21102 Strategies to Prevent Heel Ulcers and Plantar ...
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100% prevention of hospital-acquired hPUs 100% prevention of plantar flexion contractures ICU patients have a high risk of developing hPUs and plantar flexion contractures. 1-3 The prevalence of pressure ulcers (PUs) in the ICU has been estimated to range from 14% to 41%. 1 The incidence of PUs in the ICU has been estimated to range from 1% to 56%. 1 Approximately 25% of PUs develop into hPUs. 4 The estimated cost of treatment is $3,000 per hPU. 5 Plantar flexion contractures are a negative outcome in sedated ICU patients and result in a reduced quality of life. 3 The aim of this project was to assess the impact of a clinical intervention to decrease the rate of heel pressure ulcers (hPUs) and to prevent plantar flexion contractures through the use of heel protector devices in high-risk, sedated, intensive care unit (ICU) patients. Purpose Methods Study Inclusion Criteria: Sedated patient in the ICU for > 5 days Intubated or not intubated Braden score of < 16 Patients not eligible for Prevalon™ boot included in the study as control subjects; pillows used to elevate the heels Passive range of motion (ROM) as ordered for all ICU patients, not withheld or viewed as a variable in the prevention of plantar flexion contractures Procedure: 1. Heel skin assessed and Braden scale administered to all patients upon admission to the ICU 2. All ICU patients who met criteria had ankle ROM measured with a goniometer upon admission and prior to application of the Prevalon™ boot; heel skin assessed and Braden scale and Ramsey sedation scale administered 3. All patients who met criteria had ankle ROM measured every other day 4. Heel skin assessed and Braden scale and Ramsey sedation scale administered every shift and recorded as part of the study every other day 5. Measurements continued until patients transferred, boots discontinued per physician order, or patients had a Braden scale score of >16 6. Control patients also had ankle ROM measured, heel skin assessed, and Ramsey sedation scale, and Braden scale administered at admission and every other day. 7. Measurements performed by trained ICU nurses and physical therapists S S t t r r a a t t e e g g i i e e s s t t o o P P r r e e v v e e n n t t H H e e e e l l U U l l c c e e r r s s a a n n d d P P l l a a n n t t a a r r F F l l e e x x i i o o n n C C o o n n t t r r a a c c t t u u r r e e s s i i n n t t h h e e V V e e n n t t i i l l a a t t e e d d P P a a t t i i e e n n t t Tina Meyers, BSN, RN, CWOCN, ACHRN – Harris County Hospital District, Houston, TX; Rejeana Pezel, ICU/CCU; Jill Bennett, RN, MSN, ICU/CCU; Vanessa Carroll, RN, ICU/CCU; Ann Russell, RN, BSN, ICU/CCU; Sharon Lagway, RN, ICU/CCU; Salvacion Ramos, RN, ICU/CCU; Eloisa Asilo, RN, ICU/CCU; Marci Green, RN, ICU/CCU nurse – Conroe Regional Medical Center, Conroe, TX Introduction Results Process Improvement Efforts Effective prevention of hPU development in patient population [100%] Effective prevention of plantar flexion contracture development in patient population [100%] 9.4% of patients showed improvement in heel status from entry to discharge 11.3% of existing heel skin conditions stayed the same, with no change or worsening of wound status Establishment of a protocol to prevent hPUs in a high-risk patient population Establishment of a protocol to prevent plantar flexion contractures in a high-risk patient population Earlier recognition of heel skin issues in a high-risk patient population Standardization of care and ease of use intended to promote caregiver compliance with protocol Data collection tool used frequently to ensure appropriate evaluation Conclusion A comparison of the cost of heel protector devices with the projected cost of treating hPUs indicated a calculated annual savings of $1.9 million. A heel protector should be used on all immobile, sedated patients. The results of this study indicate that such use may reduce or eliminate the risk of hPUs and help prevent the development of plantar flexion contractures. An effective hPU prevention protocol that incorporates accurate risk identification, early recognition of skin