 Good afternoon, everybody. My name is Stan Stovall and I'll be your host for today's broadcast CMS Journal volume 1 pressure ulcer care before we proceed with the program Let's hear from mr. Thomas Hamilton who is the director of the survey and certification group in CMS's Center for Medicare and State operations Hello, I'm Thomas Hamilton director of the survey and certification group in the Center for Medicaid and state operations at CMS Welcome to the CMS series of satellite presentations on significant clinical and regulatory issues that affect the quality of care for our nation's nursing home residents We are calling this series the CMS nursing home journal Each installment in the series will provide the most up-to-date clinical information on each selected topic for both surveyors and providers Each volume of the journal will be devoted to a different specific issue and will include presentations by top clinicians who specialize in that topic The CMS nursing home journal satellite and webcast series will be an ongoing Accompaniment to the other work we have undertaken to update our interpretive guidance for surveyors In each installment one of our surveyors will provide the surveyors point of view And we'll enlist the help of our experts in answering some of the questions that surveyors most need to know about the changing field of practice Each show will include call-in and fax capability so that you as participating surveyors and providers Will be able to ask your questions of the experts Health care is an exciting important and dynamic field We are all challenged to stay up-to-date with our ever-changing environment of practice I hope this first in a series of broadcasts will help you in doing so Thank you for joining us and thank you for your commitment to improve the delivery of services for residents in our nation's nursing homes As mr. Hamilton said today's program is the first of a series of satellite webcast that CMS will be doing on important issues of nursing home care today's program is on pressure ulcer care and will include the following major topics physiology assessment and prevention strategies treatment of pressure ulcers end-of-life care issues and current developments in the field and We have gathered a panel of experts to help us to present both Surveyors and nursing home providers the most up-to-date information about the prevention and treatment of pressure ulcers We will be having a question an answer period periodically during this program So in order to call in your question, then you should dial the number you see on your screen right now 1-800-953-2233 Again, if you'd like to phone it in 1-800-953-2233 If you prefer to fax your question to us, then you should dial 1-410-786-0123 again The number is 1-800-953-2233 for the phone calls 1-410-786-0123 to fax in your question And this program will also be available on the website for one full year after the broadcast date at CMS.internetstreaming.com All right now that we have all of the technical things out of the way all the details Let's get started with the program. I want to let you know that today's program contains some graphically Explicit slides and video clips of actual pressure ulcers and their treatment the video clips that you will be seeing during this program Were provided by Medcom Incorporated the video is titled prevention assessment and treatment of pressure ulcers Which can be purchased by calling the number 1-800-877-1443 that number again 1-800-877-1443 But we're going to begin today's program with an introduction to the topic by our CMS Regional Office Nurse Surveyor Sharon Roberson Sharon is a nurse consultant with the Boston Regional Office of CMS She has been with CMS since 1991 She's a registered nurse and a contributing instructor at both the national long-term care basic training and hospital basic training She has been a nursing home administrator and Sharon recently participated in CMS's two-part broadcast on dementia In the nursing home setting Sharon good to see you and welcome back Thanks, Stan. I'm glad to be back Now I understand this is that this satellite is one of the first in the series that are Coming out of the project in the division of nursing homes. Give us our viewers a little more idea what that's about That's right Stan the CMS division of nursing homes has been engaged in a project to upgrade the guidance to surveyors in key regulatory areas CMS along with their contractor the American Institutes for Research has been convening expert panels to provide the latest state-of-the-art guidance about each selected issue as The work of each expert panel is completed and the new guidance is made ready for issuance CMS intends to provide a satellite broadcast as a training aid to surveyors The first regulatory area selected for revising severe guidance is pressure ulcer care and Sharon I understand that pressure ulcers are a serious medical problem To a nursing home residents health and certainly the quality of her life Stan it certainly is true that pressure ulcers are a serious issue and one that surveyors spend a lot of time investigating during surveys CMS Congress and the general accounting office have been interested in the issue of pressure ulcers for some time now CMS is nursing home initiatives of 1999 made the evaluation of each facility's program to prevent and treat pressure ulcers as a key part of the survey process at That time the new CMS database opened with a set of 24 quality indicators or QIs that surveyors and providers could use to determine the relative prevalence of several clinical conditions across facilities in each state The indicators included pressure ulcers The availability of this new data has allowed CMS to track the prevalence of pressure ulcers across time nationally and in each state in addition, it is CMS's goal under the government performance and results act called GIPRA to Decrease the national prevalence of pressure ulcers in nursing homes Providing education to surveyors and providers on this issue is part of CMS's response to the GIPRA goal and in addition the quality improvement organizations or QIO's who work under contract to CMS are also involved in pressure ulcer initiatives and have developed educational packages for use in long-term care facilities Two important websites, which are being shown in your screen contain information about the QIO pressure ulcer projects One is the National Nursing Home Improvement Collaborative Sponsored by the Washington State QIO QALIS Health and another site called MedQuik, which is the Medicare quality improvement clearinghouse At a later date We will be adding some relevant documents from each of the sites to the CMS website for the show All right, speaking of the website Sharon Let me just remind our viewers that the website for this broadcast is www.cmsinternetstreaming.com. Let me give it to you again www.cmsinternetstreaming.com Okay, Sharon, I understand that you have a lot of information regarding the prevalence or proportion of residents with pressure type ulcers Fill us in and bring us right up to date on that I recently reviewed data from our MDS set or the Minimum Data Set System for the time period ending March of 2004 The database contains the records of about 1.4 million residents in over 16,000 nursing homes I pulled my data from the CMS nursing home compare site, which is open to the public at the address on your screen The nursing home compare site shows that 14.3% of high-risk residents as well as 2.8% of those residents who are not at high-risk have a pressure ulcer High-risk residents are those who have less mobility May be undernourished or other conditions that places them at risk for the development of a pressure ulcer The data are based on quality measures and includes residents who have been at a facility for at least three months The data includes residents who have any stage of ulcer Taking the above figures. We have calculated that the overall national prevalence is approximately 9.2% I Want to make the point though that the presence of a pressure ulcer does not necessarily mean that the facility has provided Poor care. In fact, some residents are admitted with a pressure ulcer or multiple ulcers Other residents may not have been admitted with an ulcer But have commonly known clinical risk factors that do place them at risk for developing one We have a regulation for nursing homes that addresses their responsibilities in this area Disregulation at F314 has two parts the development of a pressure ulcer and the treatment For residents admitted with the pressure ulcer and residents who developed a pressure ulcer while in the facility The surveyor needs to determine whether the facility is in compliance with the portion of the regulation at tag F314 this tag requires that the resident receive the necessary treatment and Services to promote healing prevent infections and prevent new ulcers from developing In addition for a resident who developed an ulcer while in the facility The severe must also make a determination of whether the development of the pressure ulcer was avoidable or unavoidable based on their clinical condition For this resident the severe is to investigate these following things How the facility assessed and evaluated the individual resident's risk factors? What type of care plan interventions were developed whether the interventions were consistently implemented and How the facility monitored and re-evaluated the care the resident received If the facility has assessed the clinical condition of the resident identified the risk factors for the pressure ulcers developed and implemented the plan of care that is consistent with current standards of practice and Has monitored and re-evaluated their interventions the severe would then determine that the development of the ulcer was clinically unavoidable and that the facility was in compliance in this situation That's why it is so important