Skin Failure Avoidable vs Unavoidable Pressure Ulcers and

Skin Failure, Avoidable vs. Unavoidable Pressure Ulcers and Treatment Strategies: Are We Using Evidence-Based Practice? Chuck Tilley MS, ANP-BC, ACHPN, CWOCN

Objectives Discuss the concept of skin failure in the chronically ill and in terminally ill hospice patients and the development of Kennedy Terminal Ulcers Describe various position statements regarding avoidable vs. unavoidable pressure ulcers Discuss the use of some traditional pressure ulcer prevention and treatment strategies: are they evidence-based? Review a typical hospice patient’s course of treatment and identify best practices used and/or missed opportunities to utilize evidence-based strategies

Skin Failure: Fact or Fiction? First used in the literature by La Puma 1991 “An event in which the skin and underlying tissue die due to hypoperfusion that occurs concurrent with severe dysfunction or failure of other organ systems”. (Langemo & Brown, 2005)

Skin Failure: Fact or Fiction? Pathophysiology: “As a body shunts blood and nutrients to vital organs such as the heart, lungs, and kidneys, it shunts blood away from the periphery or the skin” “Damaged tissue loses its tolerance to pressure and trauma and cannot assimilate nutrients causing more tissue damage and, ultimately, necrosis” (Goode & Allman, 1989)

Chronic Skin Failure “Skin and underlying tissue die d/t hypoperfusion concurrent with an ongoing, chronic disease state” Elderly, DM, HF, CKD, MS, ALS, Paraplegics, Quadriplegics, AIDS Combination of age-related declines and chronic co-morbidities accelerate loss in functioning (Langemo & Brown, 2005)

End-Stage Skin Failure “Skin and underlying tissue die d/t hypoperfusion concurrent with end of life” (Brown, 2003) “ 62. 5% of pressure ulcers in hospice patients occurred in the 2 weeks before death” (Brown, 2003) Occurrence of skin failure, like any other organ system failure, should be used to establish goals of care and future treatment (Langemo & Brown, 2005)

Kennedy Terminal Ulcers Characteristics: Pear, butterfly or horseshoe shaped Usually develops on the sacrum Color may be red, yellow, purple or black Skin is almost always intact and looks at times almost like a black blood blister Borders of the ulcer are usually irregular Sudden onset. Starts out larger than other pressure ulcers, usually more superficial initially, and develops rapidly in size and depth Treatment for a Kennedy Terminal Ulcer is the same as if would be for any other pressure ulcer Tends to be a geriatric phenomenon. Reported frequently in hospice patients Patients have a history of dying within 8 -24 hours of development (Schank, 2009)

Kennedy Terminal Ulcers (Schank, 2009)

Avoidable vs. Unavoidable Pressure Ulcers: CMS Centers for Medicare and Medicaid (2004) Avoidable Unavoidable …. facility did not do one or more: • evaluate the resident’s clinical condition and pressure ulcer risk factors • define/implement interventions consistent with resident needs, goals, and recognized standards of practice • monitor and evaluate the impact of the interventions • revise the interventions as appropriate …. even though the facility: • had evaluated the resident’s clinical condition and pressure ulcer risk factors • defined/implemented interventions consistent with resident needs, goals, and recognized standards of practice • monitored and evaluated the impact of the interventions • revised the interventions as appropriate

Avoidable vs. Unavoidable Pressure Ulcers: WOCN Wound, Ostomy, and Continence Nurses Society, 2009 • Published a position paper in 2009 ; “There are clinical circumstances in which a pressure ulcer is unavoidable” • The presence of pressure ulcers can suggest an overall deterioration in the medical condition (included in hospice criteria) (Langemo et al. , 2006; Witkowski et al. , 2000) • In the case of palliative care, pressure ulcer prevention may be displaced by the greater need for comfort and the family’s need for support. Many pressure ulcer interventions may be inappropriate if the measures cause intractable pain or undue family burden near end of life (Brink, Smith, & Linkewich, 2006; Reifsnyder & Magee, 2005)

SCALE Skin Changes At Life’s End, 2008 • Some skin changes, including pressure ulcers, at end of life are unpreventable • SCALE is a reflection of compromised skin (reduced soft-tissue perfusion, decreased tolerance to external insults, and impaired removal of metabolic wastes • Risk factors, symptoms, and signs associated with SCALE may include suboptimal nutrition, including loss of appetite, weight loss, cachexia and wasting, low serum albumin/prealbumin levels, and low hemoglobin, as well as dehydration. • Expectations around the patient’s end-of-life goals and concerns should be communicated among members of the interprofessional team and the patient’s circle of care

