general profile of pressure sores

8/6/2019 General Profile of Pressure Sores

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General profile of pressure

soresAshwani Gupta, Jiten Jaipuria

Department of General Surgery

V.M.M.C. and Safdarjung Hospital


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Surprise Surprise !!!!!! The Agency for Health Research and Quality

(AHRQ) recently released a survey showing a 63%increase in pressure ulcer occurrence in acute carehospitals from ```1993 to 2003 (Russo,2006)

WHY???? WHAT WENT WRONG?????......canyou guess. Lessons from history....answertowards the end of discussion

Pressure sores-The devil withinthe care.the problem profile


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In a review of 218 research articles (Lyder, 2002),

it was reported the cost of treatment to range from$500 to $40,000 per ulcer and that a singlehospital stay due to a pressure ulcer often exceeds$200,000 in costs. These financial considerationsfail to take into account the additional pain andsuffering experienced by the patients.

The Advisory Board Company estimated that60,000 deathseach year are associated with complications from

pressureulcers (Hiser, 2006; Brem & L der, 2004).

Problem statement contd


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Risk factors for pressure ulcer development and theirprofile differ significantly across different healthcare scenarios with an underlying commondenominator underscoring the necessity tounderstand the pathophysiology of their

development. In acute care settings the incidence is highly variable-

5% to 15% (some reporting even higher values)

In long term settings the incidence varies between20% to 33%

In home care settings incidence varies between 0% to17%

Some wards have reported 0% pressure ulcer ratesfor long periods of time!!!!

Some obstetric wards have reported pressure ulcerrates in excess of 0.2% with a bias towards under

reporting!!!!! What is gong on?? Why is the risk so variable????

Pressure sores are they similar acrossdifferent settings.the clinical

epidemiological profile


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Patients at risk of pressure ulcer development PROBLEM AREA 1 Traditionally certain patient subgroups have beenconsidered to be high risk for pressure ulcer

development -Elderly-Those with physical impairments due to amultitude of causes (neurological deficits, polytrauma, malignancies, thermal burns etc.)

Traditionally physicians and nurses undertook amore specific assessment of pressure ulcerdevelopment in only these specific settings oftenidentifying points for intervention too late whenmanifest pressure ulcers emerged.

FORGOT PREVENTION, DIDNT VALUEPATHOPHYSIOLOGY

What is the profile of the patient who is atrisk of pressure ulcer develoment


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Any patient who is bed fast and or chair fastshould be considered at risk for pressureulcer development.*

So dont harp on the illness in the scenario-offer screening assessment to all patientswith above risk characteristics points ofintervention will obviously depend on the

illness in scenario.

*latest NPUAP and EPUAP pressure ulcer prevention guidelines

* Did you realize the pathophysiologic basis underlying this zealoussearch ????

So Finally. What is the profileof patient at risk.??


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CAUTION -1

Pressure ulcers take hours to develop butmay take >7 days to manifest.

(what is seen today may be the result ofminor neglect in continuum of patient care

many days ago) CAUTION -2

Destruction in deeper tissues may be morethan what is apparent on the surface

Presentation profile of pressureulcers-


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THANK YOU 1962 THANK YOU 1987 There have been a multitude of scales available for

researchers which are still being validated acrossdifferent clinical scenarios.

But EPUAP and NPUAP have suggested following scalesto be used across different clinical profiles

GENERAL SURGICAL PATIENT - BRADEN SCALE* INDIVIDUAL RECEIVING PALLIATIVE CARE - Marie Curie

Centre Hunters Hill Risk Assessment Tool ORBraden Scale OR Norton Scale.

PEDIATRIC PATIENTS BRADEN Q SCALE. ICU PATIENTS Cubbin Jackson Scale**

**this scale and clinical scenario is not mentioned in the EPUAP and NPUAP clinicalguidelines.

*this scale has also been validated in an ongoing study in similar subset of Indianpatients (163) in Safdarjung Hospital Assessment of risk factors inpressure sores-A Tertiary Care Centre Experience, Chintamani,

Kashish,Aliza mittal, BhatnagarD Department of Surgery, Vardhman Mahavir

Medical College & Safdarjang Hospital, New Delhi

OF COURSE NOW WE DECIDED TO ASSESS FORRISK..but IS THERE ANY RISK ASSESSMENT TOOL

WHICH QUANTIFIES THE RISK IN A PARTICULAR CASEAND IS SAME RISK ASSESSMENT TOOL APPLICABLE TO

ALL PATIENT PROFILES????


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BRADEN Scale forpredicting pressure sore

riskSENSORYPERCEPTION

Completelylimited

Very limited Slightly limited No Impairment score

MOISTURE ConstantlyMoist

Very Moist Occasionallymoist

Rarely Moist

ACTIVITY Bedfast Chairfast WalksOccasionally

WalksFrequently

MOBILITY Completelyimmobile

Very limited Slightly limited No limitation

NUTRITION Very Poor ProbablyInadequate

Adequate Excellent

FRICTION &SHEAR

Problem PotentialProblem

No apparentProblem


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PROBLEM AREA 2 - Strangely, this will NEVER HAPPEN with this

measure alone There is no decrease in pressure ulcer incidence

was found which might be attributed to use ofan assessment scale.