for Surveyors and providers alike to have the knowledge about the processes That need to be in place to assure that good preventative care is provided That's why I am so happy that CMS has gathered a panel of experts who can provide the information We need to make our determinations for assessments risk factors care practices and special considerations for pressure ulcer treatment for the residents at the end of life I'm sharing you provided me with a convenient segue here because we have invited some nationally known clinical experts to Provide us with the most up-to-date information about the key clinical issues. So let me introduce some of them right now first Let me introduce Dr. Dan Berlowits Dr. Berlowits is the director of the Center for Health Equality Outcomes and Economic Research at the VA Hospital in Bedford, Massachusetts And the vice chair for Health Services Research at Boston University School of Public Health He's an associate professor of medicine and has a clinical background in internal medicine and geriatrics He's published over 80 research papers and review articles many of which have dealt with pressure ulcers and quality of nursing home care Dr. Berlowits is currently the president of the National Pressure Ulcer Advisory Panel Which is commonly known and you will tell me if I've got this right the NPU AP as you members like to call it He's also a member of the American Geriatric Society and the American College of Physicians and the Gerontology Society of America Dr. Berlowits good to see you. Thank you for joining us You know probably a good place to start would be at the very beginning and perhaps you can explain to our viewers exactly what a pressure ulcer is Stan, I would be glad to any discussion of pressure ulcer prevention and treatment must begin with a basic understanding of what pressure Ulcers are and how they develop Specifically, I'll be describing the physiology of ulcer development and how to differentiate a pressure ulcer from other types of Dermal ulcers, but before doing this is important to introduce some definitions first What is a pressure ulcer? Very simply a pressure ulcer refers to any lesion caused by unrelieved pressure that results in damage of underlying tissue While pressure ulcers often over liaboni prominence as it's clear from the definition this need not always be the case Pressure ulcers may go by other names Including bed sores pressure sores and acubitus ulcers however pressure ulcer is definitely the preferred name One of the most important features used in evaluating and describing a pressure ulcer is the stage a Staging system describes the extent of tissue damage specifically depth of a pressure ulcer Many different staging systems exist But the one adopted by CMS was originally proposed by the National Pressure Ulcer Advisory Panel in this staging system a Stage one ulcer is an observable pressure related alteration of intact skin The ulcer appears as defined area of persistent redness and lightly pigmented skin Whereas in darker skin tones the ulcer may appear with persistent red blue or purple hues Compared to an adjacent or opposite area on the body Changes may include one or more of the following parameters skin temperature including warmth or coolness Tissue consistency such as firmness or bogginess and sensation including pain or itching Two features of this stage one definition should be highlighted first. There is no actual break in the skin yet Second the definition includes features other than erythema or redness This is because erythema may be difficult to detect in people with darkly pigmented skin Once the skin opens the pressure ulcer is a higher stage a stage two ulcer as shown here is defined as a partial Thickness skin loss involving epidermis dermis or both The ulcer is superficial and presents clinically as an abrasion blister or shallow crater a Stage three ulcer shown in the slide Represents full thickness skin loss involving damage to or necrosis of subcutaneous tissue That makes them down to but not through the underlying fascia The ulcer presents clinically as a deep crater with or without undermining of adjacent tissues Finally stage four ulcers are defined as full thickness skin loss with extensive Destruction tissue necrosis or damage to muscle bone or supporting structures Such as tendon or joint capsule Undermining and sinus tracts also may be associated with stage four pressure ulcers This slide shows hardware from prior hip surgery that was exposed as a result of a stage four pressure ulcer Because you can't see the wound bed Staging may be difficult if the wound is covered by escar Escar is thick leathery black or brown necrotic tissue that adheres to the wound It's important for surveyors to understand pressure ulcer staging as they observe and compare what they see with what's Documented in the resident's record for the purposes of documentation the facility staff when completing the MDS Must follow the resident assessment instrument or RAI users manual Which requires that pressure ulcers covered with an escar be coded as a stage four Dr. Berlow it's would you describe what causes pressure ulcers to develop? Sharon the traditional teaching is that pressure ulcers develop as a result of four external forces pressure Shear friction and moisture of these forces pressure is clearly the most important Pressure may induce a process as shown here in which there's occlusion of blood and lymphatic vessels ischemia logisticial edema and hemorrhage Resulting first in muscle and subcutaneous tissue necrosis and then epidermal and dermal necrosis Is a widely held belief that a pressure of 32 millimeters of mercury is sufficient to occlude blood flow Yet pressures with a standard hospital mattress often exceed 150 millimeters of mercury and pressure on the ischial tuberosities When sitting may exceed 300 millimeters of mercury in healthy adults Irreversible changes may occur within two hours of unreleaved pressure the greater the pressure the less time required to cause such damage. I Believe that in some situations severe tissue damage may occur with even less than two hours of pressure But this remains a controversial issue Dr. Berlow it's that's such a critical component for staff to be aware of that Irreversible changes may occur with two hours of unreleaved pressure Surveyors pay particular attention to interventions that staff are using for pressure redistribution You also mentioned other external forces such as friction and shear. Could you describe these please? Shear forces occur when residents lie on an incline because superficial skin layers don't move while deep tissues are being pulled down by gravity There is stretching and angulation of blood vessels It is generally believed that less pressure is required to cause deep tissue injury when shear forces are present Friction and moisture are different than pressure and shear in that they result in maceration of skin Friction is frequently caused by pulling a resident in bed so that the skin rubs against the bedsheets But may also occur when the resident uses elbows or heels to reposition Moisture may arise from many conditions, but urinary and fecal incontinence are the major causes Only the superficial layers of skin are involved with friction and moisture Consequently the link to deep tissue injury remains uncertain Dr. Lider will be speaking subsequently and in greater detail regarding the role of pressure and moisture So this emphasizes that any time a resident is repositioned there might be the danger of friction injury So as a surveyor this would be a good opportunity for us to observe staff repositioning residents Dr. Berlowitz we've been talking about external forces of friction and shear. Are there any other factors that impact and pressure ulcer development? Certainly one must consider a variety of resident specific or intrinsic factors that may predispose to pressure ulcer development In particular research has recently devoted considerable attention to the role of circulation Many of the large pressure ulcers tend to develop acute illnesses these illnesses are often characterized by hypotension dehydration and vasoconstriction as a result there is a failure of the micro circulation Very simply blood flow to the skin does not increase appropriately in response to an external stress This then is a major contributor to tissue ischemia as a general rule when a person is acutely ill and not perfusing vital organs Such as a kidneys and brain it is unlikely that the skin will get adequate blood flow While this may have a major role in pressure ulcer development in hospitals its role in nursing homes is uncertain This emphasizes though that tissue ischemia and deep tissue injury may be present even though there is intact skin For example on this slide the dark purple lesion We we know there is deep underlying tissue damage and that breakdown will be evident in a few days While it is currently covered by intact skin It is doubtful that any therapy could prevent a stage 3 or 4 ulcer from appearing within a few days NPUAP is currently having ongoing discussions about this issue So are you saying that a person who has intact skin and a deep tissue injury has a pressure ulcer? Yes, the person clearly has pressure induced skin injury Current recommendations are that staff document that as a stage one pressure ulcer using the MDS coding system This is why it's so important for facility staff to conduct an accurate assessment on the resident's admission to the facility an Accurate admission assessment will help staff identify the resident at risk for developing a pressure ulcer and The resident who already has pressure ulcers or areas of compromised skin This initial assessment will help staff to define and implement Essential care approaches beginning at admission and this type of documented information will help our surveyors as Well as the regulation language at F4 314 states