1.4 around prevention and treatment. However, there may be no magic number per patient with respect to the number of WOC nurses in a particular care setting.

This session emphasized the importance of experienced, dedicated, interdisciplinary wound care teams. The Agency for Healthcare Research and Quality offers an evidence-based tool, Team Steps, to assist institutions in improving their care teams. Coaching and mentoring are also important to ensure that everyone on the care team has relevant skills. There is no one right way to develop these teams, but more evidence is needed to identify best practices in team-building.

The SCI-PUMT was developed and refined through a series of summits and focus groups, with psychometric testing on some items; it was validated in a population of veterans. Although the tool is effective and addresses stakeholder concerns, pushback has occurred because it takes longer to administer than the existing PUSH tool.

Implications of Pressure Ulcer Terminology — “A Simple Term Change Is Not So Simple.” Legal Impact of Pressure Ulcer Terminology

Norris Cunningham, Esq, Katz Korin Cunningham, PC, Indianapolis, IN; Donna Cartwright, MPA, RHIA, CCS, RAC, FAHIMA, Integra LifeSciences Corporation, Plainsboro, NJ; and Caroline Fife, MD, FAAFP, CWS, FUHM, St Luke’s Hospital, The Woodlands, TX

Our legal, reimbursement, and medical systems are interrelated and depend on clear communication for an accurate understanding of ideas and concepts. As experts in our respective fields, we strive to communicate our message with as much clarity as possible. However, our ability to effectively communicate with other specialists as well as reporting agencies through clinical documentation, coded data and classification, is limited by the lexicon we utilize. Confusion, misunderstandings, and errors occur when the information received is different than what the sender intends. Similarly, these same errors occur when lexicon is not fully understood by those using it. This session highlighted aspects of the legal, coding, and clinical terminology challenges seen recently with respect to existing terminology recommendations. 

Resources

Shea JD. Pressure sores: classification and management. Clin Orthop Relat Res. 1975;112:89–100. 

International Association of Enterostomal Therapy. Dermal wound: pressure sores. Philosophy of the IAET. J Enterostomal Ther. 1988;15(1):4–17.

Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. J Wound Ostomy Continence Nurs. 2016;43(6):585–597. 

Ankrom MA, Bennett RG, Sprigle S, et al. Pressure-related deep tissue injury under intact skin and the current pressure ulcer staging systems. Adv Skin Wound Care. 2005;18(1):35–42.

Discussion points. In the American legal system, a plaintiff making a claim of negligence against a health care provider must prove that there is a duty, that there has been a breach of that duty, that an injury has occurred, and that the breach is causally related to the injury. By changing the term from pressure ulcerto pressure injury, the NPUAP has unwittingly helped plaintiffs in proving their claims. Although the NPUAP uses injuryas a medical term, jurors and judges will not distinguish this from a plain and ordinary meaning, which will favor the plaintiff. 

It should be noted that the recommended change by NPUAP to PrI does not represent a mandate. Thus, institutions must decide which term to use. The use of different terms by different organizations and institutions leaves clinicians lost as to how to best describe what they see at the bedside without opening themselves to litigation. This Summit has brought together experts from various disciplines to address this confusion and concern by fostering a collaborative effort to improve terminology based on science. This effort could build a categorization or staging system that accurately expresses both severity and prognosis.

Some PrU cases do not fit into current coding schemes. There is no way to document that a PrU is improving, because the coding guidelines do not allow for downgrading or healing. For example, if a patient comes in for a flap reconstruction and is admitted for a Stage 4 PrU, then leaves the hospital with an unstageable PrU, there is no way to code that change. Following the flap reconstruction, the PrU would no longer be coded; instead, the case would become a surgical wound and coded accordingly. Coding guidelines allow for a second code only if the PrU worsens. In another example, the NPUAP has changed the terminology to PrI, but the ICD-10 has not changed, and coders still assign codes based on words in the chart. If the clinician documents a pressure injury, that information will not be taken from the chart because there is no code in the guidelines for PrI. An improved PUDT that allows providers to accurately describe what they see can assist coders in extracting the information they need to code the case accurately.

A Call to Action Discussion Points

It is likely that not only that tissue deformation contributes to individualized biomechanical risk, but also tissue tolerance as it relates to deformation. Tissue tolerance relative to ischemia also should be considered. In considering tissue tolerance, it is important to understand the tolerance of both cells and extracellular structures. Cellular tolerance is particularly important because cells are required for tissue repair; this factor is affected by age, inflammation, chronic disease, and other characteristics that contribute to PrU risk.

Meanwhile, system physiology cannot be ignored. The pathophysiology of PrU happens at different dimensional scales. Human physiology is based on a hierarchy of micro- and macroscopic systems that are all acting at different time scales. Thus, one cannot extrapolate phenomena happening in a patient from what is observed in cellular systems. In cancer research, much work that has shown promise in in vitrocell systems has not translated successfully to humans. Thus, clinical studies are also needed to understand the complexities that distinguish those patients who will develop PrU from those who will not. For example, factors such as inflammatory biomarkers and fatty acid-binding proteins might predispose some patients to PrU based on characteristics in their adipose tissue.

It is not clear whether end-of-life PrU represent a distinct phenomenon. The skin becomes less resilient and easier to damage with age, and patients lose muscle mass as they age. Like other organs, the skin might fail at the end of life. These factors might explain the increased frequency of PrU among patients approaching the end of life. If terminal PrU are a distinct entity, risk factors that contribute to their development should be identified to help clinicians distinguish terminal PrU from PrU arising from negligence. Patients and their families also should be made aware that other terminal issues could weaken a patient enough that even minimal pressure could cause a PrU. At the same time, however, the term terminal ulcermight itself be problematic, because there is no consensus on how to determine when death is imminent.

As stakeholders continue to grapple with the terminology for describing PrU, they will need to base their decisions on science and make necessary distinctions to maintain credibility. It is also likely that existing definitions and categorizations for PrU do not account for what is happening below the skin. Even if a patient leaves the hospital with intact skin, for example, some tissue underneath the skin might be necrotic. Simply observing the skin might not be enough.

Existing guidelines for PrU prevention are directed toward institutions and organizations. It is impossible to translate them into a home-care or community setting. Yet the incidence of community-acquired PrU is skyrocketing, especially as more older adults stay at home. More work is needed to translate best practices into community settings. It is highly likely that interventions will differ across care settings, for example between the ICU/acute care and long-term care.

It is not clear whether partial wound healing is a valuable goal. In cases where wounds do not heal, palliative care can help to maintain or even ameliorate a patient’s quality of life. Efforts are under way to survey patients about the value of partial wound healing.

Conclusion

Greg Bohn, MD, AAWC President

The First AAWC PrU Summit aimed to bring together stakeholders, particularly leaders in wound care and PrU prevention, to review the latest research, explore challenges and innovations in clinical care, and identify opportunities for advancing the science of PrU. With the Summit, the AAWC sought to assemble key opinion leaders with different points of view to create new pathophysiologic models that clinicians can understand and use to make decisions at the bedside, thus advancing patient care. New technology will advance and improve our understanding of PrU and the interventions used to treat them.