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(1)

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.

(2)

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).

(3)

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).

(4)

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

(5)

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.

(6)

Risk Factors

Alderden, et al. (2011), in their retrospective analysis of

HAPUs compiled the following risk factors (see Table

1):

Braden Score <16

Use of Vasopressers

Incontinent of urine or feces

Limited self-mobility

Age >65

Diabetes

Prior recent hospital stay

Emergent admission to the ICU

(7)

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

(8)

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).

(9)

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.

(10)

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).

(11)

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.

(12)

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

(13)

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

(14)

Quick Card

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

• BMI above 35 or less than 25 • Liver failure

• Renal failure

• Braden Score below 18 • Weeping edema or anasarca

• Malnutrition (albumin at or below 2.5)

Remember to:

Date, time, and initial with a marker on

Mepilex Border prior to application And

Note application of Mepilex Border in EMR

(15)

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.

References

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