Background/Problem• Patients in the CCU and OHR are at greater risk for pres-

sure ulcers due to underlying disease processes and limited mobility related to existing cardiac conditions.

• The CCU population frequently consists of patients who are:• acute stroke patients• post-interventional cardiac procedure patients (cardiac cath-

eterization and balloon pump) requiring strict bedrest for prolonged periods of time

• cardiac arrest patients on hypothermia protocol requiring both intra-vascular cooling and immobilization due to their unstable condition

• unstable cardiac patients on strict bedrest due to existing ar-rhythmias and medication management

• The OHR population frequently consists of patients:• receiving multiple inotropic medications contributing to de-

creased perfusion to skin• with prolonged immobility due to unstable condition• requiring CRRT (Continuous Renal Replacement Therapy)

and intra-aortic balloon pumps at the bedside limiting mo-bility

• In 2010 the National Database of Nursing Quality Indicators (NDNQI) pressure ulcer prevalence data was collected cumu-latively for both CCU and OHR and showed that in the 1st and 3rd quarters of 2010, the incidence of unit-acquired ulcers was above the median range for teaching institutions.

Objectives• High risk for complications exists in the compromised cardiac

patients admitted to the CCU and OHR; therefore 6E will continue efforts to prevent pressure ulcers throughout 2011 and 2012.

• Weekly rounds on our high risk patients will be conducted to assess for the development of unit-acquired pressure ulcers.

• The incidence of unit-acquired pressure ulcers (Stage > II) on 6E will decrease to 0% during Q3 and Q4 2011.

The following steps will be taken to reduce the incidence of pres-sure ulcers in patients admitted to the CCU and OHR:• Initial skin assessment on admission to unit will be performed

to identify patients at high risk for skin breakdown.• Skin Care/Pressure Ulcer Documentation Sticker (used as a

communication tool between the nurse and provider) will be placed upon:

• initial skin assessment on all patients• assessment of high risk patients • skin breakdown present upon arrival• any changes in status, condition, and treatment

• Nurses will ensure that nutrition assessment is completed and followed.

• Nurses will communicate with physicians to ensure appro-priate treatment is ordered and documented in accordance with the SLRHC Pressure Ulcer Algorithm and any recommenda-tions for nutritional support.

Algorithm for Pressure Ulcer & Treatment Guidelines

Patient at high risk

(Braden score <_12);

no pressure ulcer

Are there pressure ulcers involving more than 2 turning surfaces?

For example, pressure ulcers on bilateral trochanters?

Air Fluidized Therapy Clinitron® Rite-Hite® Bed

CALL CALN-WOCN

Low air loss surface Synergy® Air Elite

Stage I:

Non-blanchable erythema or discoloration of intact skin

Stage II:

Blister or superficial skin breakdown that involves the epidermis and dermis

Stage III:

Full thickness skin loss involving subcutaneous tissue that may extend down to, but not through the fascia

Patient Weight > 350 lbs AND Braden score <_ 18 or has pressure ulcer

Contraindications To Continuous Lateral Rotation Therapy:

Unstable spine Long bone fracture with skeletal traction

ICP>20 Prone position

Criteria• Patient at high risk for PNA< 3 days not responding to conventional therapy• Highly sedated• Expected OR time > 6 hrs• Medical instability prevents q 2 hrs manual turns for prevention of pulmonary

complications• Immobile• Anticipated MV > 48 hrs• P/F ratio < (PaO2/FiO2%) • ARDS, Sepsis, Neuromuscular blockade• Ineffective cough, mobilization of secretions with conventional turning,

CPT and suctioning for 24 hrs

*** NOT a substitute for routine nursing assessment of skin integrity and appropriate pressure ulcer prevention measures

Patient with Braden score <_ 18, or has pressure ulcer

Is Percussion and Vibration indicated?

