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Outpatient
Connection
NPUAP Pressure Ulcer
Categories
The National Pressure Ulcer Advisory Panel (NPUAP)
has developed the following pressure ulcer stages/
categories to assist clinicians with accurate staging
of ulcers for treatment and reimbursement purposes.
• Category/Stage I: Non-blanchable erythema: Intact
skin with non-blanchable redness of a localized
area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its
color may differ from the surrounding area. The
area may be painful, firm, soft, warmer or cooler
as compared to adjacent tissue. Category I may
be difficult to detect in individuals with dark skin
tones. May indicate “at risk” persons.
• Category/Stage II: Partial thickness: Partial thickness loss of dermis presenting as a shallow open
ulcer with a red pink wound bed, without slough.
May also present as an intact or open/ruptured
serum-filled or sero-sanginous filled blister. Presents
as a shiny or dry shallow ulcer without slough or
bruising (bruising indicates deep tissue injury). This
category should not be used to describe skin tears,
tape burns, incontinence associated dermatitis,
maceration or excoriation.
• Category/Stage III: Full thickness skin loss: Full
thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.
Slough may be present but does not obscure the
depth of tissue loss. May include undermining and
tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge
of the nose, ear, occiput and malleolus do not
have (adipose) subcutaneous tissue and Category/
Stage III ulcers can be shallow. In contrast, areas of
significant adiposity can develop extremely deep
Category/Stage III pressure ulcers. Bone/tendon
is not visible or directly palpable.
• Category/Stage IV: Full thickness tissue loss: Full
thickness tissue loss with exposed bone, tendon
or muscle. Slough or eschar may be present. Often
includes undermining and tunneling. The depth
of a Category/Stage IV pressure ulcer varies by
anatomical location. The bridge of the nose, ear,
occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow.
Category/Stage IV ulcers can extend into muscle
and/or supporting structures (e.g., fascia, tendon
or joint capsule) making osteomyelitis or osteitis
likely to occur. Exposed bone/muscle is visible or
directly palpable.
Visit NPUAP for the full report: www.npuap.org/resources/
educational-and-clinical-resources/npuap-pressure-ulcerstagescategories/
OPERATing ROOm
Fiscal tension driving pressure
management reforms
by Kara Nadeau Della Vecchia
P
ressure ulcers are a prevalent and
costly yet preventable complication
that impacts 2.5 million patients annually in the U.S., according to the Agency
for Healthcare Research and Quality
(AHRQ). The condition contributes $9.1$11.6 billion per year to U.S. healthcare
costs and Medicare estimates that each
pressure ulcer adds $43,180 in costs to a
patient’s hospital stay.1 Recognizing the
care and cost implications of stage III and
IV pressure ulcers, the Centers for Medicare & Medicaid Services (CMS) has ceased
reimbursing healthcare facilities for the
condition if it was not present at the time
of patient admission.
In today’s environment of healthcare
reform, where hospitals and health systems
are increasingly reimbursed based on the
quality of patient care, there is growing
demand for products to improve pressure
management and reduce the incidence of
pressure ulcers. In this article, Healthcare
Purchasing News offers expert advice on
pressure management and presents some of
the latest innovations in this treatment area.
Factors that contribute to
pressure ulcers
Pressure management can be an uphill
battle for caregivers because there is a
broad range of factors that contribute to
pressure ulcer formation, including patient
conditions, as well as facility staffing and
workflow issues.
Patient factors
According to Sarah Cram,
PT, DPT, Valley Regional
Hospital in Claremont,
N.H., attributes and conditions that place a patient at greater risk for a
Sarah Cram
pressure ulcer include:
• Being more than seventy years of age
• Poor nutritional status
• Prolonged periods of immobilization
• Incontinence
• Uncontrolled diabetes
• Circulatory problems
• Fractures
• Dementia
• Spinal cord injury
16 October 2014 • HEALTHCARE PuRCHAsing nEWs • www.hpnonline.com
Catherine Thomas, Senior Marketing Manager, Patient & Resident Safety Solutions,
STANLEY Healthcare,
adds thinning skin due
to advanced age, weight
loss and dehydration as
additional conditions that
increase risk, emphasizing
the importance of patient
repositioning to avoid
Catherine
stress on the skin while
Thomas
minimizing pressure on
vulnerable areas.
Rochelle Froloff, RN, Nurse Consultant
from Action Products Inc., adds that shear,
heat and humidity are other contributing
factors, noting how most facilities focus on
mitigating pressure but overlook the need to
keep skin cool and dry.
Urinary or fecal incontinence is also a primary contributor to pressure ulcer formation,
notes Leighann McDonald, RN, BSN, CWON,
Clinical Director, LINET Americas Inc.
She points out that while
incontinence-associated
dermatitis (IAD) differs
from that of a pressure ulcer, these conditions often
coexist.
