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Suspected Deep Tissue Injury (sDTI). Challenges and Solutions. Karen Zulkowski, DNS, RN,CWS WOCN 2013. BACKGROUND. sDTI was first introduced as a pressure ulcer concept by NPUAP in 2003 It became part of the NPUAP staging system in 2007

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suspected deep tissue injury sdti

Suspected Deep Tissue Injury (sDTI)

Challenges and Solutions

Karen Zulkowski, DNS, RN,CWS

WOCN 2013

background
BACKGROUND
  • sDTI was first introduced as a pressure ulcer concept by NPUAP in 2003
  • It became part of the NPUAP staging system in 2007
  • It was again discussed at the NPUAP 2013 consensus conference
suspected deep tissue injury
SUSPECTED DEEP TISSUE INJURY
  • Definition
  • Purpleor maroonlocalized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear
  • Description
  • The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler than adjacent tissue
  • Deep tissue injury may be difficult to detect in individuals with dark skin tone
  • Evolution may include a thin blister over dark wound bed. The wound may further evolve and become covered by thin eschar
  • Evolution may be rapid exposing additional layers of tissue even with treatment

SalcidoR, Lee A, Ahn C. Heel pressure ulcers: purple heel and deep tissue injury. Adv Skin Wound Care. Aug 2011;24(8):374-380; quiz 381-372.

VanGilderC, MacFarlane GD, Harrison P, Lachenbruch C, Meyer S. The demographics of suspected deep tissue injury in the United States: an analysis of the International Pressure Ulcer Prevalence Survey 2006-2009. Adv Skin Wound Care. Jun 2010;23(6):254-261.

GefenA, Farid KJ, Shaywitz I. A review of deep tissue injury development, detection, and prevention: shear savvy. Ostomy Wound Manage. Feb 2013;59(2):26-35.

NPUAP. Suspected Deep Tissue Injury: State of the Science and Results of the NPUAP Consensus Conference. Paper presented at: SDTI Consensus

suspected deep tissue injury identifying an sdti
SUSPECTED DEEP TISSUE INJURY: Identifying an sDTI
  • Damage is to deeper tissue and when you see a purplish area it is too late to prevent
  • Heralding sign of Stage III or IV
  • May be from:
    • Falls
    • Long OR/ER or transportation times
    • Splints
    • Accidents

SalcidoR, Lee A, Ahn C. Heel pressure ulcers: purple heel and deep tissue injury. Adv Skin Wound Care. Aug 2011;24(8):374-380; quiz 381-372.

VanGilderC, MacFarlane GD, Harrison P, Lachenbruch C, Meyer S. The demographics of suspected deep tissue injury in the United States: an analysis of the International Pressure Ulcer Prevalence Survey 2006-2009. Adv Skin Wound Care. Jun 2010;23(6):254-261.

GefenA, Farid KJ, Shaywitz I. A review of deep tissue injury development, detection, and prevention: shear savvy. Ostomy Wound Manage. Feb 2013;59(2):26-35.

NPUAP. Suspected Deep Tissue Injury: State of the Science and Results of the NPUAP Consensus Conference. Paper presented at: SDTI Consensus

identifying sdti issues
IDENTIFYING sDTI: ISSUES
  • Difficult to say with certainty a wound is a sDTI as outer skin may be intact
    • Sometimes it really is a bruise
  • Document exactly what you see
background overall ipup results
BACKGROUND: OVERALL IPUP RESULTS

Catherine VanGilder MBA, BS, MT, CCRA , et al; Prevalence of suspected Deep Tissue Injuries: Analysis of the 2012 International Pressure Ulcer Prevalence™ Survey,

2012 NPUAP Consensus Panel, Biennial meeting, Oral presentation

overall prevalence by us care setting
OVERALL PREVALENCE BY US CARE SETTING:

Catherine VanGilder MBA, BS, MT, CCRA , et al; Prevalence of suspected Deep Tissue Injuries: Analysis of the 2012 International Pressure Ulcer Prevalence™ Survey,

2012 NPUAP Consensus Panel, Biennial meeting, Oral presentation

fa prevalence by us care setting
FA PREVALENCE BY US CARE SETTING:

