Transcript The Importance of Clinical Oral Care

Heel Pressure Ulcers
Prevalence, Cost, Etiology
and Risk Factors
Anatomic Locations of Pressure Ulcers
Occiput
1. Sacrum
36.9%
2. Heel
30.3%
3. Ischium (sit bone)
8.0% Elbow
4. Elbow
6.9% Trochanter
5. Malleolus (ankle bone) 6.1%
Ischium
6. Trochanter (hip bone) 5.1%
7. Knee
3.0% 30.3%
8. Scapula (shoulder blade) 2.4% Heels
Malleolus
9. Occiput (back of head) 1.3%
Amlung SR, Miller WL, Bosley LM, Adv Skin Wound Care. 2001 Nov/Dec;14(6):297-301.
Scapula
Sacrum
Knee
Heel
Prevention – Who is at risk?
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ICU population
Orthopedics
Neurosurgery
LTC Units
Co-morbidities: PVD, Diabetes, Immobility
The “Vent” patient (7M days*)
Operating Room – 2 hour+ procedures
*Source: Principal Procedure outcomes for respiratory intubation and ventilation: Healthcare
Cost and Utilization Project (HCUP), 2004, http://hcupnet.ahrq.gov/HCUPnet.jsp
Diabetes
• Affects 16 million Americans
• Millions at risk for skin breakdown
• 15% of diabetics develop foot ulcers
• Foot lesions = #1 reason for hospitalization
• Lower extremity amputations 15 times more
likely to occur in diabetics vs. non-diabetic
Mulder G, Armstron D, Seaman S, Wounds 15 (4):92-106, 2003
Diabetes
• The total direct and indirect cost of care
related to diabetes is estimated to be $98
billion dollars.
• Non-operable treatment of diabetic ulcers
ranges from $7,000-$8,000
• Infected Ulcers - $17,000-$18,000
• Amputation - $45,000
Mulder G, Armstron D, Seaman S, Wounds 15 (4):92-106, 2003
Facts About Pressure Ulcers
• 93% of pressure ulcers in hospital are Stage I or Stage II.1
• 30% of Pressure injury is on the heel.2
• Typical facility will spend between $400K and $700K annually on pressure ulcer
treatment.3
• Estimated cost to heel stage 1,2 or 3 is between $2,000-$30,000 and $70,000 for
full-thickness wounds.2
• JCAHO lists prevention of health care
associated pressure ulcers as a patient
safety goal.4
• Over a boney prominence.5
• CMS will not pay unless POA 10/2008.
1. Whittington KT, Briones R, “National Prevalence and Incidence Study: 6-Year Sequential Acute Care Data,” Adv Skin Wound Care. 2004 Nov/Dec;17(9):4904. 2. Amlung SR, Miller WL, Bosley LM, Adv. Skin Wound Care. 2001 Nov/Dec; 14(6): 297-301. 3. Robinson, C; Gioekner, M; Bush, S; Copas, J; et al.
Determining the efficacy of a pressure ulcer prevention program by collecting prevalence and incidence data: a unit-based effort. Ostomy Wound Manage. 2003.
May: 49(5):44-6. 48-51.4. http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_ltc_npsgs.htm.
5. 
Joan Junkin, MSN, RN, CWOCN, BryanLGH Medical Center
The CMS 10 Commandments:
If It’s Not POA, We Won’t Pay
1. Pressure Ulcers
2. Catheter-associated urinary tract
infections (UTI)
3. Objects left in surgery
4. Air embolism
5. Blood incompatibility
6. Vascular-catheter associated
blood stream infection
7. Surgical site infections:
Mediastinitis (after CABG), certain
orthopedic procedures and
bariatric surgeries
8. Falls
9. Deep Vein Thrombosis (DVT)
10. Poor glycemic control
Federal Register, Vol 73, No. 161 pgs: 48473-48474 , August 19, 2008
Who is Focused on Skin Breakdown?
CMS State Operations Manual, F314
“Because the heels and elbows have relatively little surface area,
it is difficult to redistribute pressure on these two surfaces.