“Persons with fecal incontinence are 22 times
Leighann
more likely to develop a
McDonald
pressure ulcer,” said McDonald. “Poor nutrition, reduced blood flow
due to circulatory disease, loss of sensation in
extremities from diabetes and other diseases,
cognitive impairment, restraints, medications, dehydration and old age can also be
significant factors.”
Facility factors
In addition to a patient’s physical characteristics and ailments, the environment in which
they are treated can also increase their risk for
pressure ulcer formation. Because pressure
management requires an extremely high level
of vigilance, studies have shown that healthcare facilities with nursing shortages tend to
have higher pressure ulcer rates.
A study conducted by AHRQ and the
National Science Foundation on the correlation between licensed nurse (RNs and
LPNs) staffing levels and adverse outcomes
See Operating rOOm on page 18
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among medical and surgical patients in
Pennsylvania acute-care hospitals found a
lower incidence of adverse events in those
facilities with more licensed nurses. For example, there was a 2 percent lower incidence
of pressure ulcers in those facilities with a 10
percent higher proportion of licensed nurses.2
“In our conversations with wound care experts across the healthcare industry, STANLEY Healthcare has heard many times that
turn management compliance is a serious
challenge,” said Thomas. “In many instances,
staff are simply too busy to consistently
adhere to a turn schedule for each patient
or resident, may be distracted by emergencies in other areas of the unit, or may either
intentionally or unintentionally document a
turn that was not actually completed.”
Froloff concurs that nursing shortages negatively impact turn management and other
key interventions aimed at reducing the risk
for pressure ulcer formation. She points out
how cuts in nursing staff can result in higher
costs for the facility in the long term, stating:
“Often there is too large of a patient load for
the nurses or primary care network (PCN),
so guidelines of turning the patient are minimized. For the facility, infections from open
wounds acquired in a hospital are not being
reimbursed. This lack of reimbursement has
a huge effect on the bottom line.”
Complications from poor
pressure management
Thomas notes that pressure ulcers cause a
wide range of complications for patients,
both physical and emotional. These include
pain, redness, infections of the skin and bone,
social withdrawal and emotional distress.
“Pressure ulcers can prevent full recovery
from treatment for other conditions, increase
the length of hospital stays, and result in
ongoing treatments,” said Thomas. “In
skilled nursing facilities, an average of 16.7
percent of patients develops pressure ulcers
during their stay.”3
According to the Mayo Clinic, common
complications from pressure ulcers include4:
•Sepsis: Sepsis occurs when bacteria enter
the bloodstream through broken skin and
spread throughout the body. It is a rapidly
progressing, life-threatening condition that
can cause organ failure.
• Cellulitis: Cellulitis is an infection of the
skin and connected soft tissues. It can cause
severe pain, redness and swelling. People
with nerve damage often do not feel pain
with this condition. Cellulitis can lead to
life-threatening complications.
• Bone and joint infections: An infection
from a pressure sore can burrow into
joints and bones. Joint infections (septic
arthritis) can damage cartilage and tissue. Bone infections (osteomyelitis) may
reduce the function of
• Pressure management protocols
joints and limbs. Such
need to meet all factors that coninfections can lead
tribute to pressure ulcers (presto life-threatening
sure, shear, heat and humidity)
complications.
in order to be effective.
• Cancer: Another comAction Products offers
plication is the developa variety of pads and
ment of a type of squamous
positioners to provide
cell carcinoma that develmaximum pressure
ops in chronic, nonhealing
distribution and shear
wounds (Marjolin ulcer). This
qualities to support prestype of cancer is aggressive and ususure ulcer management
ally requires surgery.
and safety protocols.
Action Products’ Pediatric Positioner Kit is
“Pressure ulcers are
Constructed from the
extremely versatile and provides optimum
painful to the patient
company’s Akton
pressure ulcer prevention
and can be very upsetviscoelastic polymer,
ting to the patient’s family and caregivers,” these products include operating room readds McDonald. “If a pressure ulcer occurs, it placement table pads, overlays, positioners
can take a week to months to heal depend- for the head, arms, legs, chest and heels,
ing on the severity, thus extending the along with a large selection of padding for
length of stay of the patient. In some severe specialty frames.
cases, septicemia can result which is a life
The company also offers white papers and
threatening condition. Patients can develop other resources to help healthcare facilities
osteomyelitis, which leads to long term and achieve “zero tolerance” of pressure ulcer forcostly intravenous antibiotic therapy. Stage mation. One such resource is a free CE course
III or Stage IV pressure ulcers may require entitled, “Basic Principles of Patient Positionsurgical debridement or muscle flap grafts ing.” It can be found on the Action Products
to help close the wound. Furthermore, once website: http://www.actionproducts.com/
a severe pressure ulcer heals, there is still po- resources/continuing-education.html.
tential for recurrence at the wound’s site due
to decreased tensile strength of the tissue.”