that a resident who is admitted without a pressure ulcer Does not develop a pressure ulcer unless it is clinically unavoidable Dr. Berlow it's as surveyors we see a number of types of skin wounds Would you provide us with information regarding the differences between pressure and non-pressure related wounds? Sharon generally Recognizing that a lesion is a pressure ulcer is not difficult based on its typical location overlying a bony prominence and Ulcer overlight overlying the coccyx ishial tuberosities or greater trochanter is almost certainly pressure induced However, sometimes it may be difficult to determine whether a lesion is a low-stage pressure ulcer with some other lesion such as dermatitis Dr. Leiter will be discussing this in more detail Additionally pressure ulcers may sometimes develop in atypical locations such as elsewhere on the buttocks on the lower leg or on the ears Pressure ulcers in these atypical locations often result from the improper use of an appliance Or trauma induced by some other foreign object such as catheter tubing braces or a cast a Large ring-shaped ulceration the buttocks can result from leaving a person on the toilet or Commode chair for a prolonged period whereas oxygen tubing may Cause a pressure-induced lesion on the nose or ears This emphasizes the need for detective work by clinical staff in determining whether a skin ulcer is pressure induced or secondary to something else Ulcers are particularly common on the feet and legs and the differential diagnosis may be especially difficult When pressure ulcers occur on the feet or legs, they are most likely to be located on the heels or lateral aspects of the ankle In a resident with contractures though pressure ulcers may occur elsewhere such as a medial or lateral aspects of the knee as well as the palms or arms Chronic venous insufficiency is the most common cause of leg ulcers venous insufficiency usually develops as a result of prior episodes of venous thrombophlebitis With associated destruction of valves in the deep venous system This is an example of such a venous ulcer also known as stasis ulcer Very evident are the irregular margins, which may be heaped up Typically a venous ulcer will be located over the medial or lateral aspect of the the medial aspect of the leg or ankle But in severe cases such as this it may extend around the leg Other signs of venous insufficiency are often present including leg edema stasis dermatitis and brownish hyperpigmentation of the skin related to hemo-sitter and deposition as is evident in this slide Pain is often not present despite the large area of ulceration How about other types of ulcers such as those caused by arterial insufficiency? Sharon arterial insufficiency is the second most common cause of leg ulcers Skin ulceration results from tissue hypoxia caused by an inadequate blood flow particularly when associated with even a minimal trauma Ulcers typically occur over the toes and lateral aspects of the ankle or legs as shown in this slide They often have round margins and they may be extremely painful These ulcers may be associated with gangrene Other signs of arterial insufficiency will usually be present such as shiny hairless skin abs and pulses and coolness of the extremity We also see ulcers occurring in residents with diabetes. Could you describe those ulcers for us? Neuropathic or dystrophic ulcer is another common cause of foot ulceration These ulcers typically occur in persons with diabetes mellitus or other conditions that cause a neuropathy The precise pathogenesis is not known but it may be caused by reduced blood flow caused by the nerve damage or the simple inability to feel a traumatic injury as Shown on the slide the sole of the feet especially under the metatarsal heads is a common location for neuropathic ulcers Pain is typically absent and a resident may be entirely unaware of an advanced ulcer With pain typically being absent and the resident being unaware of the advanced ulcer I can see the importance of facility staff being vigilant in the observation and management of the lower extremities for those residents Who have diabetes? Are there other skin wounds that we'd like to address? Those I've covered are certainly the most common causes of ulcers and counted in nursing home residents However, other conditions may rarely cause skin ulcers. These include a number of chronic infections Vasulitis especially pyoderma gangrenosum and skin cancer Squamous cell carcinoma rising in a chronic wound should always be considered when a wound healing does not occur despite appropriate therapy So then not all chronic wounds are alike, especially non pressure related ulcers I can see how important it is for facility staff to know the etiology of the ulcer in order to provide the specific treatment interventions for that particular type of ulcer identified This will be helpful information for surveyors when they're reviewing and observing care for both pressure and non pressure related wound care Dr. Berlerowitz, is it possible for a resident who has a non pressure related ulcer to also have damage from pressure to this area? Sharon that's a good question This certainly may be an interaction among predisposing factors pressure likely is an important contributor to arterial and neuropathic ulcers Well, thank you Sharon and thank you dr. Berlerowitz for this enlightening overview if you will a pressure ulcer development Continuing on now with our presentation We have had the opportunity to take a team into a nursing home setting to film a case study of a nursing home resident for our Discussion as we will be referring to mr. Smith in our broadcast I'd like to tell you a little about the gentleman the resident mr. Smith has a history of a left cerebral vascular accident Although he can respond to verbal commands. He can't always speak nor say what he needs Mr. Smith has several deficits in the area of activities of daily living Including that he is incontinent in urine and stool at least three times a day And he needs staff assistance with grooming and dressing the mr. Smith's ability to walk is greatly impaired And he spends most of his time in a chair and is unable to change positions himself His current weight is 170 pounds his height 5 feet 10 inches tall in the past month He has lost roughly 5 pounds his latest serum album is 3.0 He is unable to use his right arm to feed himself and despite assistance from the staff He is only eating half of his meals and he has difficulty swallowing and he has a lack of appetite his current medications include anti depressants anti colon coloner jigs Multi vitamins and anti platelets and as we progress through our broadcast You will hear our expert panelists refer to mr. Smith in relation to assessing his risk for pressure ulcer development and Identifying some strategies that might be effective as a preventative plan of care at this time Let me introduce you to our next speaker. Dr. Elizabeth Aiello who is a registered nurse and faculty member at Excelsior College School of Nursing in Albany, New York. She is a board certified wound Ostomy and incontinence nurse Dr. Aiello is a fellow of the American Academy of Nursing and a fellow of the American Professional Wound Care Association, she is the executive editor of the Journal of the World Council of Let me see here enter a stommel if you will as Astro stommel the therapist and Dr. Aiello serves as a senior advisor to the John a Hartford Institute for geriatric nursing in New York City and his program director for education essentials She is also the co-author and co-editor of the 2004 Lippincott publication wound care essentials practice and principles Dr. Aiello has served as president of the National Pressure Ulcer advisory panel. She is a chair of the NPU AP task force that revised the stage one pressure ulcer definition associate editor of the NPU AP 2001 publication pressure ulcers in America prevalence incidents and implications for the future and is the current chairperson of the wound Ostomy Continence Nurses Society Accreditation Committee. I hope I got all of the credentials correct doctor. Good to see you Okay, now later in the program. We will talk live with dr. Aiello, but first she had a chance to talk with Sharon previously about the importance of assessing For pressure ulcer risk and conducting skin assessments. So let's take a listen in on that conversation Sometimes people are confused between a risk assessment and a skin assessment. Would you discuss the difference? Sure Sharon and thanks for the opportunity to clarify this sometimes confusing distinction between two types of assessment pressure ulcer risk and Skin assessment as nurses we are like detectives Looking for clues that guide us in making decisions about what is wrong with our residents and how we should proceed with the case the skin can hold clues to the person's medical condition or the case a Skin assessment is different from a risk assessment because you are looking at the person's entire body for changes in the skin that might indicate a disease state or a need to change the plan of care a pressure ulcer risk assessment is Focused in that you are trying to decide if the person is at risk for developing the specific skin injury of a pressure ulcer While there is no consensus in the literature as to what to include in a skin assessment The usual clinical practice of a minimal skin assessment Evaluates the following five elements temperature color moisture Turgor and integrity now. Let's look at these five areas in more detail Temperature the question is is it warmer than normal? This might signal inflammation is a cooler than normal This could signal poor Vascularization for color Pale this may indicate poor circulation Hyper or hypo Pigmentation may reflect variations in melon deposits blood flow or even genetic disease What about moisture The questions are is the skin dry or moist is there flaking a demer