The moving feast

Clarissa Young MCN MNS Nurse Practitioner Wound Management

Launceston General Hospital

The Moving Feast •  Staging definitions

•  MASD IAD & PI

•  Pathways into practice

•  Making a difference

Changes

•  Torrance, NPUAP

•  2009 Changed to NPUAP 4 stages until

•  2012 Pan Pac 6 stages

•  2012 PI term Pan Pac

•  2016 more changes + mucus membranes NPUAP

•  2016 NPUAP Pressure Injury

•  PI NPUAP not yet EPUAP

Current

A pressure ulcer is a localised injury to the skin and/or underlying tissue usually over a bony prominence, resulting from sustained pressure (including pressure associated with shear). A number of contributing or confounding factors are also associated with pressure ulcers: the primary of which is impaired mobility

Proposed www.npuap.org

A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device.

The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.

Stage 1 PI Current

•  Intact skin with non blanchable redness of localised skin usually over a bony prominence

•  May be painful, firm soft, warm/cool compared to adjacent skin

Proposed •  Intact skin with localised

area of non blanchable erythema of intact skin

•  Blanchable erythema, changes sensation, temp. firmness, may precede visual changes

•  Does not include purple maroon

Stage 2 PI Current

Partial thickness skin loss of dermis, shallow ulcer red, pink no slough

May present shallow intact/ruptured serum blister

With slough or bruising (not skin tears, tape burns, perineal dermatitis)

Proposed Partial thickness skin loss with exposed dermis

Wound bed viable pink or red, moist intact or ruptured serous blister Fat not visible, granulation, slough eschar not present

over pelvis & heels microclimate & shear

not used for MASAD or IAD MARS

Stage 3 Current

•  Full thickness tissue loss fat may be visible but bone tendon muscle not exposed

•  Slough may be present but does not obscure depth – may undermine & tunnel

•  Depth varies body bridge nose, occiput, malleolus no subcut fat –shallow

•  Large fat can develop deep ulcers

Proposed •  Full thickness skin loss fat

visible, granulation and epibole slough may be visible

•  Depth varies anatomical location undermining & tunnelling

•  Fascia, tendon, bone not exposed if unable to see base U

Stage 4 Current

•  Full thickness tissue loss, exposed bone, tendon, muscle slough may be present + undermining

•  Depth varies according to anatomical site

Proposed •  Full thickness skin loss

exposed or palpable fascia, muscle tendon or bone

•  Slough & eschar may be visible

•  Epibole undermining & tunnelling

•  Depth varies anatomical location

•  U if slough eschar

Unstageable Current -Depth Unknown

•  Full thickness tissue loss base covered slough/eschar

•  Depth cannot be determined until base of wound exposed

•  Heels without fluctuant/erythema eschar left ‘biological cover’

Proposed - Obscured full thickness skin & tissue loss

•  Extent of damage cannot be confirmed obscured slough eschar

•  If removed stage 3 or 4 revealed

•  Stable eschar dry adherent without erythema/fluctuance on heel or ischemic limb left intact

Deep tissue Current - Suspected Deep Tissue Injury: depth unknown

•  Purple or maroon localised intact skin or blood filled blister

•  Evolution may include thin blister over dark wound bed

•  May develop thin eschar

Proposed – Deep Tissue PI: Persistent non-blanchable deep red, maroon or purple discolouration

•  Intact or not, localised area of persistent non blanchable deep red, maroon purple or blood filled blister

•  Injury intense/prolonged pressure shear bone muscle interface

•  Not vascular, traumatic, neuropathic derm. conditions

Medical Device Related PI

•  Use of device designed and applied for diagnostic or therapeutic purposes

•  conforms to the shape of device

•  staged using the system

Mucosal Membrane PI •  Found in mucous membranes from device with a

history of medical device in use at the location of injury.

•  Cannot be staged due to the anatomy of the tissues

Summary changes NPUAP •  Still 6 stages

•  Pressure Ulcer to Pressure Injury (April 2016)

•  Staging classifications (Arabic numbers)

•  Suspect removed from DTI

Additional •  Medical Device Related PI

•  Mucosal membrane PI

The Journey

•  1996 – 1st point prevalence survey

•  6 set reporting criteria

•  Annual for 10 years until 2005

•  Snap shot 2014

•  Going again Oct 2016

Incidence

•  Counted admissions & Occupied bed days

•  Celebrated 15 years 2013

•  Data collection

Last survey 2013 PI  prevalence  is  expressed  in  the  following  formula    

Total  number  of  patients  with  pressure    injuries            159        x        100                1.6%  

Separations                                                                                          9934  

 

PI  incidence  is  a  measure  of  new  cases  (individuals)  by  separation  over  a  defined  period  of  time.      