Turn management
Froloff points out that complications Because pressure ulcer prevention requires
from poor pressure management programs nursing staff to be vigilant for risk factors and
are seen in the unrelenting infection rates proactive in measures to inhibit ulcers from
throughout the healthcare system, stating forming, medical product suppliers have
that, “patients will leave the hospital with- developed technologies to aid them in these
out realizing an ulcer has formed, only to efforts. Studies have shown frequent manual
later be readmitted for costly treatments. repositioning of patients at risk for pressure
The prolonged healing process is painful ulcers can significantly reduce incidence of
and expensive, and for the most part could the condition, with the National Pressure
be preventable with adequate nursing care Ulcer Advisory Panel (NPUAP) recommendand devices.”
ing bed-bound persons are repositioned
at least every two hours and chair-bound
Processes and products to
persons every hour, consistent with overall
reduce the risk of pressure ulcers goals of care.5
Because there are many contributing factors
To address this issue, STANLEY Healthto pressure ulcer formation, nursing staff care launched its Patient Safety Monitoring
and other caregivers are challenged with solution (PSM), the company’s newest in procontinuously monitoring patients for the active and dignified monitoring of a facility’s
various signs and symptoms of the condi- patients or long-term residents. Caregivers
tion, and rapidly intervening when they
believe someone is at risk.
Froloff offers the following tips to help
healthcare facilities in their efforts to
minimize pressure ulcers:
• Institutions should re-evaluate their
staffing parameters to ensure that
there is adequate personnel to care for
patients on the different units.
• Skin assessments should be done
The STANLEY Healthcare Patient Safety
frequently to catch ulcers before they Monitoring solution enables caregivers, managers
progress.
or administrators to easily check the status of
• Product selection to prevent decubitus
each resident to ensure turn compliance.
ulcers should be tested and validated.
18 October 2014 • HEALTHCARE PuRCHAsing nEWs • www.hpnonline.com
OPERATing ROOm
are empowered to reliably and discretely
monitor individuals at a risk of developing
pressure ulcers by tracking and reporting on
turn management practices. PSM contributes
to a better quality of life with non-invasive
and touchless monitoring, while improving
safety and clinical outcomes through continuous capturing and reporting of:position
changes,bed exit/entry,sleep patterns, and
vital sign trends.
Caregiver safety
According to McDonald, one challenge in
the manual repositioning of patients is that
it poses a risk of occupational injury for the
caregiver. The Occupational Safety & Health
Administration (OSHA) website notes that
musculoskeletal disorders (MSDs) are a
major source of injury to healthcare workers,
with nursing aides, orderlies, and attendants
having the highest rates of MSDs. In 2010,
there were more than 27,020 cases of MSDs
among healthcare workers, which equates
to an incidence rate of 249 per 10,000 workers, more than seven times the average for
all industries.6
To minimize the risk for injuries among
healthcare workers as they manually reposition patients, LINET offers the Multicare
LE acuity-adaptable Med-Surg bed and the
Multicare Critical Care bed, both of which
are equipped with the company’s unique
Lateral Tilt functionality. Lateral Tilt significantly reduces the mechanical load on tissue
and vastly improves the task of repositioning
a patient. Turning a patient with Lateral Tilt
lessons the stress to the caregiver and patient
with a controlled, gentle rotation. The ease of
positioning promotes dignity for the patient
with quicker cleanups for incontinence and
also ensures Q2 turn schedule compliance by
reducing the number of caregivers required
to turn a patient. The outcome is improved
skin care and reduction in mechanical
load, which ultimately results in helping
reduce pressure ulcer incidence.
In addition, LINET’s support surface
portfolio features a diverse range of pressure
redistribution surfaces, including surfaces
that are integrated with microclimate management. Microclimate management
The Multicare bed from LINET offers features
designed to help improve skin care and reduce
the mechanical load for the caregiver.
therapy provides a flow of air within a
support surface to help wick away heat and
moisture from a patient’s skin, keeping them
cool and dry which in turn helps maintain
skin integrity and reduce IAD through
decreased maceration. Optimal immersion,
envelopment and microclimate management increase patient comfort and aid in the
prevention and treatment of pressure ulcers
through the management of tissue loads
while also controlling the heat and humidity
(microclimate) of a patient’s skin. HPn
References
1. http://www.ahrq.gov/professionals/systems/long-term-care/
resources/pressure-ulcers/pressureulcertoolkit/putool1.html
2. http://www.ahrq.gov/research/findings/factsheets/services/
nursestaffing/index.html
3. Wulffson, Robin. “New UCLA study reports bedsores can be
fatal.” http://www.examiner.com/article/new-ucla-study-reportsbedsores-can-be-fatal
4. http://www.mayoclinic.org/diseases-conditions/bedsores/basics/
complications/CON-20030848
5. http://www.npuap.org/resources/educational-and-clinicalresources/pressure-ulcer-prevention-points/
6. https://www.osha.gov/SLTC/healthcarefacilities/safepatienthandling.html
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• HEALTHCARE PuRCHAsing nEWs • October 2014 19
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