or rash is present Turgor what is the person's hydration status, especially hydration deficits? Integrity are there open areas if so Use the correct classification system to identify the skin injury Pressure ulcer assessment is about asking different questions While a pressure ulcer risk assessment begins with assessing the condition of the skin over the bony prominences It is more than skin it encompasses looking at the whole person who lives in that skin and Evaluating the fact is that we believe that science has told us affect skin breakdown So surveyors may see different types of assessments conducted on the resident You would mention the use of a pressure ulcer risk assessment CMS does not mandate that a facility use the particular assessment tool So facilities are able to choose which tool is most suitable for their needs as Surveyors we verify the accuracy of their assessments regardless of which tool they use Yes, Sharon surveyors will see a variety of risk assessment tools and use You might see the Norton the Braden the Waterloo the Gosnell and even homegrown scales Assessing a resin for pressure ulcer risk is a comprehensive process Not something that can be wrapped up only into a scale That's why it's so important to remember why a risk assessment is done in the first place It's to identify which residents might get a pressure ulcer so that as nurses We can do something about it before it happens by doing a risk assessment We make a clinical decision about what to use and when to begin using prevention strategies So our resident does not get a pressure ulcer Interventions are expected to be put into place so the outcome or the pressure ulcer does not develop What constitutes the risk assessment? It involves many things Remember our role as a nurse is as detectives to see if our resident is at risk for pressure ulcer breakdown So like any good detective we can find the answer by asking questions such as Does the resident have diseases conditions? Comorbidities that affect the skin and thus place the resident at risk for pressure ulcer development. If so What are they and can they be modified or treated? How stable is the resident's condition has the resident been to the hospital recently is There a repeated pattern of hospital admissions. That's an important clue What is the nutritional status is the resident getting adequate nutrients so the skin cells can do their work? Some people have other factors that are easy to measure and are captured on many of the tools Can they move do they have pain so that they don't want to move do they have sufficient cognition or? Are they incontinent it is looking at all of these puzzle pieces and putting them together And then making a good clinical decision as to what to do about the situation Another question nurses can ask is what does the skin look like? One of the most important things to look at is whether the resident had a prior pressure ulcer So I may find that some facilities might have different pieces of the assessment in different parts of the resident's record It just might not be a single tool Surveyors can still validate all we need to know about the facilities assessment of risk with different tools for assessments Yes, it's like the pieces of a puzzle Remember we said that pressure ulcer risk assessment is more than simply evaluating the skin There may not be one section of the record where everything is all wrapped up in one place easy for us to find Sometimes a skin detectives we have to go looking for it You mentioned earlier that it's very important to identify whether or not the resident had a history of a previous ulcer Can you elaborate on this? Certainly when assessing a resident for risk of pressure ulcers It is important to ask the resident if he has ever had pressure ulcers And if so, what was the location and how were they treated? Sometimes the residents are not able to tell you their history So it is important to talk to responsible people who might be knowledgeable of the resident's history Let's talk about a clinical example Here's a resident who had a pressure ulcer on his heel which healed after six months of treatment It would be important to know that his heels are more vulnerable to breakdown as his care is being planned That's interesting many would think that after an ulcer heals the skin is tougher But you're saying it's actually compromised and more prone to another ulcer in the same area Exactly the ability of the skin to tolerate pressure Maybe altered since the tensile strength of wounded skin is 80% of unwounded skin Most people who experience pressure on their skin are going to do something about it They will change positions What if someone has lost sensation or the ability to feel pressure on their skin? You and I are going to get up and move when we feel that our bottom hurts from sitting in one position too long I call it the commercial effect. I get up and move during the TV commercials If they have dementia, if the skin has lost sensation, if the person cannot process what is happening to them Or doesn't have the knowledge of what to do or cannot move about by themselves They have lost the early warning sensor That's the skin's ability to tolerate pressure and it's being challenged This resident is at risk and staff must do for them what the resident cannot do for themselves One intervention for a resident at risk for pressure ulcer development would be to redistribute the pressure The kinds of support services we may want to use may be different Based on our analysis of the risk factors It's like assessing the treatment for women who are pregnant The medical treatment is different based on what trimester they are in and what their needs are specifically at that time That reinforces the individualized approach to care in the first place Yes The degree to which a resident is at risk and the type of pressure ulcer risk will dictate what treatment is best So what will this risk assessment tool say? If you can't measure it, you can't manage it Pressure ulcer scales were developed for research as a guide to quantify the degree of risk by Assigning numeric values to pressure ulcer risk factors Since it was helpful. It has been adopted for use in the clinical setting I've seen the Norton scale more often than the Braden scale other other tools There are actually several risk assessment tools besides the Norton and Braden scale There's the Waterloo, Gosnell, Knoll and homegrown tools AHRQ formally AHCPR guidelines recommend that risk assessment be done using a validated tool and Suggest that the Norton and Braden scales have a research base supporting their reliability and validity While no specific tool other than the RAI is mandated Use of a pressure ulcer risk assessment tool is helpful for determining at-risk residents Some nurses believe that intuition or informal pressure ulcer risk assessment is enough and Using a pressure ulcer risk tool is unnecessary Research supports that when a formal tool is not used Clinicians only intervene for persons at the highest level of risk For example in one study few within 50% of patients at mild moderate risk for developing pressure ulcers were turned Research supports that when formal risk assessment is linked to preventative protocols The incidence of pressure ulcers Dropped by 60% and the severity and cost of pressure ulcers decreased too So you're saying the total score by itself is enough No, the global scores are not the end of the story Two people may have the same total score But they have that score based on different sub-scales, so they will need different components of treatment Does it really matter if a facility chooses to use the Braden or the Norton? Can you explain the coding differences? Both scales have validity, but they are different So it is important to know the correct way to use your facility's selected scale The Norton scale is the grandmother of all pressure ulcer risk assessment scales Created in the early 1960s It was based on older persons in a hospital in the United Kingdom and it has five factors physical condition mental condition activity mobility and incontinence each Factor is ranked numerically from a high score of four meaning good to a low score of one Notice that nutrition is not a separate discrete factor Doreen Norton believed that nutrition was integrated throughout each of the five factors and so it is not a separate category Let's look at a copy of the Braden scale and using the data about our resident Mr. Smith Do a pressure ulcer risk assessment using the scale The sensory perception subscale of the Braden scale has two levels The top descriptors measure the person's level of consciousness While the bottom descriptors measure cutaneous sensation Because mr. Smith can respond to verbal commands, but can't always speak His score for top subscale category of level of consciousness is slightly impaired or three Because he has paralysis and cannot feel pain over half of his body His score on the bottom descriptor of cutaneous sensation is very limited or two If a person has a different score on each of these levels the lower score is used So for this resident mr. Smith his score would be two for sensory perception Looking at the moisture subscale mr. Smith is incontinent of urine and stool at least three times a day So once a shift he needs changing Using the descriptors in the moisture category his subscale score is very moist or two Under the activity subscale because mr. Smith sits in the chair most of the day His score on the activity subscale is two for chairfists Under the mobility subscale mr. Smith's ability to walk is greatly impaired from his cva And he is unable to change positions by himself This makes him completely immobile and thus gives him a mobility subscale of one Let's look at the nutrition subscale next mr. Smith has several factors Which impact on his nutrition? He has difficulty swallowing Lacks an appetite eats about half of