Therefore, it is important to pay particular attention to reducing
the pressure on these areas for the resident at risk in accord with
resident’s overall goals and condition.”
“Based on the comprehensive assessment of a resident, the
facility must ensure that-(1) A resident who enters the facility without pressure sores does
not develop pressure sores unless the individual’s clinical
condition demonstrates that they were unavoidable; and
(2) A resident having pressure sores receives necessary
treatment and services to promote healing, prevent infection and
prevent new sores from developing.”
Centers for Medicare & Medicaid Svcs, CMS Manual System, Pub. 100-07 State Operations, Provider Certification, Appendix PP Guidance to Surveyors for
LTC Facilities, F314 483.25(c) Pressure Sores, (Rev. 4, Issued/Effective 11-12-2004). Dept of Health & Human Svcs, Transmittal 12, 14 Oct 2005:144
(available at new.cms.hhs.gov/transmittals/downloads/R12SOM.pdf).
Heel Ulcer Prevention: Current Practice
• Pillows…nursing standard
• Booties…many
• Orthotics…doctor and clinician request and expensive
• Prevention…protocols: too general or inaccurate. Ownership.
• Treatment…ulcers and foot drop
• Nothing…
Heel Protector or Orthotic?
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DM Systems
Gaymar
KCI
Spanamerica
EHOB
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Hollister
Posey
L’Nard
Anatomical
Concepts
• DeRoyal
• Multi Podus
What is a Heel Protector?
“Sheepskin”
Pillow-based
“Bunny” boot
Foam-based
Air-based
Rigid splints
Current Protocol ?
Especially Important:
•Mobility
•Activity
Simple Intervention,
Extraordinary Outcomes
Jill Walsh, JWOCN March 2007
• Objective: To identify risk factors (Braden
score and co-morbidities)
• Study Method: Two year Retrospective
chart review of patients admitted with or
developed heel ulcers. Pts. on HU Prevention
protocol for 10 days. Braden + co-morbidity.
Compared Prevalon to Waffle-boot
• Results: 53 patients. 0 Heel Ulcers. 8 hip
fractures. Prevalon preferred: comfort, warmth,
heel protection, DVT compression compatibility.
• Conclusion: Heel Ulcer prevention protocol
(Braden’s 16-18 and co-morbidities) and the use
of a pressure-relieving device is effective in
reducing the rate of heel pressure ulcers. Prevalon
outperformed the ‘control’ product
(p>.05; stat. sign.)
Evaluation of a Protocol for
Heel Ulcer
Retrospective Chart Review (24 mo.)
National Avg. for Heels =30%
Protocol- Who gets boots?
Braden Scale 16 or Lower
Braden Scale 18 + 1 co-morbidity
Walsh J, et al., Keeping Heels Intact: Evaluation of a protocol for prevention of facility-acquired heel pressure ulcers.
Adventist Hinsdale Hospital, IL. Poster presented at the Symposium on Advanced Wound Care, San Antonio, TX. April, 2006.
Prevalon® Case Study
Denice Garrett, WOCN
Salem Village Nursing and
Rehab Center Joliet, IL
• October 2004, patient admitted
with severe contractures to his
knee and existing heel ulcer and
lateral malleolus
• July 2005, a skin graft was
performed which did not take
• In total, two years were spent
trying to heal ulcer with no
success
http://www.sageproducts.com/education/pmedia.asp
Prevalon® Intervention
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October 2005 Prevalon launched at
Advances in Skin and Wound Care
Conference in Las Vegas (Denice
received sample)
December 2005, surgeon recommends
amputating leg above the knee
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Denice Garrett, WOCN inspired by
Prevalon and thinks this may help her
patient
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Denice pleads with family to try
Prevalon for one month before
amputation
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After success in the first month, family
granted clinicians another month to
continue treatment.