Adult FTT Patient: Admission Case: 82 yo female with a history of NIDDM, HTN, CKD Stage III, HLD, Vascular Dementia and weight loss of 20 lbs over 5 months admitted to a hospice residence with a L Trochanteric Stage III pressure ulcer s/p 1 week stay at a local hospital for a fall at home with surgical pinning of R hip Advance Directives: DNR/DNI/DNH, HCA: husband, HCP states she doesn’t want artificial nutrition/hydration: no tube feeds, IV fluids/TPN Functional: A & Ox 1, bedbound, total care for all ADLs, incontinent of B & B, eats 25 -50% of most meals (NAS, NCS diet), frequently spits out meds, egg crate mattress, uses adult diapers and soap and water to manage incontinence

Adult FTT Patient: Admission Pain: Moans and calls out with facial grimacing when turned- especially onto R hip: turns self onto left side where she appears comfortable PE: Dry flaky skin, poor turgor, oral mucosa slightly moist, cachectic, temporal wasting, observed intermittently coughing after meals, incontinent of urine Q 2 H, stools at least twice daily VS: 132/86 98 -88 -20 FS range: 244 -288 BMI: 18. 1 Braden Score: 9 Labs: Albumin 2. 0

Adult FTT Patient: Admission Orders: Advance Directive: DNR/DNI/DNH Diet: NCS, NAS Pureed consistency Aspiration precautions, Nutrition consult Activity: Bedrest, T & P Q 2 H VS: Routine Weights: Weekly Wound Care: Hydrocolloid L Hip Q 72 H Meds: MVI 1 po daily, Zinc 220 mg po daily, Vitamin C 500 mg po BID, Lisinopril 10 mg po daily, Metphormin 500 mg po BID, Metoprolol 25 mg po BID, Tylenol 650 mg po/PR Q 6 H PRN Therapy: Swallow evaluation for diet recommendations

Adult FTT Patient: Day 21 Course: Developed Aspiration PNA with deterioration in VS (profound hypotension) and neurological function. Developed a sacral Kennedy Terminal Ulcer which was found on Day 19. L Trochanteric wound deteriorated to a Stage IV pressure ulcer with periwound Incontinence Associated Dermatitis (IAD). Day 21 patient expired. BMI: 17 Functional: Despite being changed every two hours she is frequently found wet (incontinence care with adult diapers and soap and water), despite T & P she continued to migrate to L Trochanter for comfort, egg crate mattress,

Adult FTT Patient: Day 21 Orders (Day 19): Wound Care: Hydrocolloid Q 72 H to both wounds Meds: Vitamin C 500 mg po BID, MVI 1 po daily, Zinc 225 mg po daily, Augmentin 875 mg po BID x 10 D, Roxanol 5 mg po/sl Q 2 H PRN pain/tachypnea/dyspnea Diet: NPO except meds Incontinence Care: Attends, soap and water Oxygen: O 2 2 L NC humidified

WOCN Guideline Recommendations WOCN developed a Guideline For Prevention and Management of Pressure Ulcers first published in 2003 then updated in 2010 Examined the evidence surrounding pressure ulcer prevention and treatment with recommendations based on an extensive literature review with over 300 articles reviewed

WOCN Guideline Recommendations Level A: Two or more supporting RCTs of at least 10 humans with pressure ulcers, a metaanalysis of RTCs, or a Cochrane Systematic Review of RCTs Level B: One or more supporting controlled trials of at least 10 humans with pressure ulcers or two or miore supporting non-randomized trials of at least 10 humans with pressure ulcers Level C: Two supporting case series of at least 10 humans with pressure ulcers or expert opinion

Evaluating the Plan of Care: Evidence-based? Risk Identification: Use of a valid and reliable risk assessment tool is recommended (Level of Evidence = B) Risk assessment should be performed upon entry to a health care setting, and repeated on a regularly scheduled basis, or when there is a significant change in the individual’s condition. (Level of Evidence = C) (WOCN, 2010) The Braden, the Norton and Waterlow PU risk assessment scales have been found valid for the prediction of PU risk in a variety of health care settings and in multiple countries Hospice is identified as an appropriate unit to administer the Braden Scale (Bolton, 2007)

Evaluating the Plan of Care: Evidence-based? Nutrition: Routine Vitamin C & Zinc supplementation Vitamin C: “The use of Vitamin C and Vitamin A supplementation remains unproven”. (Gray & Whitney, 2003; Gray, 2003) Zinc: “There is no evidence to conclude that routine administration of supplemental zinc will promote healing of pressure ulcers. In fact, doses of zinc greater than 40 mg per day may effect copper levels with possible anemia” (NPUAP/EPUAP, 2009)

Evaluating the Plan of Care: Evidence-based? Turning and positioning: Q 2 H Repositioning and turn; regularly and frequently (Level of Evidence C) (WOCN, 2010) The frequency of repositioning is unknown and lacks scientific evidence (Moore & Cowman, 2009; Pieper, 2007)

Evaluating the Plan of Care: Evidence-based? Dressing Selection: Hydrocolloids Studied more than any other dressing Recommended Stage II and IIIs with minimal depth (NPUAP/EPUAP, 2009) May be undermined by urine or stool and can aggravate wounds/IAD etc.