his meals Even though staff is assisting him due to his problems of not being able to use his right arm and has lost five pounds in the past month All these assessments support that his nutrition is probably inadequate and thus a sub-score of two And lastly friction and shear because Smith to Smith has right-sided paralysis and needs so much Assistance to change positions and walk his friction and shear is a problem giving him a sub-score of one So what's your clinical decision about mr. Smith's risk for a pressure author? By adding the six sub-scores mr. Smith's total Brayden score is 10 The onset of pressure also risk for the general population is 16 For elderly or doggly pigmented persons the onset of risk score is at the higher number of 18 Numerical scores lower than these numbers mean that the person is at risk for developing Pressure ulcers, but it's not just the singular number. That's important. That's only part of the story In fact, if we as nurses ignore the type of risk, then we are missing the point of a risk-based protocol The tool by itself is not the critical piece It is the ability to take the resident data and put it into the tool of choice Then what is important is how you use what you have incorporated How is skin detectives you determine the best approach or approaches and how to treat the issue in either case The resident had a score of 10 the number is not what is important It is what the number represents this resident is at risk. The facility must take action So since mr. Smith's Brayden score is 10. He's at high risk for developing pressure ulcers Don't just rely on the total score for deciding on when and what to implement for prevention protocols It's also important to look at which sub-scales are lowest For example for mr. Smith its mobility and friction or shear By customizing your interventions to the lowest sub-scores first It will address the most critical areas of pressure ulcer risk and also help with resource usage When should surveyors expect to find a risk assessment? How often should they reassess? Well research by Brayden and Berkstrom has shown that the majority of pressure ulcers occur Within the first three weeks of admission to a long-term care facility based on this It's recommended that pressure ulcer risk assessment be done on admission Weekly for the first four weeks and then monthly to quarterly Whenever there is a change in the resident's condition their pressure ulcer risk needs to be reassessed After the surveyor has determined that the facility accurately assessed the resident at risk for pressure ulcers what next? By looking at the clinical clues We as skin detectives can come up with a plan of action to prevent skin injury Clinical decision-making based on our elements of risk assessment that we have discussed is the first step in solving the mystery of skin breakdown Thank You dr. Aiello for all that helpful information This has helped me to further understand the difference between the two types of assessments the significance of an accurate skin assessment And the identification of risk factors I just a fascinating exchange of information about pressure ulcers and how to identify them how to begin to treat them Sharon you engage in the conversation with dr. Aiello I would imagine that this would be a good point that we can get at some follow-up questions, right? Dr. Aiello could you clarify for me about when to implement pressure ulcer prevention strategies? I mean is it only when a resident has an overall score indicating that they are at risk? No Sharon This is missing the point of a risk assessment Prevention protocols should be custom designed according to which pressure ulcer assessment sub skill scores are low What that means is the resident risk factors are high Don't wait until the resident is at a highest risk. It's about knowing the unique risk Factors of your resident and acting immediately to protect the skin from pressure damage One of the factors mentioned by dr. Aiello was the issue of nutrition as a risk factor So let's look at a tape of a conversation that Sharon had with dr. Berlow. It's about the issue of nutrition dr. Berlow it's during her presentation dr. Aiello identified under nutrition as a risk factor for the development of pressure ulcers When surveyors are investigating the development of a pressure ulcer they review the resident Whole listically including how the facility identified the individual risk factors for the resident in question For the resident in our case study. What should a surveyor look at concerning nutritional parameters? Sharon that is an important question for surveyors to evaluate when they are assessing the facilities response to identified risk factors One individual resident nutritional status has long been thought to be an important predictor of both the development and healing of pressure ulcers yet I believe there is no part of the risk assessment process that is more difficult than determining Whether or not a nursing home resident is malnourished. This is certainly the situation for the case under discussion There are many clues here that the resident mr. Smith may have nutritional issues He has lost five pounds in the past month. His albumin is 3.0, which is low Moreover, he has difficulty swallowing no appetite isn't and is unable to use his right arm for feeding himself Based on this information would mr. Smith be considered to be malnourished and other specific Nutritional interventions required for reducing his risk for developing a pressure ulcer Well to begin the discussion of nutritional aspects of this case We need to understand what is meant by malnutrition Certainly nursing home residents may have isolated deficiencies of important nutrients Deficiencies of vitamin D and B12 are particularly common among nursing home residents a zinc deficiency May be especially relevant for pressure ulcers But these isolated deficiencies are not what we should consider as malnutrition Rather in thinking about risk for pressure ulcers We should be most concerned with the specific condition of protein energy malnutrition as the name implies Protein energy malnutrition arises when the intake of calories and protein is insufficient to meet the metabolic demands Protein energy malnutrition arises through three main mechanisms first in some situations It may arise solely from inadequate intake of nutrients. The resident is underfed second malabsorption in which Nutrients are consumed but not absorbed may contribute to underfeeding But much more common in nursing home residents is a third mechanism an Increased requirement for energy and protein brought on by some stress such as injury or infection Common causes of such stress may be a new bacterial infection Cancer chronic obstructive pulmonary disease chronic heart failure or renal failure in all these conditions There will be hormonal changes and release of cytokines This in turn will result in anorexia the depletion of visceral protein stores liver dysfunction and malabsorption Thus a cycle may be generated of malnutrition leading to anorexia and malabsorption resulting in further malnutrition But the important point is to recognize that many cases of protein energy malnutrition Arise from chronic illnesses present in nursing home residents and may have little to do with the care actually provided by the nursing home During observations of meal services survey has observed the assistance provided by the staff to the residents who need it When we observe a resident who's being assisted to eat and that resident is not consuming the food items served We investigate to determine if any of the clinical conditions you described are contributing to this problem in Those cases the surveyor should be able to obtain this type of assessment information from the record review and interviews of the staff Including the physician the dietitian and nursing staff It is important to verify assessment information with staff as they should be able to provide the most up-to-date Clinical information regarding the current status of the resident Earlier you said we should be most concerned about protein energy malnutrition for those residents at risk for pressure ulcers What should a surveyor be looking for? Sharon that's a good question the detection of protein energy malnutrition is often difficult and there is no single test That can make this determination Rather an array of assessments is required that provides information on overall nutritional status The physical examination may reveal muscle wasting and loss of subcutaneous fat The resident will appear thin wasted and kik-ek-sek the skin may be dry and flaky in rare cases Edema and ascites may develop and the resident will often but not always be underweight This should be determined by the body mass index or BMI This is calculated as the weight in kilograms divided by the height in meters squared a BMI below 22 is often a cause for concern Current BMI must of course be interpreted in light of any recent weight changes a weight loss of 5% in one month Or 10% over six months is usually considered significant Such weight changes should reflect changes in fat and muscle and not fluids as may occur from a diuresis As surveyors those indicators of weight changes would certainly require Investigation as to how the facility assessed and identified the changes in the individual resident's nutritional status The requirement at 483 25 I States that based upon a resident's comprehensive assessment the resident maintains acceptable parameters of nutritional status Such as body weight and protein levels unless the resident's clinical condition demonstrates that this is not possible Are there other components of the assessment that surveyors should review? Laboratory assessments may be an important component of the nutritional assessment The most commonly used test is a serum albumin level which provides good evidence of protein stores But