However, the use of scales increases theintensity and effectiveness of prevention

interventions *

Why ??? Further answers in anatomical andpathophysiological and psychosocial profiles ofpressure sores and the derived prevention andtreatment philosophy.

*PANCORBO-HIDALGO P.L. , GARCIA-FERNANDEZ F.P. , LOPEZ-MEDINA I .M. & ALVAREZ-NIETO C. (2006) Journal of Advanced Nursing 54(1), 94110 Risk assessment scales for pressure ulcer prevention: a systematic review

GREAT NOW I WILL USE SCALES, NOW THEULCER INCIDENCE WILL BE ZERO !!!


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FIRSTLY OBVIOUS FACTS


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Where do ulcers develop most when aperson is supine

Anatomical profile of pressuresores


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Where do pressure ulcers develop when apatient is wheelchair bound


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Which part of body is expected to be mostvulnerable in case of pediatric patients

Which parts of body are expected to be mostvulnerable in case of parturient females.

Be careful to assess while grading pressure soresin areas where there is little fat. (depth can bemisleading)

GOD HAS HELPED ALREADY (3d anatomicalprofile of human anatomy) CAN YOUHELP????

Anatomical profile of sores


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What if this patient is turned laterally 90degrees or what if the head end is raised

Concept of friction and shear forces and role

while transfers and turning (did you know that theconcept of continuing care in pressure ulcer patients in transition fromone point of care to another evolved only recently and is yet to acquire acommon place status )

CAN YOU SEE THE BASICPHYSICS OF BAD POSITIONING

TECHNIQUES -


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a e ergonom cs o spatient in the wheel chair are

altered?(did you know that guidelines for wheelchair bound patients were first widely

issued as late as in 2007)


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Can you see how patient is vulnerable to multiple bed sores atthe same time.

Actually the average number of bed sores noted over a periodof time in persons susceptible to bed sores is >1 (1.7 inmany studies)

Can you see how effects of nearby areas can alter themicrobiological profile of bacteria found in pressure sores ( Ecoli in wounds near the anus) (beta hemolytic streptococciand coagulase negative staph in wounds over occiput andother areas). Surprisingly pseudomonas aeruginosa isinfrequently found in pressure ulcers found in Indian studies(unless cocomitantly diabetes was present) *. Many bacteriamay be present in chronic wounds which may be mere

contaminants and colonisers but not critical colonisers orinfective (how about acinetobacter isolated in nonprogressive and slowly healing wounds)

* A Prospective, Descriptive Study to Identify the Microbiological Profile of ChronicWounds in OutpatientsOstomy Wound Management VOLUME: 55 Issue Number: 2009;55(1)author: Somprakas Basu, MS; Tetraj Ramchuran Panray, MBBS; Tej Bali Singh, PhD; Anil K.

Gulati, MD; and Vijay K. Shukla, MS, MCh(Wales), FAMS

Obviously apparent facts fromabove data in the presentation

profile


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Can you see how complex issue of psychosocialstatus and family support can affect the simpleissue of positioning of the patient.

What if the patient is unable to afford higher endmattresses. What if he was the sole breadwinner.

What if the patient to bed ratio is too high. What if the genetic and nutritional profile of the

population in question different from thewestern standards. What if clinical care givers are not following the

recommended guidelines. What if the quality of nursing care is poor. What if the patient and attendants are

uneducated and are difficult to initiate intocomplex education process of woundprevention.

What if the patient is too depressed to followcommands.

WELCOME TO THE GREAT INDIAN SCENARIO


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It became clearly apparent to policy makersupon closer inspection that expensivemattresses and elaborate scoring systemsalone would give unsatisfactory results ifcontinuing care philosophy at all points ofhealth care including home did not includethe comprehensive elements of patienteducation and training, health provider

awareness, structured risk assessment,skin care and appropriately goal directedinterventions including nutritionalinterventions.


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Dictum - 1

It is obsolete to think in terms ofpreventable and non preventable pressure

ulcerations All pressure ulcers are now seen as

preventable except in the rarecircumstance of terminally ill patient nearthe end of life who refuses nutrition

Re evaluation of profiles of patients with riskfor/presence of pressure ulcerations in the light of

new understanding


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Risk factors common to


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Risk factors common topatients across all profile

characteristics


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Annual incidence rates in developed world 20% to 30%and prevalence rates 10% to 30% with most commonsites being ischium, sacrum and trochanter.

25% of pressure ulcers in the community were classified assevere (Grade 3 or 4).

Other epidemiological studies indicate that 36% to 50% ofpersons with SCI who develop pressure ulcers willsubsequently develop another ulcer within 1 yearfollowing initial healing.