Catherine VanGilder MBA, BS, MT, CCRA , et al; Prevalence of suspected Deep Tissue Injuries: Analysis of the 2012 International Pressure Ulcer Prevalence™ Survey,

2012 NPUAP Consensus Panel, Biennial meeting, Oral presentation

by worst stage patient level analysis
% BY WORST STAGE – PATIENT LEVEL ANALYSIS

Catherine VanGilder MBA, BS, MT, CCRA , et al; Prevalence of suspected Deep Tissue Injuries: Analysis of the 2012 International Pressure Ulcer Prevalence™ Survey,

2012 NPUAP Consensus Panel, Biennial meeting, Oral presentation

2012 us data op and fa by stage all ulcers
2012 US DATA: OP AND FA BY STAGE (ALL ULCERS)

9.5%

13.4%

Catherine VanGilder MBA, BS, MT, CCRA , et al; Prevalence of suspected Deep Tissue Injuries: Analysis of the 2012 International Pressure Ulcer Prevalence™ Survey,

2012 NPUAP Consensus Panel, Biennial meeting, Oral presentation

2012 us acute care sdti by unit type
2012 US ACUTE CARE sDTI BY UNIT TYPE

sDTI AS A PERCENT OF ULCERS

Catherine VanGilder MBA, BS, MT, CCRA , et al; Prevalence of suspected Deep Tissue Injuries: Analysis of the 2012 International Pressure Ulcer Prevalence™ Survey,

2012 NPUAP Consensus Panel, Biennial meeting, Oral presentation

what causes sdti
WHAT CAUSES sDTI?

Pressure/shear

  • Deep muscle that covers bony prominences may have higher overall pressure
  • Shear lowers the ulceration threshold 6-fold1 so depending on the circumstances of immobility this may also be a factor

Ischemia—Reperfusion Injury

  • Tissue reperfusion following ischemia can result in a cascade of events that leads to inflammation and edema in the tissue2
  • Persons with DM are higher risk for reperfusion injury3

Long transportation, OR, ER times4

SalcidoR, Lee A, Ahn C. Heel pressure ulcers: purple heel and deep tissue injury. Adv Skin Wound Care. Aug 2011;24(8):374-380; quiz 381-372.

GefenA, Farid KJ, Shaywitz I. A review of deep tissue injury development, detection, and prevention: shear savvy. Ostomy Wound Manage. Feb 2013;59(2):26-35.

NPUAP. Suspected Deep Tissue Injury: State of the Science and Results of the NPUAP Consensus Conference. Paper presented at: SDTI Consensus Conference2013; Houston TX

Zulkowski K, Zinnecker P, Blackwell C, et al. Examination of Skin Injuries/Lesions on Admission to an ICU JWCET. 2007;27(1).

.

impact on caregiver and patient
IMPACT ON CAREGIVER AND PATIENT

Caregiver—Stress is problematic for caregivers with many situations1

Patient—Anxiety is less if the wound is healing but patients expressed disgust with the wound on their body and dependence on others2

2

Davis C, Bullard D, Brothers K, Semich B. Time out! Recognizing caregiver fatigue. Nursing made Incredibly Easy. 2012;10(5):45-49.

Gorecki C, Nixon J, Madill A, Firth J, Brown J. What influences the impact of pressure ulcers on health-related quality of life? A qualitative patient-focused exploration of contributory factors. Journal of Tissue Viability. 2012;21(1):3-12.

pressure ulcers impact on patient quality of life
PRESSURE ULCERS IMPACT ON PATIENT QUALITY OF LIFE

Pain—Pressure ulcer pain can restrict desire to move and reposition, may lead to diminished activities of daily life and social isolation

Odor—Malodor from a necrotic pressure ulcer and wound visibility may restrict social interactions

Emotional Impact—Wounds perceived as betrayal of one’s own body; associated with horror movies; shameful; repulsive

Financial Impact—

  • “All the medical supplies you need to treat these bedsores. I think in the past two months, I’ve spent close to $300 out of my pocket and I’m on a fixed income.”1
  • “We had to live on $302 a month.”1

Blame—Healthcare professionals often blame patients and caregivers for the development and recalcitrance of pressure ulcers

1. Baharestani, MM. Advances in Wound Care. 1994;7:40-52.

impact on facilities
IMPACT ON FACILITIES

Facility—Difference between present on admission and “facility acquired”

  • For NH this is now broken down on MDS and coded on the MDS for Stage II–IV unstagable(sDTI is considered unstagable)
  • Acute Care is not reimbursed for facility acquired Stage II and IV

Hospital Acquired Conditions. 2008. http://www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acquired%20Conditions.asp. Accessed May 16, 2013.