albumin may be affected by many conditions other than nutritional status and any physiologic stress may lower it Thus a low serum albumin does not always mean protein energy Malnutrition sometimes a pre albumin level is checked instead of the albumin as this may be more sensitive to recent changes in nutritional status Total lymphocyte count Cholesterol transferrin retinal binding protein and skin test antigens may also be ordered by the practitioner as part of a comprehensive nutritional assessment The identification of protein energy malnutrition also depends on a comprehensive history Changes in appetite and dietary intake must be determined This should be combined with a broader assessment that captures preferences for specific types of food and the ability to taste and enjoy foods Reflecting this lack of a gold standard for malnutrition No single marker has consistently been shown to be an independent predictor of pressure ulcer development Confounding the problem is that malnutrition is often associated with other risk factors for pressure ulcers such as immobility While some studies have identified a low serum albumin level as a predictor of pressure ulcers Other nutritional markers such as current inadequate intake of food were more important than albumin in other studies This emphasizes then determining pressure ulcer risk a comprehensive nutritional assessment rather than any single test is required That's helpful to know in evaluating the status of a resident's nutritional parameters Based on these facts, would you consider the nursing home resident in our case study to be malnourished? The answer is most likely yes His body mass index is low at 21 Even though he did not lose 5% of his body weight in the past month The albumin is also low at 3.0. He appears to have anorexia as only half of his food is being consumed Moreover, he is post-stroke a situation known to be associated with an almost 30% occurrence of protein energy malnutrition Malnutrition should be addressed as part of the treatment plan Well for mr. Smith, what are some of the things the facility should consider in order to prevent the pressure ulcers from occurring? This resident requires an aggressive nutritional intervention It is worth noting though that while malnutrition appears to be associated with an increased risk of pressure ulcer development The ability of nutritional interventions to lower this risk has not been conclusively shown Four clinical trials have evaluated nutritional supplements provided either orally or by a tube in Patients hospitalized with a critical illness or recent hip fracture all of these studies had serious methodological concerns and many did not have sufficient numbers of residents to be able to show a meaningful difference Yet collectively the studies did suggest a benefit in terms of lower rate of pressure ulcer development Whether these results apply to nursing home residents with their many chronic illnesses is unclear Nevertheless, this lack of convincing evidence should not be taken as suggesting that nutritional supplementation is of no benefit in preventing pressure Ulcers as for mr. Smith. He should receive an enhanced meal plan to provide the protein and calories He requires staff should be assessing his intake in order to determine if additional nutritional supplementation is warranted. I Know that during observations of meal services Some residents who are not eating well will state that they are just not hungry and they have no appetite in Reviewing mr. Smith's case it looks like one problem contributing to this residents poor nutritional status is anorexia Would you please discuss the issues of anorexia? There are many causes of anorexia and as I mentioned earlier chronic illnesses and malnutrition may in itself induce anorexia However an important treatable cause of anorexia that should always be considered in nursing home residents is depression This resident is already on an antidepressant, but the adequacy of this therapy should be reassessed Sometimes medications are used to stimulate the appetite the two most commonly used medications are the progestational agent Megastrol acetate and the cannabis derivative Dronabinol most of the studies Demonstrating the efficacy of these drugs have been performed on people with cancer or HIV infection No firm guidelines exist for their use in nursing homes Caution is required particularly for megastrol acetate as it may predispose to deep venous thrombosis in residents who are already bedbound and immobile Finally mr. Smith may have a problem with eating and feeding himself difficulty with swallowing is common post stroke although in most residents this resolves in several weeks a Swallowing evaluation would be indicated in this resident and all durations in the diet may facilitate swallowing The right-sided weakness suggests that mr. Smith may not be able to feed himself an Occupational therapist may be able to help him and close attention should be given to how the resident is currently being fed at Mealtimes in some nursing home residents Enteral feeding through a nasogastric or pegged tube has been considered as a way of providing nutritional supplements Both short and long-term use may need to be considered however the benefits and risks of enteral feeding remain poorly defined and Considerable regional differences exist in its application to nursing home residents Decisions regarding enteral feeding should usually be made in conjunction with the resident and family members I'm glad you brought up the point regarding enteral feeding There is a nursing home requirement that states that based upon the comprehensive assessment a resident Who has been able to eat enough alone or at least with assistance is not to be fed by tube Unless the clinical condition demonstrates that the use of a tube was unavoidable Our guidance is clear that the intent of the requirement is to prevent the use of tube feeding when ordered over The objection of the resident or when it's not likely to be of benefit We review to see if the decision about the appropriateness of tube feeding for a resident has been developed with a physician and The resident or his or her representative This would also include a review of advanced directors regarding this issue if the resident has made an advanced directive It is very important that the practitioners and the resident and his or her Representatives are involved in the decision-making regarding the nutritional interventions to be provided So far we've discussed the role of nutrition and pressure also prevention. What about the role of nutrition and pressure also treatment? Nutritional status is one of the most important reversible factors contributing to wound healing and much of the previous discussion Is also relevant to pressure ulcer treatment a number of studies have suggested that dietary intake of protein is particularly Important in healing pressure ulcers the optimum dietary protein though is unknown and current recommendation suggests 1.2 to 1.5 grams of protein per kilogram per day Higher amounts should be avoided as it may promote dehydration Individual nutrients especially vitamin C and zinc are often used to promote healing While they may be of benefit in residents with an isolated deficiency of that nutrient There is little evidence to suggest their benefit in most pressure ulcer patients In summary many nursing home residents have protein energy malnutrition Careful attention to this problem will do much towards promoting their overall health status as well as contributing to the prevention and treatment of pressure ulcers Dr. Berlow it's thank you so much. I find that information very helpful. I Think records for residents with pressure ulcers and the doctor's orders will say to administer zinc for healing My understanding was that this is a controversial issue and that zinc is necessary for pressure ulcer healing. Can you elaborate? The use of zinc of a zinc supplement is certainly a common practice yet clinical trials have not demonstrated that zinc supplementation results in improved healing for the majority of pressure ulcer patients There may be isolated residents though in whom it would benefit the difficult issue is how to identify these very few residents Just for clarification. You had mentioned the use of nutritional supplementation in nursing homes We see the use of liquid supplements frequently could the use of small more frequent high nutrient meals serve the same purpose Yes, it can serve that purpose the important point though is ensuring that residents receive adequate nutrition through any means All too often nutritional supplements are used in place of a resident's normal meal and that may be problematic Thank you, Dr. Berlow. We're going to move on in our discussion now and discuss some other risk factors of pressure ulcer development I'd like to introduce Dr. Courtney at Leider who is a University of Virginia medical center professor of nursing and a professor of internal medicine and geriatrics an interim chair of the Department of Acute and Specialty Care at the University of Virginia and he recently moved to his new position from Yale University where he was a ten-year associate Professor of nursing and gerontology and director of the adult family gerontological and women's health division at the school of nursing Dr. Leider is a fellow of the American Academy of Nursing diplomat of the American Academy of Wound Management and former president of the National Pressure Ulcer Advisory Panel He has over 145 publications including books book chapters journal articles and abstracts his writings can be found in journals such as the Journal of the American Medical Association the archives of internal medicine and American Journal of Surgery He sits on the editorial advisory boards of advances in skin and wound care Ostomy wound management and the international wound journal He's given over 200 lectures