Pressure Ulcers 101Pressure Ulcers 101oror

Hospital Acquired Pressure Hospital Acquired Pressure UlcersUlcers

What you need to knowWhat you need to knowKristin Moeller, M.D.Kristin Moeller, M.D.

Contra Costa Regional Medical CenterContra Costa Regional Medical Center

July 2009July 2009

Learning Objectives

• Learn the definition of a Hospital Acquired Pressure Ulcer (HAPU)

• Learn the significance of HAPU• Learn how to stage HAPU• Learn who is at risk for HAPU• Learn how to prevent HAPU

Pressure Ulcer

• DefinitionDefinition: Localized skin injury which : Localized skin injury which develops as a result of unrelieved pressuredevelops as a result of unrelieved pressure• Frequently over a bony prominenceFrequently over a bony prominence• Can be as a result of a medical device (Foley)Can be as a result of a medical device (Foley)• Often is a result of shear or friction forces Often is a result of shear or friction forces

combined with pressurecombined with pressure

HAPU(Hospital-acquired pressure ulcer)

• HAPU is the new buzz-word:HAPU is the new buzz-word:• Prevention of HAPU is keyPrevention of HAPU is key• Preventing Stage 1 and 2 ulcers from Preventing Stage 1 and 2 ulcers from

progression to Stage 3 or 4 is the next goalprogression to Stage 3 or 4 is the next goal

HAPUCMS (Medicare/Medicaid) will CMS (Medicare/Medicaid) will no no longerlonger reimburse for treatment of reimburse for treatment of

Stage 3 or 4 pressure ulcers Stage 3 or 4 pressure ulcers acquiredacquired at our hospital at our hospital

• Stage 3 and 4Stage 3 and 4 ulcers are reportable events:ulcers are reportable events:• If acquired at CCRMC If acquired at CCRMC oror if present on admission fill out if present on admission fill out

SERS (Safety and Event Reporting System) report on SERS (Safety and Event Reporting System) report on computer computer

• SERSSERS information goes to Hospital Administration and information goes to Hospital Administration and the State!the State!

Who’s at risk?• Everyone!Everyone!

• Well, OK, not everyone but lots of our Well, OK, not everyone but lots of our patients.patients.

• Risk factors: : limited mobility, poor limited mobility, poor nutrition, critical illness, chronic disease, nutrition, critical illness, chronic disease, dehydration, incontinence, fever, infection, dehydration, incontinence, fever, infection, poor sensation, obesity, age, medications, poor sensation, obesity, age, medications, and various other medical diagnosesand various other medical diagnoses

Whose job is it to prevent Pressure Ulcers?

Everyone’s!Everyone’s!

• Look at the skin, especially in high risk patientsLook at the skin, especially in high risk patients

• Document what you seeDocument what you see• Ulcer, no ulcer/intact skin, color changesUlcer, no ulcer/intact skin, color changes• If Stage 3 or 4, document in H & P and fill out SERS or If Stage 3 or 4, document in H & P and fill out SERS or

bring to attention of the Charge Nursebring to attention of the Charge Nurse

• If you can stage the ulcer, great; if not, talk to an If you can stage the ulcer, great; if not, talk to an attending or the nurses to help youattending or the nurses to help you

Why????

• Good, complete patient careGood, complete patient care• If no ulcer on admission, prevent oneIf no ulcer on admission, prevent one• If there is an ulcer, heal it & prevent worseningIf there is an ulcer, heal it & prevent worsening

• Money $$$Money $$$• CMS is one of our main sources of CMS is one of our main sources of

reimbursement – we are charged with caring for reimbursement – we are charged with caring for some of the most vulnerable members of the some of the most vulnerable members of the populationpopulation

What do I have to do?

• We allWe all need to Look and Document need to Look and Document• Document skin exam on H & PDocument skin exam on H & P• Check the skin regularly, especially in high risk Check the skin regularly, especially in high risk

patients and document updated examspatients and document updated exams• Request help from Attending Staff or Nursing Request help from Attending Staff or Nursing

regarding staging and treatmentregarding staging and treatment

• If nursing brings an ulcer to your attention – see If nursing brings an ulcer to your attention – see it and document it a.s.a.p.it and document it a.s.a.p.

What if I identify a Pressure Ulcer?

• Put it in your H & P (or Progress Note)Put it in your H & P (or Progress Note)• Put it in your orders as an admit diagnosis, either as a Put it in your orders as an admit diagnosis, either as a

primary or secondary diagnosisprimary or secondary diagnosis• Write orders for wound careWrite orders for wound care• Notify the Charge Nurse and fill out a SERS reportNotify the Charge Nurse and fill out a SERS report• Not sure? Ask a Staff member for help (Attending Not sure? Ask a Staff member for help (Attending

M.D. or Charge Nurse)M.D. or Charge Nurse)

Staging Basics

• Don’t be intimidated, the rules are easyDon’t be intimidated, the rules are easy

• ONLY Pressure Ulcers are stageableONLY Pressure Ulcers are stageable

• Other wounds (surgical, venous stasis, Other wounds (surgical, venous stasis, neuropathic/diabetic ulcers) are neuropathic/diabetic ulcers) are notnot

• A wound never “regresses” in stageA wound never “regresses” in stage

• A Stage 2 is always a Stage 2A Stage 2 is always a Stage 2

• As it heals, it becomes a “healing Stage 2 As it heals, it becomes a “healing Stage 2 ulcer”ulcer”

Stage 1 Pressure UlcerNon-blanching erythema over a pressure point; Non-blanching erythema over a pressure point; area may be painful, firm, soft, warm or cool.area may be painful, firm, soft, warm or cool.