issues, and methods to maintain heel suspension should be established. hPUs and plantar flexion contractures may be preventable if standardized protocols designed to ensure consistent application of heel protector devices are followed. The proposed hPU prevention protocol represents a shift in clinical paradigm from traditional methods, substantially reducing the risk of heel injury, and concomitantly reducing the risk of plantar flexion contracture in this high-risk patient group. The clinical and economic outcomes of this intervention should be studied further. The estimated annual savings due to prevention ($1,904,220) are based on the literature. However, additional research is needed to determine the cost benefit of hPU prevention. References Data Collection Tool for Conroe Hospital Prevalon II Plantar Flexion Prevention MRN_________________________ AGE_____________ GENDER ____________ DIAGNOSIS____________________________________________________________ ADMISSION DATE________________________________ INTUBATED: YES or NO DATE__________________ SEDATED: YES or NO DATE__________________ PREVALON BOOT APPLIED: YES or NO PILLOWS USED: YES or NO Ankle Measurement Braden Scale Heel Skin Assessment Ramsey score Comments Admission Day 3 Day 5 Day 7 Day 9 Day 11 Day 13 Day 15 Assessment of hPU Prevention n = 53 total patients n = 106 total heels Percentage of total heels in study (%) 15 12 9 6 3 0 Patient Status* Heel Status** Comparison of Entry with Exit Status Abnormal:Abnormal Abnormal:Normal Normal:Abnormal * Abnormal patient status means that patient had at least one abnormal heel ** Abnormal heel defined as having status OTHER than pink, clean, clean and dry, OK or intact 11% of patients stayed same 9% of patients showed positive change 8% of heels showed positive change 8% of heels stayed same No new hPUs developed No new hPUs developed Change in Heel/Patient Status Percentage of total heels or patients (%) 100 90 80 70 60 50 40 30 20 10 0 Heel Entry Status Heel Exit Status Patient Entry Status Patient Exit Status Comparison of Entry with Exit Status Normal Abnormal* n = 106 total heels n = 53 total patients 8% increase in normal heel status 50% decrease in abnormal heel status Assessment of Development of Plantar Flexion Contractures No. of ankles/patients with no plantar flexion contractures (normal) 120 100 80 60 40 20 0 On Entry On Exit No. of normal* right ankles No. of normal* left ankles No. of normal* patients * Normal = measurements with goniometer within normal range and showing no evidence of plantar flexion contractures n = 53 patients, 106 ankles 100% normal 100% normal 100% normal 100% normal 100% normal 100% normal * Abnormal patient status means that patient had at least one abnormal heel. Abnormal heel defined as having status OTHER than pink, clean, clean and dry, OK or intact Use of a heel protector to maintain heel suspension and proper foot and ankle alignment in 53 sedated ICU patients prevented the development of any new hPUs in this high-risk patient population during this 7-month study. In addition, an assessment of all individual heels (n = 106) indicated that 16 heels were abnormal upon entry into the study compared with only 8 heels on study exit, which indicated a 50% decrease in abnormal heel status. Measurement of ankle ROM with a goniometer upon admission and every other day for the duration of the study showed no development of plantar flexion contractures in any patient (based on definition of contracture -50 [90°=0]). Financial Benefits of hPU Prevention The heel prevention protocol resulted in annual savings of $1,904,220. [Avg census 260; 7.3% 4 may develop PUs = 19; 28% 4 may develop HPUs = 5; total hPU days (365) = 1825; avg LOS 4.6 (NIS Data) = 397 actual hPU days; 93% stage 1 or 2 4 = 369; 7% stage 3 or 4 4 = 28] Cost of prevention effort Projected Cost of Projected Cost of (Prevalon purchased) Stage I & II Ulcers Stage III & IV Ulcers $83,443 $1,249,728 $737,935 369 patients 4 $2K each aver. cost 9 28 patients 4 $45K each aver. cost 9 $1,400K $1,200K $1,000K $800K $600K $400K $20K 0 1. Keller BP, Wille J, van Ramshorst B, van der Werken C. Pressure ulcers in intensive care patients: a review of risks and prevention. Intensive Care Med. 2002;28:1379-1388. 