throughout the United States and abroad Dr. Leider Welcome and good to see you once again. Good to see you Stan. Okay As we had discussed before you know You had a chance to do a live interview during this interview with Sharon and the two of you had a chance to talk Previously about things like moisture friction shear and pressure Redistribution so before we go into an extended conversation. Let's take a look at that interview that the two of you did During our surveys part of our tasks include the record review and one of the responsibilities is to evaluate the comprehensive assessment That's completed by the staff for a resident who has a pressure ulcer or who has been identified at risk for the development of pressure This assessment usually identifies several factors that place the resident at risk for the development of a pressure ulcer Surveyors review the care plan to identify the approaches that staff developed to address the identified risk factors Risk factors of moisture and conditions that lead to unrelief pressure Would you please discuss the relevance of the evaluation of moisture as a risk factor? Sharon you are right. There are many risk factors associated with pressure ulcer development Moisture in particular perspiration urinary and fecal incontinence can increase the development of pressure ulcers by altering the integrity of the skin When residents are diaphoretic it is possible that excessive skin wetness can increase the friction gradient between skin and The external surface while the resident is being turned or reposition further Prolonged exposure to skin wetness may lead to maceration predisposing the resident to pressure ulcer development both urine and fecal incontinence have been implicated in Pressure ulcer development when the skin is exposed to these two substances for an extended period of time It will increase the possibility of maceration Furthermore, both urine and feces contain substances that are irritating to the skin in particular Several studies have found that fecal incontinence is a better predictor of pressure ulcer development Since feces contain greater irritants than urine Clearly the type and frequency of incontinence will predispose the skin to break down That's important information, but how does this relate to mr. Smith our case study? Well in our case study mr. Smith is most susceptible to the effects of moisture on his skin He is both incontinent of urine and stool with three daily incontinent episodes Research has found that three or more incontinent episodes may place him at a higher risk for the development of perineal dermatitis As well as pressure ulcers that is why it is also important for the nursing staff to delineate between Pressure ulcers and perineal dermatitis which can also be caused by incontinence. I Can see how important it is for the care plan to address the issue of moisture in order to help reduce the potential for friction and shear During repositioning and to decrease the potential for dermatitis Sometimes dermatitis has been confused with the development of a stage 1 pressure ulcer. Dr. Leiter What is the difference? What should surveyors look for and could you clarify this issue as well? Yes, as Dr. Browitz discussed earlier Pressure ulcers are due to the amount of time and pressure needed to obstruct normal capillary closure leading to tissue necrosis Pressure ulcers can range in stages 1 through 4 Pressure ulcers precipitated by incontinence will usually appear as a stage 1 or stage 2 Most often pressure ulcers are a single lesion and quite circumscribed Conversely perineal dermatitis often appears as a diffuse area of erythema a Perineal dermatitis is usually located where the incontinence has come into contact with the skin The erythema tends to be more diffuse and covers a larger area Dermatitis is commonly associated with itching papuels and weeping skin When the skin is not protected from the effects of the irritants it may even ulcerate in our case study The goal for mr. Smith is to maintain his skin integrity by monitoring his skin condition and providing care as needed His skin should be assessed daily paying particular attention to the most vulnerable and anatomical areas for ulceration The coccyx sacrum trochanters and heels which are most likely to develop pressure ulcers If soiling with fecal matter or urine should occur The skin should be cleansed with warm water and a mild cleansing agent to minimize irritation and dryness of the skin Moisturizers should also be used if the skin appears dry Massaging erythematic bony promises should be avoided since it has been found not to increase circulation But rather increase degenerated tissue Given mr. Smith's multiple incontinence episodes the use of a moisture barrier should be used after each incontinence episode That was helpful information on assessing for moisture and providing concepts for care planning You also mentioned paying particular attention to the foremost vulnerable anatomical areas for ulceration The coccyx the sacrum trochanters and heels Talk to us about excessive pressure on the skin in these areas There is little discourse that excessive pressure over a period of time may result in a pressure ulcer development Thus a major preventive intervention should be removing or redistributing the pressure-sensitive areas of the body Few studies on repositioning have been published since the landmark study on repositioning in 1964 This prospective observational study found that older adults when repositioning two to three hour intervals Developed less pressure ulcers than the less frequently turned cohorts a more recent study investigating 48 healthy older Dells found a significant increase in skin surface temperature at the end of a two-hour turning schedule an Increase in skin surface temperature can suggest early stages of pressure ulcer development thus repositioning and offloading is essential An example is our case study mr. Smith has lost the ability to reposition himself Thus the nursing home staff must pay particular attention to repositioning or offloading him while in bed or chair Diagram one indicates the pressure areas of most concern depending on the position that mr. Smith is placed When mr. Smith is lying on the bed He should be turned maximally every two hours when reactive hyperremia of more than five minutes is noted The frequency of repositioning should be increased Prolonged reactive hyperremia has been noted to be a precursor to the development of a pressure ulcers Ideally the head of mr. Smith's bed should be at the lowest degree of elevation hence no greater than 30 degrees Which is consistent with his medical condition to decrease friction and shear forces If he has to have the head of the bed elevated then the nursing home staff should consider the use of wedge cushions or Pillows to decrease the forces of friction and shear Moreover the use of draw sheets or trapeze should be used to reposition him to decrease mechanical forces That information will help me as a surveyor when observing a resident who's on bedrest What else does a surveyor need to be aware of when a resident is in a chair or in a recliner and has issues with positioning and offloading? In our case study when mr. Smith is sitting in a chair He should be offloaded hence relieved of all pressure on his seating surface every hour It should be noted that when offloading mr. Smith in his chair He should be completely removed off the chair for one minute to facilitate tissue Reprefusion in mr. Smith's case. He cannot be taught to offload independently However, if the resident can be taught to shift his weight while seated he should be taught to offload every 15 minutes Good postural alignment is also essential to decrease the forces of friction and shear while the resident is sitting After positioning the resident in the wheelchair the nursing home staff should always think have I accomplished proper postural alignment? Proper distribution of weight proper balance and stability proper pressure redistribution Since the majority of residents spend some time sitting in a chair the use of pressure redistributing devices should be used Some of those seating devices include foam gel air or combination seating surfaces However, donut type devices should not be used since they do not evenly redistribute pressure The physical therapy department can often assist the staff with determining the best alignment Seating surface or whatever for the resident and that should be consulted on a regular basis. I Can see that relieving the excessive pressure from the tissue over time is an important intervention for the prevention of pressure ulcers But surveyors have heard many times how difficult it is for staff to remember that they need to frequently change a resident's position What have you seen facilities do in this case? For some nursing home staff it may be difficult to remember turning intervals thus the use of turning clocks Audible sounds or music that would trigger the staff that is time to turn and reposition the resident could be used Dr. Lidah you mentioned reactive hyperremia in relation to unrelieved pressure What should a surveyor expect the nursing home staff to assess in relation to the skin and color changes that might happen when pressure is Unrelieved The skin should be assessed on a daily basis for those residents at risk during bathing and routine skin care When the skin is assessed on a daily basis It helps to ensure that any alterations can be identified and interventions can be implemented quickly During the observations color changes to the skin may have occurred Much confusion still exists between identifying reactive hyperremia and stage one pressure ulcers The reactive hyperremia is often the first external sign that is chemia due to pressure has occurred When the skin becomes ischemic under pressure for more than a minute It becomes reddened or hyperremic after the pressure has been