• Note: the skin is intactNote: the skin is intact

Stage 2 Pressure Ulcer

Partial thickness disruption of the dermis with Partial thickness disruption of the dermis with shallow red/pink wound bed shallow red/pink wound bed withoutwithout slough; slough; no undermining or tunneling.no undermining or tunneling.

• Note: this includes blistersNote: this includes blisters

Skin Tears

• Do not confuse a Stage 2 Pressure Ulcer with a skin tear.

Stage 3 Pressure UlcerFull thickness tissue loss with disruption of Full thickness tissue loss with disruption of the dermis and into SubQ; may have slough, the dermis and into SubQ; may have slough, tunneling,undermining. tunneling,undermining. NoNo muscle, tendon or muscle, tendon or bone is exposed.bone is exposed.

Stage 4 Pressure UlcerAny deeper disruption, which disrupts the Any deeper disruption, which disrupts the fascia and may or may not involve muscle, fascia and may or may not involve muscle, bone, tendon or ligament.bone, tendon or ligament.

• Note: does not necessarily go to bone but Note: does not necessarily go to bone but be suspicious for osteomyelitisbe suspicious for osteomyelitis

Deep Tissue Injury I

Purple or maroon localized area of discolored Purple or maroon localized area of discolored intact skin or blood-filled blister due to intact skin or blood-filled blister due to damage to underlying soft tissue from damage to underlying soft tissue from pressure.pressure.

Deep Tissue Injury II

The area may be preceded by tissue The area may be preceded by tissue that is painful, firm, boggy, warmer that is painful, firm, boggy, warmer or cooler as compared to adjacent or cooler as compared to adjacent tissue. tissue.

Evolution may be rapid exposing Evolution may be rapid exposing additional layers of tissue even with additional layers of tissue even with

treatment.treatment.

Unstageable I

Full thickness tissue injury in which the base Full thickness tissue injury in which the base of the ulcer is covered by slough (yellow, tan, of the ulcer is covered by slough (yellow, tan, gray, green, brown) or eschar (tan, brown, gray, green, brown) or eschar (tan, brown, black).black).

Unstageable II

* Special care must be taken with heel ulcers. * Special care must be taken with heel ulcers. Do NOT unroof unless aided by an Do NOT unroof unless aided by an

experienced physician. They may be better experienced physician. They may be better left intact.left intact.

Treatment I• Keep wounds moist but not too moist.Keep wounds moist but not too moist.

• Debride any necrotic or excess fibrinous tissueDebride any necrotic or excess fibrinous tissue

• Sharp, chemical or autolytic debridement.Sharp, chemical or autolytic debridement.

• If you are getting near bone, tendon or ligament, If you are getting near bone, tendon or ligament, STOPSTOP until you have more experienced hands & eyes with until you have more experienced hands & eyes with you.you.

• Unless the wound is a Stage 4 or causing sepsis, this can all Unless the wound is a Stage 4 or causing sepsis, this can all be done slowly and cautiously.be done slowly and cautiously.

• Damp to dry dressing with Saline will get you through Damp to dry dressing with Saline will get you through the night.the night.

• If you are the new primary team in the AM, look at the If you are the new primary team in the AM, look at the identified wound a.s.a.p. and begin to formulate a treatment identified wound a.s.a.p. and begin to formulate a treatment plan.plan.

Treatment II• Initiate/reassess prevention strategies:Initiate/reassess prevention strategies:

• Pressure reducing mattressPressure reducing mattress• Maximize mobilityMaximize mobility• Maximize NutritionMaximize Nutrition• Minimize devicesMinimize devices• Good skin hygieneGood skin hygiene• Be sure to communicate with your patient & caregiver Be sure to communicate with your patient & caregiver

in his/her native languagein his/her native language

Empower your patient to partake in his/her careEmpower your patient to partake in his/her care

Wound Care Team“Wound Wednesdays”

• Goal 1: Educate!Goal 1: Educate!• Goal 2: Prevent Pressure UlcersGoal 2: Prevent Pressure Ulcers• Goal 3: Prevent worsening of Pressure Ulcers Goal 3: Prevent worsening of Pressure Ulcers

(avoid progression to Stage 3 or 4)(avoid progression to Stage 3 or 4)• Goal 4: Help guide treatment via Goal 4: Help guide treatment via

interdisciplinary team approachinterdisciplinary team approach

• Goal 5: Planned Obsolescence!Goal 5: Planned Obsolescence!

Forms – more paperwork!

• Yes, they are coming.Yes, they are coming.

• Initial Documentation and order formInitial Documentation and order form

• Follow-up documentation formFollow-up documentation form

• Q week or for any significant change of Q week or for any significant change of statusstatus

Forms – Initial Documentation

Photo – op?

• All Pressure Ulcers All Pressure Ulcers must bemust be documented documented with photoswith photos

• Upon diagnosis and Q week on Upon diagnosis and Q week on WednesdaysWednesdays

• Photos are uploaded in PACS (yup, with Photos are uploaded in PACS (yup, with the Xrays)the Xrays)

• Other wounds Other wounds may bemay be documented with documented with photos to document wound progressionphotos to document wound progression

In Brief• Documentation is keyDocumentation is key

• Physician must be part of documentation of Physician must be part of documentation of HAPUHAPU

• Must be documented on admit H & P to Must be documented on admit H & P to document that it was not caused at our document that it was not caused at our facilityfacility

• Prevention is keyPrevention is key

• Ask for help as we are all learning this new Ask for help as we are all learning this new systemsystem