2. Jastremski CA. Pressure relief bedding to prevent pressure ulcer development in critical care. J Crit Care. 2002;17:122-125. 3. Latronico N, Shehu I, Seghelini E. Neuromuscular sequelae of critical illness. Curr Opin Crit Care. 2005;11:381-390. 4. Whittington KT, Briones R. National prevalence and incidence study: 6-year sequential acute care data. Adv Skin Wound Care. 2004;17:490-494. 5. Courtney B, Ruppman J, Cooper H. Save our skin: initiative cuts pressure ulcer incidence in half. Nurs Manage. April 2006;37:36-45. 6. Hoppenfeld S. Physical Examination of the Spine and Extremities. Norwalk, CT: Prentice-Hall; 1976. 7. Kapandji IA. Ilustrated physiology of joints. Med Biol Illus. 1964;14:72-81. 8. Kendall FP, McCreary EK, Provance PG, et al. Muscles: Testing and Function with Posture and Pain. 5th ed. Baltimore, MD: Lippincott Williams and Wilkens; 2005. 9. Young ZF, Evans A, Davis J. Nosocomial pressure ulcer prevention: a successful project. J Nurs Adm. 2003;33: 380-383. 4 Whittington KT, Briones R. Adv Skin Wound Care. 2004;17:490-494; 9 Young ZF, Evans A, Davis J. J Nurs Adm. 2003;33:380-383. Source: Research Institute for Human Engineering for Quality Life, “Measurement and evaluation of the human dynamic characteristics,” Joint Passive Resistance Database a4, 2000. Available at: http://www.dh.aist.go.jp/bodyDB/a/HQL-00-04e.html 21102 11% increase in normal patient status 55% decrease in abnormal patient status 3rd Congress of the World Union of Wound Healing Societies: June 4-8, 2008 Ramsey Score Averages Score Entry Totals Exit Totals 1 7 7 8 8 2 22 44 20 40 3 3 9 9 27 4 11 44 11 44 5 7 35 4 20 6 0 0 0 0 Avg. 2.78 2.67 Modified Ramsey Sedation Scale: 1. Anxious, Agitated, Restless 2. Cooperative, Oriented, Tranquil. Accepts mechanical ventilation. 3. Responds to commands only 4. Brisk response to light glabellar tap or loud noise. 5. Sluggish response to light glabellar tap or loud noise. 6. No Response. Goniometer used by trained and licensed clinicians to assess for plantar flexion contracture 6-8
Transcript of 21102 Strategies to Prevent Heel Ulcers and Plantar ...
100% prevention ofhospital-acquired hPUs
100% prevention of plantarflexion contractures
ICU patients have a high risk of developing hPUs and plantarflexion contractures.1-3
The prevalence of pressure ulcers (PUs) in the ICU has beenestimated to range from 14% to 41%.1
The incidence of PUs in the ICU has been estimated to rangefrom 1% to 56%.1
Approximately 25% of PUs develop into hPUs.4
The estimated cost of treatment is $3,000 per hPU.5
Plantar flexion contractures are a negative outcome in sedatedICU patients and result in a reduced quality of life.3
The aim of this project was to assess the impact of a clinicalintervention to decrease the rate of heel pressure ulcers (hPUs) and toprevent plantar flexion contractures through the use of heel protectordevices in high-risk, sedated, intensive care unit (ICU) patients.
Purpose
Methods
Study Inclusion Criteria: � Sedated patient in the ICU for >5 days � Intubated or not intubated � Braden score of <16 � Patients not eligible for Prevalon™ boot included in the study as
control subjects; pillows used to elevate the heels � Passive range of motion (ROM) as ordered for all ICU patients,
not withheld or viewed as a variable in the prevention of plantar flexion contractures
Procedure: 1. Heel skin assessed and Braden scale administered to all
patients upon admission to the ICU
2. All ICU patients who met criteria had ankle ROM measured with a goniometer upon admission and prior to application of the Prevalon™ boot; heel skin assessed and Braden scale and Ramsey sedation scale administered
3. All patients who met criteria had ankle ROM measured every other day
4. Heel skin assessed and Braden scale and Ramsey sedation scale administered every shift and recorded as part of the study every other day
5. Measurements continued until patients transferred, boots discontinued per physician order, or patients had a Braden scale score of >16
6. Control patients also had ankle ROM measured, heel skin assessed, and Ramsey sedation scale, and Braden scale administered at admission and every other day.