Obtain MD order

Low air loss surface TotalCare® Bariatric Bed with Air

(max patient weight 500 lbs)

Standard surface Excel Care® Bariatric Bed with Foam

(max patient weight 1000 lbs)

Low air loss surface Excel Care® Bariatric Bed with Air

(max patient weight 1000 lbs)

TotalCare® Connect Bed

Assess patient mobility requirements for exiting bed

No preference: front or side exit

Side exit preferred

Stage IV:

Full thickness tissue loss with extensive destruction, tissue necrosis, damage to muscle, bone or supporting structures

Other:

Steven-Johnson Syndrome, burns, posterior flaps or grafts

No Yes

Yes

Algorithm For Bed Selection Algorithm For Bariatric Bed Selection Intensive Care Units: Algorithm For Bed Selection

On admission/transfer: conduct a complete skin assessment and risk assessment using the Braden scale

Algorithm For Pressure Ulcer Prevention & Treatment Guidelines

Patient at risk (Braden Score <_18); no pressure ulcer Patient has pressure ulcer(s) Patient NOT at risk

(Braden Score >18)

Stage I

Protective ointment: Moisture Barrier Ointment.

Treatment Guidelines

Stage II

Trypsin/Balsam Peru/Castor oil ointment, or Hydrocolloid or foam dressing.

Stage III

Hydrogel to wound bed and cover with dry dressing; or: Calcium Alginate to wound bed and cover with dry dressing.

Stage IV

See Stage III or: Apply enzymatic / chemical debrider on slough/necrotic tissue. Request surgical consult for excisional debridement.

Suspected DTI

Avoid positioning on affected area; Protective ointment: Moisture Barrier Ointment or skin sealant.

Unstageable

Apply enzymatic / chemical debrider. Request surgical consult for excisional debridement.

Include in hand-off report Include in hand-off report

Educate patient/ family: Provide Skin Saver

brochure

Educate patient/ family: Provide Skin Saver

brochure

Notify MD/NP/PA Initiate

ORANGE STICKER

Notify MD/NP/PA Initiate ORANGE STICKER and request

pressure redistribution / low air loss bed

Continue to assess skin q shift and do a risk assessment q 24 hr

Initiate pressure ulcer prevention protocol Initiate pressure ulcer treatment guidelines and prevention protocol

Call WOCN for Stage III / IV or necrotic tissue

Continue to do a skin and risk assessment

Braden score <_18?

Protocol / PreventionReposition/turn & position q 2h

Encourage mobility/perform ROM Elevate heels

Minimize friction & shear Manage moisture

Manage nutrition & hydration

Request pressure redistribution / low air loss mattress bed if Braden score <_12

(REFER TO ALGORITHM FOR BED SELECTION)

Pressure ulcer develops after admission?

Continue to do a skin and risk assessment

No

No

Yes

Yes

• Wedges will be used to position all patients.• Pressure redistribution surfaces will be ordered for all patients.

• Early implementation of a pressure redistribution surface for patients admitted on hypothermia protocol. A dedicat-ed surface will be made available (effective in the second quarter 2011).

• Protective moisture barrier cream will be applied to all patients.

• Patient education: Skin Saver brochure will be provided and reviewed with patients who are able to communicate and/or to family members. Posted at each bed side.

Patient EducationSkin SaverGuide

• Inspect your skin at least once a day.

• Bathe when needed and moisturize yourskin to prevent dryness.

• Change position at least every two hours.

• Ask your doctor about a special mattress tohelp prevent pressure on your skin.

• Change position every hour.

• Use a foam, gel or air cushion to relievepressure.

• When changing position: lift, don’t drag.

• Do not use donut-shaped cushions.

• Use pillows or wedges to keep knees orankles from touching each other.

• In bed, place pillows under the legs frommidcalf to ankle to keep heels off ofthe bed.

• Clean skin if soiled.

• Protect skin with cream or ointment.

• Eat a balanced diet.

• If a healthy diet is not possible, ask yourdoctor about nutritional supplements.

Always ask yourdoctor, nurse orcaregiver aboutyour concerns.

Daily Routine

Bed Confinement

ChairConfinement

Reduce Friction

Inability to Move

Loss of Bowel orBladder Control

Nutrition

Skin SaversA Guide for Patients,Families and Caregivers

Pressure ulcers can be prevented by using,or making sure your caregiver uses, theseessential skin saving techniques

• Nurses will:• Document every shift on skin assessment findings, treat-

ments, use of pressure reduction surfaces, use of wedges, dressing changes, protective barrier ointments, and any changes in size, staging, location for skin breakdown

• Conduct hand-off communication on skin assessment and treatment at change of shift

• Conduct weekly pressure ulcer monitoring every Wednes-day

• Turn clock sign (used as a reminder) posted at each bed side.