MDS 3.0 Manuel V01 07. HHS; 2011. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html. Accessed April 16, 2013.

sdti state of the evidence
SDTI STATE OF THE EVIDENCE
  • Persons with sDTI were older than the general patient population
  • Theses wounds were more commonly found on the heels (41%) followed by the sacrum (19%) and buttocks (13%)…
  • And were likely to be nosocomial
  • The heel is at greater risk for development of sDTIs. It has a small radii of curvature of the bony prominence and relatively thin overlying soft tissue
  • These factors contribute to a greater index of compression and greater mechanical loading intensity applied by the bony prominence to the overlying soft tissue
slide17

SDTISTATE OF THE SCIENCE; KEY CONSENSUS POINTS FROM NPUAP BIENNIAL CONFERENCE

  • An sDTI can precede admission to a health care facility
  • Given that the standard of care was met, the evolution of a sDTI into a full thickness PU, not present on admission, is NOT evidence of inadequate care
  • A history of friction/shear in the injured tissue makes the diagnosis of sDTI more likely
  • Distinguishing sDTI from other causes of purple/maroon tissue is a complex process
prevention and treatment strategies
PREVENTION AND TREATMENT STRATEGIES
  • Watch and document the pressure areas carefully (especially important for heels)
  • If wound is on the heels elevate them off the bed
  • Turn the patient off any affected area
  • If wound is on buttocks limit the time in the chair and use a chair pressure redistribution pad
  • Place the person on an appropriate support surface
  • Always remember frequent turning and repositioning based on the patient’s condition in the bed and chair

CHECK HEELS AND ELEVATE

TURN & REPOSITION

USE APPROPRIATE SUPPORT SURFACE FOR BED AND CHAIR

appropriate support surface how does a support surface help off loading
APPROPRIATE SUPPORT SURFACEHOW DOES A SUPPORT SURFACE HELP OFF LOADING?

1. Immersion: Depth of penetration into Surface

2. Envelopment: Contact area of level of immersion

  • Design choices to optimize can include
    • Conformable, stretchy surface materials
    • Bladder design(horizontal or vertical shape)
    • Fluid support(Air Fluidized)
  • Design choices to optimize can include
  • Powered, multi-zone surface adjust to separate body areas
  • Surface algorithms tuned to adjust by body weight,
  • and when HOB raised

Single zone surface

4 zone surface

slide20

PREVENTION AND TREATMENT STRATEGIESCONSIDER THE USE OF AIR-FLUIDIZED THERAPY BEDS

OTHER AIR FLUIDIZED THERAPY STUDIES

In a retrospective review of 664 nursing home patients were placed on 3 groups of surfaces:

Those placed on AFT beds experienced significantly faster healing rates and fewer hospitalizations than those patients placed on AIR surfaces (Group 2).2

In a comparison of post-cardiovascular surgery patients, 27 patients were identified based on common risk characteristics and placed on AFT:

The patients remained on AFT until they were extubated, able to bear weight or weaned off vasopressors.

These extremely high-risk patients had a 96% reduction in expected ulcers.3

  • In a study, 5 patients with sDTIs were placed on AFT within 12 hours of discovery:
  • Patients experienced much less tissue breakdown than expected, sDTIs can rapidly develop into Stage III or IV wounds
  • 4 injuries healed prior to discharge; 4 developed into Stage II ulcers, and 2 remained sDTIs at discharge1

Allen L. J Wound Ostomy Continence Nurs. 2012;39:555-561.

Ochs RF, et al. Ostomy Wound Manage. 2005;51:38-68.

Jackson M, et al. Crit Care Nurse. 2011;31:44-53.

slide21

KNOW IF THE BED IS WORKING

  • If powered, be sure surface is plugged in and working correctly
  • Be sure it is the right size for the patient (especially important for larger persons whose weight may be centered in one area)

IN ADDITION….

