Identification and Prevention Pressure Ulcers in the ED - Evidence Based Practice Project UC Davis Medical Center's Nurse Residency Program Janine ...

Identification and
       Prevention
Pressure Ulcers in the ED
           Evidence Based Practice Project
  UC Davis Medical Center’s Nurse Residency Program
              Janine Taylor R.N., B.S.N.
               Peg Freitag R.N., B.S.N.

Hospital Acquired Pressure
      Ulcers (HAPUs)
• Patient safety, quality of care, and the
  patient’s (and family’s) perception of both
  have become a major driver for the
  establishment of best practices.

• CMS no longer reimburses for “never”
  events, events they have designated as
  entirely preventable (Centers for Medicare
  and Medicaid Services, 2008).

Prevalence
• Approximately 2.5 million patients are treated
  for pressure ulcers in acute care facilities in
  the United States annually, and approximately
  60,000 patients die each year of complications
  related to pressure ulcers (PU). (Tschannen,et
  al., 2012).

What does this have to do with the
   Emergency Department (ED)?
• The ED is the single greatest point of entry into
  the hospital (Denby & Rowlands, 2010).
• Wait times in EDs are increasing as patient
  demographics increasingly shift from life-
  threatening conditions to acute and critical
  illnesses
   – Pressure ulcers can develop in only a few hours
   – The equipment and supplies used in the ED are often
     not designed with reduction of HAPUs in mind
     (Naccarato & Kelechi, 2011).

So What Can We Do?
First step is understanding the risk factors and
  utilizing the nursing process to assess each
  patient as to what their individual risk is.

Risk Factors
• Alderden, et al. (2011), in their retrospective analysis of
  HAPUs compiled the following risk factors (see Table
  1):
   –   Braden Score 65
   –   Diabetes
   –   Prior recent hospital stay
   –   Emergent admission to the ICU
   –   BMI 35

Risk Factors, cont.
• Other risk factors include (Tschannen, et al.,
  (2012)
  – Recent Cardiac Arrest
  – SHOCK/Sepsis
  – Hx of pressure ulcers
  – Current redness in area
  – Going to the OR? Multiple procedures > 6 hrs
  – Quad/Para/Hemiplegic
  – Stroke/Paralysis

Best Practice Intervention
• Most HAPUs are located in just three areas:
  heels, sacrum, and coccyx (Denby & Rowlands,
  2010).
• The Institute for Clinical Systems Improvement
  has identified several key interventions to
  promote PU prevention, including
  minimizing/eliminating friction and shear,
  minimizing pressure, providing support
  surfaces, managing moisture, and ensuring the
  patient maintains adequate nutrition/hydration
  (2012).

Additional Interventions
• UC Davis Medical Center O.R. unit already
  uses Mepilex borders prophylactically on pts
  to help prevent the development of HAPUs.
• Case studies indicate this is a cost-effective
  intervention with significant real-world
  results.

Case Studies
• In Connecticut, an ICU that began to use
  Mepilex (the brand of silicon foam dressing UC
  Davis utilizes) in their ICU saw sacral HAPU
  incidence decrease from 12.5% to 7% in one
  year (Walsh et al., 2012).
• A Chicago ICU saw an even more significant
  reduction going from 13.6% to 1.8% during a
  6-month prospective study utilizing Mepilex
  (Chaiken, 2012).

What’s the Goal?
• The purpose of this project is to prevent
  further damage to existing pressure ulcers and
  to prevent the development of pressure ulcers
  in those patients found to be at risk.

• The recommendations for the use of
  preventative measures are part of an
  evidence-based care plan.

What should We Do?
• While routine use of a silicone border foam dressing
  should not be the only intervention employed to
  reduce HAPU in the ED, it should become standard
  practice for any patient who meets the criteria for
  being at risk for potentially developing a pressure ulcer
  to have a Mepilex foam dressing applied to the sacrum,
  pelvic area, occiput or heels

• This is an economically sound measure to prevent the
  development of a HAPU, and to prevent further
  damage to an existing PU.