7. Measurements performed by trained ICU nurses and physical therapists
SS tt rr aa tt ee gg ii ee ss tt oo PP rr ee vv ee nn tt HH ee ee ll UU ll cc ee rr ss aa nn dd PP ll aa nn tt aa rr FF ll ee xx ii oo nn CC oo nn tt rr aa cc tt uu rr ee ss ii nn tt hh ee VV ee nn tt ii ll aa tt ee dd PP aa tt ii ee nn ttTina Meyers, BSN, RN, CWOCN, ACHRN – Harris County Hospital District, Houston, TX; Rejeana Pezel, ICU/CCU; Jill Bennett, RN, MSN, ICU/CCU; Vanessa Carroll, RN, ICU/CCU; Ann Russell, RN, BSN, ICU/CCU; Sharon Lagway, RN, ICU/CCU; Salvacion Ramos, RN, ICU/CCU; Eloisa Asilo, RN, ICU/CCU; Marci Green, RN, ICU/CCU nurse – Conroe Regional Medical Center, Conroe, TX
Introduction
ResultsProcess Improvement Efforts
Effective prevention of hPU developmentin patient population [100%]
Effective prevention of plantar flexioncontracture development in patientpopulation [100%]
9.4% of patients showed improvement inheel status from entry to discharge
11.3% of existing heel skin conditionsstayed the same, with no change orworsening of wound status
Establishment of a protocol to preventhPUs in a high-risk patient population
Establishment of a protocol to preventplantar flexion contractures in a high-riskpatient population
Earlier recognition of heel skin issues in ahigh-risk patient population
Standardization of care and ease of useintended to promote caregiver compliancewith protocol
Data collection tool used frequently toensure appropriate evaluation
Conclusion A comparison of the cost of heel protector devices with the projected cost of treating hPUs indicated a calculated annual savings of $1.9 million.
A heel protector should be used on all immobile, sedated patients. The results of this studyindicate that such use may reduce or eliminate the risk of hPUs and help prevent thedevelopment of plantar flexion contractures.
An effective hPU prevention protocol that incorporates accurate risk identification, earlyrecognition of skin issues, and methods to maintain heel suspension should be established.hPUs and plantar flexion contractures may be preventable if standardized protocolsdesigned to ensure consistent application of heel protector devices are followed.
The proposed hPU prevention protocol represents a shift in clinical paradigm fromtraditional methods, substantially reducing the risk of heel injury, and concomitantlyreducing the risk of plantar flexion contracture in this high-risk patient group.
The clinical and economicoutcomes of thisintervention should bestudied further. Theestimated annual savingsdue to prevention($1,904,220) are based on theliterature. However,additional research isneeded to determine the costbenefit of hPU prevention.
References
Data Collection Tool for Conroe Hospital Prevalon II Plantar Flexion Prevention
MRN_________________________ AGE_____________ GENDER ____________
DIAGNOSIS____________________________________________________________
ADMISSION DATE________________________________
INTUBATED: YES or NO DATE__________________
SEDATED: YES or NO DATE__________________
PREVALON BOOT APPLIED: YES or NO PILLOWS USED: YES or NO
Ankle Measurement
Braden Scale
Heel Skin Assessment
Ramsey score Comments
Admission
Day 3
Day 5
Day 7
Day 9
Day 11
Day 13
Day 15
Assessment of hPU Preventionn = 53 total patients n = 106 total heels
Perce
ntage
of to
tal he
els in
stud
y (%
) 15
12
9
6
3
0 Patient Status* Heel Status**Comparison of Entry with Exit Status
Abnormal:Abnormal Abnormal:Normal Normal:Abnormal* Abnormal patient status means that patient had at least one abnormal heel** Abnormal heel defined as having status OTHER than pink, clean, clean and dry, OK or intact
11% ofpatientsstayedsame 9% of
patientsshowedpositivechange
8% ofheels
showedpositivechange
8% ofheels
stayedsameNo new
hPUsdeveloped
No newhPUs
developed
Change in Heel/Patient Status
Perce
ntage
of to
tal he
els or
patie
nts (%
)
100908070605040302010
0 Heel Entry Status Heel Exit Status Patient Entry Status Patient Exit Status
Comparison of Entry with Exit Status
Normal Abnormal*
n = 106 total heels n = 53 total patients
8%increase
in normal
heelstatus
50%decrease inabnormal
heel status
Assessment of Development of Plantar Flexion Contractures
No. o
f ank
les/pa
tients
with
no pl
antar
flexio
n con
tractu
res (
norm
al)
120
100
80
60
40
20
0 On Entry On ExitNo. of normal* right ankles No. of normal* left ankles No. of normal* patients
* Normal = measurements with goniometer within normal range and showing no evidenceof plantar flexion contractures
n = 53 patients, 106 ankles
100%normal
100%normal
100%normal
100%normal
100%normal
100%normal
* Abnormal patient status means that patient had at least one abnormal heel. Abnormal heeldefined as having status OTHER than pink, clean, clean and dry, OK or intact
Use of a heel protector to maintain heel suspension and proper foot and anklealignment in 53 sedated ICU patients prevented the development of any newhPUs in this high-risk patient population during this 7-month study.