Total  number  of  new  cases  (individuals)                  110          x          100            1.1%  

Population  at  risk  (separations)                                                                        9934  

 

By occupied bed day PI  prevalence  by  occupied  bed  days  is  the  measure  of  the  total  number  of  PI’s    

Total  number  of  pressure  injuries                  229      x        1000          3.8%  

Occupied  bed  days                                      60110  

 

PI  incidence  by  occupied  bed  days  is  a  measure  of  acquired  PI  4.  

Total  number  of  acquired  pressure  injuries                  156      x        1000          2.6%  

Occupied  bed  days                                                                            60110  

 

Data collection

•  PulcerMan 1998 June 2010

•  PI Man July 2010 March 2014

•  2607 individuals

•  5990 PI’s

Gold Coast Journey 2003

Thelma & Louise moment

Count PI’s by location Over 50% posterior pelvis

BMap©

•  First presented 2004 Orlando (20 anatomical sites)

•  Darwin 2008

•  Used LGH 2005 (now 6 anatomical sites)

PI by stage

Bmap total 1 July 2010 – 31 March 2014

Bmap site LGH S1 pre S1 LGH S2 pre S2 LGH S3 pre S3

11 sacrum 34 15 64 54 1 4

12a sacro coc 7 5 38 22

12b cleft 9 7 49 20

12c buttock 23 9 92 55 1

13 trochant 1 6 3

14 ischium 1 3 4 2

73 37 247 161 5 6

LGH S4 pre S4 LGH U pre U LGH SDTI

pre SDTI

1 5 1 1 1 3 2 2 2

0 3 3 3 8 1 Total 546

Audit & Pathway to Practice

•  Access databases

•  IAD not counted

•  Matching records & photographs

Many Stage 2 PI’s now IAD

•  Why

•  We don’t define IAD in PI guidelines

•  Continence & Stomal Nurses?

Three stage 2 pressure ulcers (2008)

Grid 3 Grid 4 Grid 5

IAD & MASD WOCN – 2007 consensus statements

Queensland study ¼ incont. >40% IAD PI rate of 6% 12% incont. had PI (unreported stages) Campbell JL, Coyer FM, Osborne SR. Incontinence-associated dermatitis: a cross-sectional prevalence study in the Australian acute care hospital setting. Int Wound J 2014

2015 Global IAD Expert Panel

Nothing AWMA – WA

Straw poll

Spot the difference

IAD MASD & PI

Standard Education •  Across THS North

•  Acute facility

•  Rural sites

•  Community nursing

•  Residential facilities

Pressure Injury (PI)

Incontinence-Associated Dermatitis (IAD)

Moisture-Associated Skin Damage (MASD)

Pressure Injury Forum THS-North

A quick guide to each topic

April 2016

 

THS-North Pressure Injury Forum April 2016

THS-North Pressure Injury Forum April 2016

Pressure Injury (PI) a localised injury to the skin and underlying tissue usually over a bony prominence

History   Symptoms  

Location  

Depth  

Shape/Edges  

Other

Exposure to pressure/shear

 

Pain, discomfort      

Usually over a bony prominence      

Varies from intact skin non blanching erythema to full thickness skin loss

     

Well defined      

Reduced mobility, sensory impairment  

THS-North Pressure Injury Forum April 2016

Pressure Injury (PI) a localised injury to the skin and underlying tissue usually over a bony prominence

History   Symptoms  

Location  

Depth  

Shape/Edges  

Other

Exposure to pressure/shear

 

Pain, discomfort      

Usually over a bony prominence      

Varies from intact skin non blanching erythema to full thickness skin loss

     

Well defined      

Reduced mobility, sensory impairment  

THS-North Pressure Injury Forum April 2016

Moisture-Associated Skin Damage (MASD) an umbrella term that includes perspiration, wound exudate (+/- urinary & faecal incontinence)

S K I N Surface �  support surface –basic

mattress and cushion including inflation

� wrinkle free sheets, pillows

� Roho support surface

Keep moving �  PIPP - pressure injury

prevention plan �  encourage bed mobility

in/on/out � written advice for

patients/carers

S K I N Inspection �  regular skin hygiene �  reassess with Braden Risk

Tool at least daily �  assess and implement skin

care plans (continence management)

Nutrition �  nutritional assessment -

Braden �  encourage optimal

intake diet and fluids including nutritional supplements

Making a difference •  Continuous education

loops

•  Risk Assessments

•  Audits &Surveys

•  Data

•  Champions

Questions and discussion

We all change with time…… it will be OK