relieved The rush of blood back into the ischemic tissue is noted as reactive hyperremia This protective mechanism of the body Dilates the vessels and increases the amount of blood available to oxygenate the tissue The increase in blood flow has also been associated with increase in skin temperature and swelling in the ischemic area Although difficult to quantify Reactive hyperremia usually lasts up to 50% less than a true pressure ulcer Thus reactive hyperremia can last as little as one minute and up to one hour If pressure exceeds tissue tolerance the mechanisms of reactive hyperremia becomes insufficient To meet the demands of the compromised circulation Research has found that sustained pressure results in persistent tissue ischemia leading to the accumulation of metabolic breakdown products failure of cellular membrane integrity and tissue necrosis with perivascular hemorrhage thus Inflammation and Extroversation of red blood cells results in persistent erythema consistent with a stage one pressure ulcers Repetitive cycles of prolonged pressure with tissue ischemia Proceeded by pressure relief and return of blood flow can lead to reperfusion injury which contributes tissue damage and further ulcer progression Based on the literature there appears to be a clear link between reactive hyperremia and stage one pressure ulcers Therefore, it is essential to properly relieve the pressure while reactive hyperremia is still present thus avoiding the development of a stage one pressure ulcer This certainly reinforces the need to be vigilant in assessing the condition of the skin during repositioning and offloading for the resident There's been a lot of research on the classification of stage one pressure ulcers and a lot of ongoing dialogue about the Identification of stage one ulcers especially in residents with darkly pigmented skin. Could you tell us more about this? There is more variability in research that attempts to classify the stage one pressure ulcer than in any other ulcer The majority of classification systems define the stage one pressure ulcer as non-blanching erythema These classification systems also note that reactive hyperremia will develop if pressure is unrelieved However, if pressure continues to be unrelieved it will eventually lead to non-blanching erythema Thus reactive hyperremia or blanching erythema is often noted as the precursor to a stage one pressure ulcer In 1998 the National Pressure Ulcer Advisory Panel revised its definition of a stage one pressure ulcer To encompass the skin alterations that might be seen in stage one pressure ulcers regardless of skin pigmentation This definition notes that a stage one pressure ulcer is an observable pressure related alteration of intact skin Whose indicators as compared to the adjacent or opposite area of the body May include changes in one or more of the following skin temperature warmer or cooler tissue consistency firm or baggy or sensation pain or itching The National Pressure Ulcer Advisory Panel definition further states that the pressure ulcer appears as a defined area of Persistent redness in lightly pigmented skin But in darker skin tones the pressure ulcer may appear with persistent erythema blue or purple hues for example Residents with dark brown skin the erythema will usually appear as blue Compared to the adjacent area of the body a resident with black skin the erythema will most likely appear as Purple compared to the adjacent area The National Pressure Ulcer Advisory Panel classification of the stage one pressure ulcer is the only Classification that includes non white skin This is a very important since most clinicians have little experience detecting stage one pressure ulcers in darkly pigmented skin In assessing erythema Quantity and quality of the light source may alter skin color hues and thus impede most clinicians ability to accurately assess skin color changes the use of skin temperature Tissue consistency and skin sensation as possible indicators of stage one pressure ulcers may make identifying pressure ulcers more accurate Skin temperature elevations has been associated with the inflammatory phase of tissue ischemia Hence the warmth to the ischemic area can be attributed to increases in local blood supply coupled with edema and engorgement of surrounding vessels conversely coolness to the Arithmetic area has been attributed to decreased blood flow due to destruction of capillaries Thus both warmth and coolness indicate that tissue injury has occurred and potentially indicates the duration of injury Hence warmth being recent with coolness representing less recent This sounds like a difficult area for assessment Are there any technologies in the field that might help in the identification of this stage of pressure ulcer development? There have been numerous advanced skin technologies developed to measure tissue perfusion However, no technologies have been specifically developed to detect stage one pressure ulcers Although these technologies are not used by most nursing homes. They can be utilized The most promising advanced skin measurement technologies due to their not invasive methods and portability are thermography spectroscopy and portable ultrasound All three technologies do not require differentiation between light pink and dark reprimanded skin For example ultrasound is based on acoustic waves traveling through tissue Hence portable ultrasound is colorblind and not dependent on skin pigmentation. I Haven't heard about thermography. What is it? Thermography measures skin thermal patterns because blood flow causes the core body temperature to rise to the surface Alterations in blood flow may alter skin temperature It is believed that 95% of adults will only deviate about three Celsius from one anatomical location To the other thus permanent tissue trauma such as pressure ulcer should have a skin temperature variance as compared to the adjacent skin Spectroscopy is new to me as well. What's this all about? spectroscopy also called tissue reflectance spectrometer Measures blood content in the micro circulation of the skin by quantifying hemoglobin Dermatologists have long been interested in studying changes in skin color during and after treatment using this technology. I Have heard about ultrasound. Could you tell us more about this? Ultrason has been utilized for diagnosis over the last two decades However, only recently has it been applied to studying tissue damage and healing Dyson and colleagues used a high frequency and Ultrasound and therefore high resolution ultrasound to detect dermal response to pressure and to monitor wound characteristics such as depth edema Scar tissue and granulation tissue It's good to see how technology continues to advance in the areas of assessing and Evaluating the types of tissue changes that occur Now for our case study, we didn't use any of the newer technologies in assessing the skin changes How would you assess the skin integrity of mr. Smith? For mr. Smith who has light pink skin It was noted that he had a hyper remake areas on three turning surfaces that lasted approximately one hour At this juncture the nursing home staff decided to place him on a group to support surface to better We distribute his pressure You mentioned the use of group to support surfaces What different types of support services might a surveyor see used in nursing homes? The use of support surfaces on beds is an important consideration in helping to redistribute pressure It has long been believed that support services fall into two groups Pressure reducing support surfaces which reduce pressure But not completely below 32 millimeters of mercury and pressure relieving support services Which reduce pressure below 32 millimeters of mercury? However, within the last few years the world community has embraced the concept of pressure Redistribution which notes that since we can never totally relieve pressure The best we can do is redistribute pressure for example if we relieve pressure on the heels We will most likely increase pressure somewhere else on the body Group one devices are those support services that are static. They do not require electricity static devices include air Foam whether the foam is convoluted or solid gel and water overlays or mattresses These devices are ideal when a resident is at low risk for pressure ulcer development. They redistribute pressure May decrease sharing and are relatively inexpensive If foam is used it should be one point three pounds per cubic foot and greater than three inches Group two devices are powered by electricity or pump and are considered dynamic in nature These devices include alternating and low air loss mattresses These mattresses are good for residents that are moderate to high risk for pressure ulcers or have full thickness pressure Ulsers the advantages of alternating air mattresses include portability redistribution of pressure Reduction of sharing and they are moderately priced to purchase or rent the Disadvantage however of these mattresses is your inability not to reduce heat accumulation on the resident's body The advantages of low air loss mattresses are pressure reduction Low moisture retention and reduction of heat accumulation The disadvantage however of low air loss beds is that they can be expensive to purchase or rent Finally group three devices are also considered dynamic in nature This classification comprises only air fluidized beds These beds are electric and contain silicone coated beads When air is pumped through the bed the beads become liquid They are used for residents at very high risk for pressure ulcers More often they are used for residents with non-healing full thickness pressure ulcers Or when there are numerous truncal full thickness pressure ulcers The advantages of air fluidized beds are their ability to redistribute pressure and to reduce heat accumulation moisture retention and sharing forces the major disadvantages of these beds