  • Document the bed use in the nursing notes daily
  • Be sure the staff knows how the bed works
  • Teach the patient and family how the bed works and how it is helping with skin care

Remember…

  • A support surface does not replace good nursing care
  • Patients still need skin checks, and to be turned & repositioned
in summary
IN SUMMARY
  • Carefully inspect the skin on admission
  • If you are unsure, document exactly what you see
  • Remember long transportation, OR, ER times impact skin
  • Above all, DOCUMENT
  • Use evidence based best practices to monitor, prevent and treat
  • Plan care based on individual patient needs
questions
QUESTIONS?

drkarenz@aol.com

karenz@montana.edu

(406)671-2909

slide24

REFERENCES

  • SalcidoR, Lee A, Ahn C. Heel pressure ulcers: purple heel and deep tissue injury. Adv Skin Wound Care. Aug 2011;24(8):374-380; quiz 381-372.
  • VanGilder C, MacFarlane GD, Harrison P, Lachenbruch C, Meyer S. The demographics of suspected deep tissue injury in the United States: an analysis of the International Pressure Ulcer Prevalence Survey 2006-2009. Adv Skin Wound Care. Jun 2010;23(6):254-261.
  • GefenA, Farid KJ, Shaywitz I. A review of deep tissue injury development, detection, and prevention: shear savvy. Ostomy Wound Manage. Feb 2013;59(2):26-35.
  • NPUAP. Suspected Deep Tissue Injury: State of the Science and Results of the NPUAP Consensus Conference. Paper presented at: SDTI Consensus Conference2013; Houston TX.
  • Catherine VanGilder MBA, BS, MT, CCRA , et al; Prevalence of suspected Deep Tissue Injuries: Analysis of the 2012 International Pressure Ulcer Prevalence™ Survey, 2012 NPUAP Consensus Panel, Biennial meeting, Oral presentation
  • Zulkowski K, Zinnecker P, Blackwell C, et al. Examination of Skin Injuries/Lesions on Admission to an ICU JWCET. 2007;27(1).
  • Davis C, Bullard D, Brothers K, Semich B. Time out!
  • Recognizing caregiver fatigue. Nursing made Incredibly Easy. 2012;10(5):45-49.
  • Gorecki C, Nixon J, Madill A, Firth J, Brown J. What influences the impact of pressure ulcers on health-related quality of life? A qualitative patient-focused exploration of contributory factors. Journal of Tissue Viability. 2012;21(1):3-12.
  • Baharestani, MM. The lived experience of wives caring for their frail, homebound, elderly husbands with pressure ulcers. Advances in Wound Care. 1994;7:40-52.
  • Hospital Acquired Conditions. 2008. http://www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acquired%20Conditions.asp. Accessed April 11, 2008.
  • MDS 3.0 Manuel V01 07. HHS; 2011. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html. Accessed April 16, 2013.
  • Allen L. J Wound Ostomy Continence Nurs. 2012;39:555-561.
  • Ochs RF, et al. Ostomy Wound Manage. 2005;51:38-68.
  • Jackson M, et al. CritCare Nurse. 2011;31:44-53.

Additional Resources

  • GoreckiC, Brown JM, Nelson EA, et al. Impact of pressure ulcers on quality of life in older patients: a systematic review. Journal of the American Geriatrics Society. 2009;57(7):1175-1183.
  • GoreckiC, Lamping DL, Brown JM, Madill A, Firth J, Nixon J. Development of a conceptual framework of health-related quality of life in pressure ulcers: a patient-focused approach. International journal of nursing studies. 2010;47(12):1525-1534.
  • Yamamoto Y, Hayashino Y, Higashi T, et al. Keeping vulnerable elderly patients free from pressure ulcer is associated with high caregiver burden in informal caregivers. Journal of Evaluation in Clinical Practice. 2010;16(3):585-589.
  • Allen V, Ryan DW, Murray A. Air-fluidized beds and their ability to distribute interface pressures generated between the subject and the bed surface. Physiol Meas. Aug 1993;14(3):359-364.
  • Baharestani MM. Quality of life and ethical issues. In: Baranoski S, Ayello EA eds. Wound Care Essentials. 3rd ed. Wolters Klower;2012;2-20.