Individuals with paraplegia have the highest rate of recurrence, estimated at 80% (Wilhelmi &Neumeister,2002).

Our experience at Safdarjung Hospital (83 patients)

Patients with polytraumaand spinal cord injury as a groupdeveloped pressure ulcers more commonly than othergroup of patients.

Hemiplegics were least prone to develop pressure ulcersover the duration of hospital stay.

Paraplegic patients constituted the maximum number of

patients in the cohort but were found to develop pressureulcers at a rate similar to quadriplegics over the duration

Pressure ulcer characteristics in specificscenarios spinal cord injuries and neural

deficits


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Interesting insight into the behavioral patterns and risk of developingpressure ulcers once patients with SCI are discharged home

Patients who remain ulcer free perform on an

average 7.8 transfers from the wheelchair ascompared to 4.2 transfers for the patients whofrequently develop ulcers.

Patients who remained ulcer free were morelikely to be found with a positive employment

status. Finally, each group was asked what self-practices

they believed to be the most important inpreventing serious pressure ulcers. Statisticallysignificant differences betweengroups,ps < .05, were noted for three success factors:Participants in the ulcer-free group were morelikely to identify general activity level orsquirming (shifting in their chair) andsensation in the buttocks as important successfactors; those in the pressure ulcer group weremore likely to identify frequent skin checks and

Wh t i t ti l f d i


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96.3% of patients enrolled into the studyreceived satisfactory physiotherapy but yetdeveloped pressure ulcers.*

Most of the physiotherapy in Indian setting wasfound to be provided by the relatives.*

It was strangely noted that 54% of the patientswith duration of stay


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Over 163 patients that were studied datawas showing a heavy gender bias towardsmales

Overall profile of patients developingpressure ulcers in a tertiary care hospital

(V.M.M.C. & S.J.H.) in India -


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HE AGE AND SEX DISTRIBUTION OF THECOHORT ( = )163

= .Mean age 44 52ears= -Range 7 90years

( )AGE YRS

Distribution of Cases According to Diagnosis


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Distribution of Cases According to Diagnosis

.

No

Of

Pa

ti

en

ts


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.rade 1 Non blanchable erythema with intact skin- . .rade 2 Partial thickness skin loss i e epidermis is interrupted an , .brasion blister or shallow crater-rade 3 Full thickness skin loss involving damage of subcutaneousissue that .ay extend to the underlying fascia- ,rade 4 Full thickness skin loss with extensive destruction tissueecrosis or , .amage to muscle bone or supporting structures

*

*


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OMORBID CONDITIONS

(One patient may have more than one

condition)atients with comorbid conditions eveloped higher grade of( / ).edsores 3 4[ = . ; = ; = . ]Chi Square 8 34 df 1 p 0 0038


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OBSERVATIONS:

n = 163 Mean Age = 44.52 yrs. , Range - 7 to

90 yrs.

Mean Duration of Hospital Stay = 4.25

Weeks Mean Time Interval (Between

hospitalization and development of

bedsores ) = 1.88 weeks 86.53% were anaemic , Average

Hb=9.27gm%

Average Waist Hip Ratio = 0.848(Range

0.7 to 1.2),


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The Braden scaleAssessment

( )CALE 6 TO 23=AVEARGE .3 12


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BRADEN SCALE SCORE V/SPRESSURE SORE GRADE

BRADEN SCALESCORE

GRADE 1, 2 GRADE 3, 4

>15 13 25

< 15 62 63

,h e l ow er th e B r a d e n s s c al e sc or e th ei g he r is t h e r i s k f o r de v e l op in g p r e s s u r e.o r e s < , ,a t ie nt s w it h s c o r e 1 5 d e ve lo p g ra de 3 4r e ss ur e s or e m o r e o f t e n t h a n th os e w i t h a> (score 15 chi

s = . , = , = .quare 3 977 df 1 p 0 0461)

AGE V/S GRADE


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AGE V/S GRADE

AGE( )years

- . - .,It was observed that in the age group of 21 40yrs and 41 60yrs/ / .patients more often developed grade 2 3 bed sores than grade 1 4 No

.significant association was found between the age and the grade


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54% of the patients with duration of stay


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In addition to the usual risk factors, certain additional risk factors havebeen identified

history of vascular disease

treatment with Dopamine or Dobutamine, intermittent haemodialysis(IHD) or continuous veno-venous haemofiltration (CVVH)

mechanical ventilation.

Also preventive measures were statistically positively associated withpressure ulcers grade 2-4: turning, floating heels, alternatingmattresses, adequate prevention.*

But some recent studies have concluded that There is no relationshipbetween pressure ulcer development and APACHE II score, or anymedication that affects skin integrity. The frequency of turning andrepositioning and patients with an emergency admission to the

ICU/HCU can be the prognostic indicators for developing scoringsystem in critical care settings. Relevance to clinical practice**

*Incidence and risk factors for pressure ulcers in the intensive care unit

Patient profile characteristics of patientsdeveloping pressure ulcers in ICU

general profile of pressure sores

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