Garrett D, Salem Village Nursing and Rehab Center, Joliet, IL
Patient Outcomes
• At the end of the second month,
the wound was closing for the
first time in two years
• Wound completely healed in May
‘06
• Only intervention changes were
using the Prevalon boot and
silver alginate for wound dressing
Vicki Burda Poster Presentation at
SAWC in APRIL 2007
Three Key Take-Aways:
1)
Prevalon significantly reduces the risk of developing heel pressure ulcers in a
high-risk population – 95% reduction of heel ulcer incidence! (From 39 to 2)
2)
Positive outcomes attributed to protocol and Prevalon
3)
Process improvement for heel ulcer prevention can be effective
Poster Presentation at 2007 WOCN
by Dr Harriett Loehne
Three Key Take-Aways:
1)
Prevalon® effective for treatment and prevention of heel ulcers
2)
0 Heel pressure ulcers during 10-week trial on 8 “high-risk patients”
3)
Staff and patients prefer: Standardized all units to Prevalon
You’ve Got Nerve!
Nerve Wedge…
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The peroneal nerve takes origin
from the sciatic nerve The nerve
divides:
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Deep branch supplies the anterior
compartment of the lower leg and
the muscles that dorsiflex the foot.
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Superficial branch supplies the
peroneus longus and brevis and
then becomes a sensory branch
supplying the top of the foot.1
•The Nerve Wedge limits external rotation
and potential damage to nerve – which can result in foot drop
1 Source:
http://www.microsurgeon.org/peroneal_nerve.htm
Contracture Strap
Plantar Flexion Contratures: ‘Heel Chord’/ “Achilles Tendon”
“The problem, called “heel cord shortening,” can result in foot drop…
Prevalon® helps prevent Achilles tendon shortening by maintaining the
foot at 90o while the patient is in bed”.
Strap helps maintain
position to reduce risk of
contractures
Saving heels in critically ill patients Cuddigan J, Ayello E, Black J World Council of Enterostomal Therapists Journal
Prevalon® with Wedge
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Prevents Pressure Ulcers of the Heel!
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II.
Stays in Place!
Floats the Heel!
Stretch Panel – No Trauma!
Reduces Risk of Plantar Flexion
Contractures!
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Foot Remains Upright!
Contracture Strap Adjusts Tension
Boot is Stabilized; Nerve Wedge
Tina Meyers BSN, RN, CWOCN, ACHRN
Harris County Hospital District, Houston, Texas
• Title: Successful Prevention or Heel Ulcers and Plantar Flexion
Contractures in High Risk Ventilator Population
• Objective: Targeted reduction of heel injury and plantar flexion
contractures in the sedated, ICU patient
• Intervention: Use of heel protector with contracture strap on 53 high
risk patients
• Results: 0 PF contractures; 0 Heel Ulcers; 5 patients with abnormal
ankle ROM improved; Revenue Preservation of $1.9MM
• Conclusion: New Heel Protector with Contracture Strap effectively
reduced the risk of heel ulcers and PF contractures in 53 patients
Presenting at NPUAP Educational
Conference; March 2009 Washington DC
Presented at World Union of Wound
Healing Society Meeting in Toronto, May 2008
Head over Heels
Evonne Fowler, Suzy Scott-Williams
•CMS
•NPUAP
•Decision Tree
•Question to ask when
deciding if patient needs
a heel protector: Can the
patient lift his or her leg
independently?
Poster Presented at SAWC, April 2008
Decision Tree For Heel Pressure Relief
Is Patient at Risk for Heel Pressure Injury?
NO
YES
• Follow nursing guidelines for routine
skin care.
• Ensure adequate position changes
• Follow nursing guidelines for routine skin care.
• Ensure adequate position changes
• Institute “Pressure Ulcer Prevention – Skin Care
Preventions”
o Elevate heels off bed
o Reposition every 2 hours
o Assess skin integrity every shift
YES
Is Patient Ambulatory?