Mepilex Foam & Turn Clock

• The WOCN (Wound, Ostomy & Continence Nurse) will be consulted only for wounds that are difficult to stage or that are not responding to prescribed treatment.

• The use of a sacrum border foam (Mepilex) was initiated in October 2011 for all patients at risk for development of a pres-sure ulcer.

• Use of TAP (Turn & Position system) started on November 2011.

Reduction In Unit-Acquired Pressure UlcersLeonida Lacdao, RN, Nurse Manager and the 6E Nursing Staff

6 EAST Cardiac Care Unit (CCU)/Open Heart Recovery (OHR), St. Luke’s - Roosevelt Hospital Center, New York, NY

TAP (Turn & Position System)

ResultsPercent of Surveyed Patients with Unit Acquired Pressure Ulcers Stage II and Above

2011 Q1 2011 Q2 2011 Q3 2011 Q4

25

20

15

10

5

0Quarter

Perce

nt

21.43

0

7.69

0 0 0 0 0

Stage ≥ IINDNQI Median

Conclusion• In the first quarter of 2011, 21.4% of patients surveyed had a

unit-acquired pressure ulcer (Stg > II). This was attributed to:• Post cardiac arrest & post open heart patients who are hemo-

dynamically unstable, thereby limiting turning & positioning• Hypothermia protocol patients who have decreased perfu-

sion to skin• Inability to change regular beds to specialty beds due to

life-saving equipment that is attached to patients• Nutritionally compromised patients

• Due to interventions implemented, there has been significant improvement in the incidence of unit-acquired pressure ulcers during the 2nd – 4th quarters of 2011.

• We reached the NDNQI comparative benchmark of 0% in the 4th quarter of 2011.

ReferencesCarlson, EV, Kemp, MG, Shott, S. “Predicting the risk of pressure ulcers in critically ill patients.” American Journal of Critical Care. July, 1999. 8(4):262-9.Jastremski, CA. “Pressure relief bedding to prevent pressure ulcer development in criti-cal care.” Journal of Critical Care. June, 2002. 17(2):122-5.

Methods

A Guide for Patients, Families and CaregiversSkin is your first line of defense. It’s impor-tant to protect it. Confinement in a bed orchair, inability to move, loss of bowel orbladder control, poor nutrition, andlowered mental awareness while you aresick or recovering, can place you at risk fordeveloping pressure ulcers, also known asbedsores.

What is a pressure ulcer?A pressure ulcer is an injury to the skinand the tissue underneath. It is caused byunrelieved pressure and/or rubbing orfriction to an area of the skin. The skin canbe reddened or discolored, and deepwounds can expose muscle or bone.

Where do pressure ulcers form?Pressure ulcers form where skin and under-lying tissue is pressed against bone by aperson’s body weight or some otherpressure. The location of the wounddepends upon the person’s position andtheir ability to move. For example, a person

confined to bed may develop a pressureulcer on their lower back, over their hipbone or on their heels. A person in awheelchair may develop ulcers on theirbuttocks, ankles, shoulder blades, elbows,back of their head or spine. For people usingsupplemental oxygen, pressure ulcers canalso occur around the ears and face from theoxygen tubing.

Pressure ulcers can be prevented by using,or making sure your caregiver uses, thefollowing important skin saving techniques:

• Inspect the skin at least once a day.Report any redness, broken skin or pain toyour doctor.

• Keep skin clean and dry Avoid hot waterand excess bathing. Use pads to absorbwetness; clean skin as soon as possible aftersoiling from urine or stool.

• Prevent dry skin by using creams ormoisturizers.

• Do not rub or massage the skin overbony parts of the body; this can hurt theskin and tissue underneath.

• If you can, move or change yourposition: if you are confined to bed,change position at least every two hours;if sitting in a chair, change positionevery hour.

• Use pillows to keep bony areas (ankles and knees) from direct contactwith each other.

• Avoid friction or rubbing againstthe sheets when being moved. (Lift; don’t drag.)

• Skin needs nourishment to stayhealthy. If you cannot eat a healthy diet,talk to your doctor.

• Tell your doctor or nurse about anyproblems with your skin.

This material was prepared by IPRO, the Medicare Quality ImprovementOrganization for New York State, under contract with the Centers for Medicare &Medicaid Services (CMS), an agency of the U.S. Department of Health and HumanServices. The contents presented do not necessarily reflect CMS policy.9SOW-NY-THM6.2-09-64