Evaluating the Plan of Care: Evidence-based? Support Surfaces: Egg Crate Mattress Pressure redistributing surfaces are recommended for individuals with full thickness or ulcers that involve multiple turning surfaces (Nix, 2007) For patients with a large stage III or IV pressure ulcers or ulcers on multiple turning surfaces; a lowair-loss or air-fluidized surface may be indicated. (Level of Evidence B) (WOCN, 2010)

Evaluating the Plan of Care: Evidence-based? Incontinence Care: Soap and Water/ Adult Diapers Use of soap is discouraged as it is more alkaline and causes skin irritation Consider using briefs when out of bed and underpads when in bed to minimize moisture and heat trapping p. H-balanced perineal skin cleanser and barrier ointments are recommended for incontinence care Indwelling Foley: Indicated for stage III-IV pressure ulcers (WOCN, 2011)

What Do You Think? Did we: ▪ Evaluate risk factors? ▪ Follow established standards of practice? ▪ Consider patient’s goals of care? ▪ Monitor, evaluate and revise interventions? Was the deterioration of the L Trochanteric pressure ulcer avoidable or unavoidable? Was the Kennedy Terminal Ulcer avoidable or unavoidable?

References Bolton, L. (2007). Which pressure ulcer risk assessment scales are valid for use in the clinical setting? Journal of Wound, Ostomy and Continence Nursing, 34(4 ). 368 -381. Brown, G. (2003). Long-term outcomes of full thickness pressure ulcers: healing and mortality. Ostomy Wound Management, 49, 42 -50. Centers for Medicare and Medicaid Services. (2004). Guidance to surveyors for long term care facilities (CMS Manual Pub. 100 -07 state Operations). Washington, DC: Author. Retrieved November 1, 2012 from http: //www. cms. hhs. gov/transmittals/Downloads/R 4 SO M. pdf

References Goode, P. S. & Allman, R. M. (2003). The prevention and management of pressure ulcers. Medical Clinics of North America, 1989, 1511 -24 Gray, M (2003). Does oral zinc supplementation promote healing of chronic wounds? Journal of Wound, Ostomy and Continence Nursing, 31(4): 157 -60. Gray, M. , & Whitney, J. D. (2003). Does vitamin C supplementation promote pressure ulcer healing? Journal of Wound, Ostomy and Continence Nursing, 30: 245 -249.

References La Puma, L. (1991). The ethics of pressure ulcers. Decubitus, 4, 43 -4. Langemo, D. , & Brown, G. (2006). Skin fails too: Acute, chronic, and end-stage skin failure. Advances In Skin & Wound Care, 19, 206 -211. Kennedy, L. Kennedy Terminal Ulcer (2004, August 14). Retrieved November, 11 2012 from http: //kennedyterminalulcer. com/index. html

References Krasner, D. (1995). The chronic wound pain experience: A conceptual model. Ostomy Wound Management, 41, 20 -29. Moore, Z. , & Cowman, S. (2009). Repositioning for treating pressure ulcers. Cochrane Data base of Systematic Reviews, 2, CD 006898 Mortimer, P. S. (1998). Management of skin problems: Medical aspects. In D. Hanks & N. Mac. Donald (Eds. ), Oxford Textbook of Palliative Medicine (2 nd ed. , pp. 61727). Oxford: Oxford University Press.

References National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel (NPUAP/EPUAP). (2009). Prevention and treatment of pressure ulcers: Clinical practice guideline. Washington, D. C. : National Pressure Ulcer Advisory Panel Nix, D. (2007). Support Surfaces (2007). In R. Bryant and D. Nix (Eds. ), Acute and Chronic Wounds: Current Management Concepts, 3 rd ed. St. Louis, MO: Mosby Elsevier. Pieper, B. (2007). Mechanical forces: Pressure, shear and friction. In R. Bryant and D. Nix (Eds. ), Acute and Chronic Wounds: Current Management Concepts, 3 rd ed. pp. 205 -235. St. Louis, MO: Mosby Elsevier.

References Schank, J. (2009). Kennedy Terminal Ulcer: The “Ah-Ha!” moment and diagnosis. Ostomy Wound Management, 15; 55(9): 40 -4. Sibbald, G. , Krasner, D. , Lutz, J. (2011). Tip the SCALE toward quality end-of-life skin care. Nursing Management, 42(3): 24 -32. Wound, Ostomy and Continence Nurses Society. (2007). The WOCN image library [Image database]. Retrieved from http: //images. wocn. org

References Wound, Ostomy and Continence Nurses Society. (2009). Position paper: Avoidable versus unavoidable pressure ulcers. Glenview, IL: Author Wound, Ostomy and Continence Nurses Society. (2010). Guideline For Prevention and Management of Pressure Ulcers. Glenview, IL: Author Wound, Ostomy and Continence Nurses Society. (2011). Incontinence Associated Dermatitis (IAD): Best Practice for Clinicians. Mount Laurel, NJ: Author