• Educate Patient on Pressure Reducing
Techniques
• Establish patient appropriateness
NO
NO
• Review Criteria for Pressure-Relieving Heel Protector
• Establish patient appropriateness
PATIENT MUST:
1- Be NON-AMBULATORY
2- Have a total Braden Score of 15 or less
1- Have the potential to be AMBULATORY
3- Have TWO or more co-morbidities
2- Be AMBULATORY
o
Determine “Can the patient lift his/her
3- Be recommended for off loading heel
leg?”
with gait/mobility
o
If patient does not meet the above criteria
but the nurse has concerns about heel
4- Referral to Physical Therapy
protection – call for a wound care consult to
Modified from decision tree developed by Christine Baker, RN, MSN, CWOCN, APN
PATIENT MUST:
Pressure Ulcers in the O.R.
• 40.4 M inpatient; 31.5 M out-patient surgical procedures
annually1
• 4.4 M surgeries longer than 3 hours2
• 1.7 – 4.5 million hospital-acquired pressure ulcers
(HAPU) in U.S.2
• Surgeries greater than 3 hours account for almost 25%
of HAPM.2
1. http://www.cdc.gov/nchs/products/pubs/pubd/series/sr13/140-131/sr13_139.htm
2. Beckrich K, Arnonovitch S, Nursing Economics. Sept-Oct 1999 Vol. 17/No. 5: 263-271
Identify patients at risk for Perioperative Pressure
Ulcers: The Scott Scale1
• AGE (62+)
• ALB (Albumin < 3.5)
• ASA (American Society of Anesthesiologist)
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–
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Category 1 Healthy
Category 2 One co-morbid condition
Category 3 1+ co-morbid condition
Category 4 Life threatening
Category 5 Moribund
• Length, type of surgery, position, and skin condition
1. Scott-Williams S., and Lummus, A. (2005) Perioperative Pressure Ulcer Assessment and Prevention: Efficacy Study of a Multi-Layer
Pressure Relief Pad in the Operating Room (OR) unpublished research.
Market Innovation:
How Prevalon® Improved Upon the Pillow
Vs.
Prevalon
Pillow
Features:
Prevalon contains no hard, sharp or rough
edges, and has a comfortable interior
Comfortable – no hard edges that can irritate
sensitive skin
Prevalon consistently floats the heel for
total pressure relief
When properly positioned, effectively
floats heel – helps prevent pressure ulcers
Simplified instructions and tethered stretch
panel make Prevalon easy to apply
Readily available and easy to use
Improvements:
Disadvantages:
Prevalon’s pontoon bottom design and
adjustable stretch panels keep foot properly
positioned while minimizing friction and shear
Difficult to maintain proper positioning –
patient movement and gravity can increase
risk for pressure, friction and shear
Prevalon maximizes support under the foot
to help prevent foot drop. The new
stabilizer wedge is available to help
prevent lateral leg and foot rotation
Does not prevent “foot drop” (plantar
flexion) and/or lateral foot and leg rotation
Prevalon® Pressure-Relieving
Heel Protector
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Pillow Top…floats heel and distributes weight
Pontoon Bottom…stabilize boot and limit rotation
Comfort stretch panel…no straps, no trauma
Dermasuede fabric…breathable, grasps foot, stays in place
Contracture strap…adjustable to keep all feet upright (Soft brace)
Smooth exterior…easily slides within bed linens
One size ambidextrous…fits most patients, both feet
SCD sleeve compatibility…prevent DVT and foot problems
Nerve Wedge … reduces risk of peroneal nerve damage
3 clinical benefits in one product (Risk reduction for: Contractures, Nerve
damage and Heel Ulcers)