In addition, an assessment of all individual heels (n = 106) indicated that 16 heelswere abnormal upon entry into the study compared with only 8 heels on studyexit, which indicated a 50% decrease in abnormal heel status. Measurement ofankle ROM with a goniometer upon admission and every other day for theduration of the study showed no development of plantar flexion contractures inany patient (based on definition of contracture -50 [90°=0]).
Financial Benefits of hPU Prevention
The heel preventionprotocol resulted in
annual savings of $1,904,220.
[Avg census 260; 7.3%4 may develop PUs =19; 28%4 may develop HPUs = 5; total hPU
days (365) = 1825; avg LOS 4.6 (NIS Data) =397 actual hPU days; 93% stage 1 or 2 4 =
369; 7% stage 3 or 4 4 = 28]
Cost of prevention effort Projected Cost of Projected Cost of(Prevalon purchased) Stage I & II Ulcers Stage III & IV Ulcers
$83,443
$1,249,728
$737,935
369patients4
$2Keachaver.cost9
28patients4
$45Keachaver.cost9
$1,400K
$1,200K
$1,000K
$800K
$600K
$400K
$20K
0
1. Keller BP, Wille J, van Ramshorst B, van der Werken C.Pressure ulcers in intensive care patients: a review of risksand prevention. Intensive Care Med. 2002;28:1379-1388.
2. Jastremski CA. Pressure relief bedding to prevent pressure ulcer development in critical care. J Crit Care.2002;17:122-125.
3. Latronico N, Shehu I, Seghelini E. Neuromuscular sequelaeof critical illness. Curr Opin Crit Care. 2005;11:381-390.
4. Whittington KT, Briones R. National prevalence andincidence study: 6-year sequential acute care data. AdvSkin Wound Care. 2004;17:490-494.
5. Courtney B, Ruppman J, Cooper H. Save our skin: initiativecuts pressure ulcer incidence in half. Nurs Manage. April2006;37:36-45.
6. Hoppenfeld S. Physical Examination of the Spine andExtremities. Norwalk, CT: Prentice-Hall; 1976.
7. Kapandji IA. Ilustrated physiology of joints. Med Biol Illus.1964;14:72-81.
8. Kendall FP, McCreary EK, Provance PG, et al. Muscles:Testing and Function with Posture and Pain. 5th ed.Baltimore, MD: Lippincott Williams and Wilkens; 2005.
9. Young ZF, Evans A, Davis J. Nosocomial pressure ulcerprevention: a successful project. J Nurs Adm. 2003;33:380-383.
4 Whittington KT, Briones R. Adv Skin Wound Care. 2004;17:490-494; 9 Young ZF, Evans A, Davis J. J Nurs Adm. 2003;33:380-383.
Source: Research Institute for Human Engineering for Quality Life, “Measurement and evaluation of the human dynamic characteristics,” JointPassive Resistance Database a4, 2000. Available at: http://www.dh.aist.go.jp/bodyDB/a/HQL-00-04e.html
21102
11%increase
in normalpatientstatus
55%decrease inabnormal
patientstatus
3rd Congress of the World Union of Wound Healing Societies: June 4-8, 2008
Ramsey Score Averages Score Entry Totals Exit Totals
1 7 7 8 8 2 22 44 20 40 3 3 9 9 27 4 11 44 11 44 5 7 35 4 20 6 0 0 0 0
Avg. 2.78 2.67
Modified Ramsey Sedation Scale: 1. Anxious, Agitated, Restless 2. Cooperative, Oriented, Tranquil.
Accepts mechanical ventilation. 3. Responds to commands only4. Brisk response to light glabellar tap or loud noise. 5. Sluggish response to light glabellar tap or loud noise. 6. No Response.
Goniometer used by trained and licensedclinicians to assess forplantar flexion contracture6-8
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