Let’s Make it Easy
• ‘Best Practice’ means nothing if not used

• “quick card” reference guide to identify the at risk
  patient population as part of the assessment

• Apply the Mepilex Borders when appropriate.

• The “quick card” should serve to raise awareness of
  the importance of the application of the dressing
  and the patients with which the dressing is
  appropriate.

Quick Card
                   FRONT                                                BACK
Apply Mepilex to all patients with:
•   Recent Cardiac Arrest
•   Vasopressor Rx > 48 hrs
•   SHOCK and/or Sepsis
•   Hx of pressure ulcers
•   Current redness in area
•   Emergent OR or ICU dispositions
•   Quad/Para/Hemiplegic
•   Stroke/Paralysis

And to pts with 3 or more of the below criteria :
•   Ages 65 -70 or above
•   Fecal or urinary incontinence
•   Prolonged bed rest = or > 4 hrs AND unable to shift
    weight, independently
•   Diabetes                                              Remember to:
•   BMI above 35 or less than 25                          Date, time, and initial with a marker on
•   Liver failure
•   Renal failure
                                                          Mepilex Border prior to application And
•   Braden Score below 18                                 Note application of Mepilex Border in EMR
•   Weeping edema or anasarca
•   Malnutrition (albumin at or below 2.5)

References:
Alderden, J., Whitney, J. D., Taylor, S. M., & Zaratkiewicz, S. (2011). Risk profile characteristics associated with
      outcomes of Hospital-Acquired Pressure Ulcers: A retrospective review. Critical Care Nurse, 31(4), 30-43.
      doi:10.4037/ccn2011806
Centers for Medicare and Medicaid Services. Medicare and Medicaid move aggressively to encourage greater
      patient safety in hospitals and reduce never events [press release]. July 31, 2008.
      https://www.cms.gov/apps/media/press/release.asp?Counter=3219&intNumPerPage=10&checkDate=&c
      heckKey=&srchType=1&numDays=0&srchOpt=0&srchData=&keywordtype=All&chkNewsType=1%2C+2%2
      C+3%2C+4%2C+5&intPage=&showAll=1&pYear=1&year=2008&desc=false&cboOrder=date.
Chaiken, N. (2012). Reduction of sacral pressure ulcers in the Intensive Care Unit using a silicone border foam
      dressing. Journal of Wound, Ostomy and Continence Nursing, 39(2), 143–145.
      doi:10.1097/WON.0b013e318246400c
Denby, A., & Rowlands, A. (2010). Stop them at the door: should a pressure ulcer prevention protocol be
      implemented in the emergency department?. Journal of Wound, Ostomy & Continence Nursing, 37(1), 35-
      38. doi:10.1097/WON.0b013e3181c68b4b
Institute for Clinical Systems Improvement. (2012). Pressure ulcer prevention and treatment: Health care
      protocol. Institute for Clinical Systems Improvement (ICSI).
Naccarato, M., & Kelechi, T. (2011). Pressure ulcer prevention in the Emergency Department. Advanced
        Emergency Nursing Journal, 33(2), 155-162. doi:10.1097/TME.0b013e3182157743
Tschannen, D., Bates, O., Talsma, A., & Ying, G. (2012). Patient-specific and surgical characteristics in the
      development of pressure ulcers. American Journal Of Critical Care, 21(2), 116-125.
      doi:10.4037/ajcc2012716
Walsh, N., Blanck, A., Smith, L., Cross, M., Andersson, L., & Polito, C. (2012). Use of a sacral silicone border
      foam dressing as one component of a pressure ulcer prevention program in an intensive care unit setting.
      Journal Of Wound, Ostomy & Continence Nursing, 39(2), 146-149. doi:10.1097/won.0b013e3182435579