• Very cost effective for “at risk” patient…save money, use preventatively
Key Reference Accounts
Cleveland Clinic
Emory University Hospital
MA General Hospital
Conroe Med Center
St. Luke’s Hospital
Arrowhead Reg Med Ctr
Creighton Medical Center
Northwest Community Hospital
Piedmont Hospital
VA Medical Center
Meritcare Med Center
University of Chicago
Cleveland, OH
Atlanta, GA
Boston, MA
Conroe, TX
Chesterfield, MO
Colton, CA
Omaha, NE
Arlington Hts, IL
Santa Rosa, CA
Miami, FL
Fargo, ND
Chicago, IL
HEEL PROTECTION
50%
Annual 2011 Market
40%
30%
20%
10%
0%
59.3%
19.8%
4.3%
* others include: Hollister, Medline, Sunrise, DM Systems (traced sales), Ali-Med, Joerns
3.7%
2.2%
<2.0%
each
Source: GHX Trend Report (Dollars) 2nd Quarter, 2011 Hospital;
Annual market represents last 4 quarters of data, heel protection only
PREVALON MARKET SHARE
2005 - 2011
60.0%
51.6%
48.1%
50.0%
53.1%
54.5%
55.6%
57.0%
58.3%
59.6% 59.3%
46.6%
44.7%
41.4%
40.0%
37.6%
33.2%
30.5%
27.8%
30.0%
23.9% 24.4%
18.3%
20.0%
14.2%
10.0%
7.0%
2.7%
0.3%
0.0%
Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
2005 2006 2006 2006 2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010 2011 2011
Source: GHX Trend Report (Dollars) 2nd Quarter, 2011 Hospital;
Annual market represents all 4 quarters of data, heel protection only
HEEL PROTECTION
30%
25%
20%
15%
10%
5%
0%
28.1%
18.8% 11.5%
5.9%
* others include: Hollister, Joerns, Medline, Sunrise, DM Systems (traced sales), Ali-Med
5.9%
5.6%
<5.1%
each
Source: GHX Trend Report (Dollars) 2nd Quarter, 2011 Hospital;
Annual market represents last 4 quarters of data, heel protection only
Prevalon® Cost Justification Tool
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Census
Pressure Ulcer Clinical Data
Length of Stay (LOS)
Cost of Pressure Ulcers
Total Treatment costs:
$1,637,000
• Estimated Costs for
Prevalon: $67,133
• Projected Revenue
Preservation:$1,569,687
•
Treatment/Cost Preservation Scenario
200 Bed Hospital
200 bed census – 7.3% incidence rate of pressure ulcers1 = 15 pressure
ulcers/day
• 28% of Pressure Ulcers are on the Heels1 =~4 HPUs, per day
• 365 days/yr x 4 HPUs = ~1,492 HPU patient days
• Average Length of Stay (LOS) = 4.6 days3
• HPU patient days/LOS = ~324 HPU patients per year
Cost of Treatment:
– 93% of HPUs are Stage I and II1 = 301
– 7% of HPUs are Stage III and IV1 = 23
– Estimated cost of Stage I and II Ulcers= $604,000
• (301 patients x $2K/ea in treatment costs2)
– Estimated cost of Stage III and IV Ulcers = $1,035,000
• (23 patients x $45K/ea in treatment costs2)
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•
Total Treatment costs: $1,637,000
Estimated Costs for Prevalon: $67,133
•
(324 patients*2 boots at $56/ea*1.85 for prevention factor)
•
Projected Revenue Preservation (Treatment costs-Prevalon Costs):
$1,569,867
1Whittington
KT, Briones R, Adv Skin Wound Care. Nov/Dec 2004; 17 (9):490-4; 2Young, ZF, Evans A, Davis J, J Nurs
Admin (JONA). Jul/Aug 2003;33(7/8):380-3; 3 National Inpatient Survey (NIS) data 2005, Agency for Healthcare Research
and Quality (AHRQ), hhtp://hcupnet.ahrq.org; 4 Meyers T, “Successful Prevention of Heel Ulcers and Foot Drop in the High
Risk Ventilator Patient Population,” Conroe Medical Center, Conroe TX, Poster presented at IHI National Forum, December
Our Recipe…
• Assessment – Identify High Risk
• Evidence-based protocols
• Targeted outcome Vs baseline
• Educate
• Implement interventions
• Measure (PST, CJT)
• Celebrate
• Posters
• Papers
• Speakers, Web, Guidelines
Thank You For Your Time