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• W2142121749 abstract "The skin is the largest nonsolid organ in the human body. However, the skin does not receive the same kind of attention that solid organs such as the heart, lungs, or brain do. The skin certainly does not receive the kind of urgent attention that solid organs receive when they display signs of compromise.Patients admitted to the intensive care unit (ICU) are the most disadvantaged when it comes to maintaining intact skin, starting from day one of their stay.1,2 Critically ill patients may be sedated, receiving mechanical ventilation, and confined to bed for long periods. Prolonged pressure on areas where bony prominences are located predisposes these patients to pressure ulcers.1(p1383) Because of critically ill patients’ inability to turn themselves, caregivers must reposition them in bed. If improperly performed, repositioning can cause friction and shearing, which lead to pressure ulcers.Many of these patients also receive vasopressors to support blood pressure and maintain adequate cardiac output. Unfortunately, the same infusions that control patients’ blood pressure also constrict peripheral circulation and deprive the capillary beds that supply the skin of the oxygen and nutrients that it needs.1,2Although research has not proven a link between poor nutrition and development of pressure ulcers, weight loss in ICU patients has been observed. As a result of feeding often being delayed, the loss of subcutaneous tissue, especially over bony prominences, can cause pressure ulcers to develop more easily.In the cardiothoracic ICU, patients can also be highly unstable hemodynamically. Patients’ chests can stay open for some time, and therefore, turning the patients requires great caution. Multiorgan failure, which causes cytokine release and starts the inflammatory process, leads to edema, and fluid-overloaded skin is a pressure ulcer waiting to happen. In addition, incontinence is common in ICU patients. If the skin is left in contact with caustic substances from urine and feces for prolonged periods, it can become macerated, and the resultant skin impairment can lead to pressure ulcers.In the past, the development of pressure ulcers has been considered a problem belonging to long-term facilities, nursing homes, and institutions providing care for chronically ill patients. In the past few years, however, regulatory agencies in health care have started looking into new indicators of quality care in acute care facilities. One of the National Patient Safety Goals put forth by the Joint Commission is prevention of hospital-acquired complications. Some complications considered indicative of poor quality care are catheter-associated bloodstream infections, catheter-associated urinary tract infections, and the development of pressure ulcers.3The Commission on Medicare and Medicaid Services (CMS) has also developed new criteria for reimbursement. Starting in October 2008, CMS has withheld reimbursements for what it considers complications unrelated to the original diagnosis or the original reason for hospitalization.4 Examples include surgical site infection after coronary artery bypass graft, air embolism, blood transfusion incompatibility, and, again, pressure ulcers.At New York Presbyterian Hospital, the senior leadership started to look at this problem from a new perspective. We started institution-wide initiatives that gave the integumentary system more attention than it used to get.5 Best practice efforts continued, such as benchmarking with hospitals and sharing information with the National Database for Nursing Quality Indicators. Use of the Braden scale to evaluate risk of pressure ulcers also continued.In addition, new initiatives were instituted. One of the earliest initiatives was to invest in new beds for patients. Our new beds with a pressure redistribution surface provide protection from skin breakdown in several ways. Pressure is redistributed by separate cushion channels in the head, sacrum, and heel, preventing blockage of circulation and allowing adequate blood flow to different areas of the body. The beds also have a micro-cooling air management system that ensures a breathable ventilated surface, thereby reducing heat buildup in regions prone to skin breakdown.Every unit identified a staff member who focuses on prevention of pressure ulcers; they are called “skin champions.” The skin champions make sure that pressure ulcer prevention protocols are put in place in their units. If the skin becomes impaired despite these efforts, or if an already existing impairment gets worse, the skin champion, in collaboration with the physician, requests a consultation with a wound ostomy and continence (WOC) nurse to help with the management and recommendations for treatment.Rounds with the WOC nurse to monitor progress of these patients are planned weekly or more often if necessary. The skin champions meet monthly to discuss problems, evidence-based practices and treatments, and implementation of solutions and to hear about new products and learn through educational lectures and presentations. In addition, the skin champions moved better products for prevention of skin breakdown to the forefront.A new protocol for pressure ulcer prevention and treatment was implemented in the cardiothoracic ICU, almost simultaneously with the hospital-wide initiatives. The new protocol allows skin care and assessment to be incorporated into the nursing care activities that start from the time patients are admitted and throughout their average stay in the cardiothoracic ICU.Instead of waiting until the patient is awake and able to be turned before checking the skin visually, we start pressure ulcer prevention when the patient arrives in the unit. Interventions for preservation of skin integrity are incorporated into corresponding nursing activities performed during admission into the ICU (see Table).Care of a newly admitted patient is a very involved process that includes initial assessment, continuous monitoring, titration of dosage of vasoactive intravenous medications, implementing interruptions in sedation, preparing for extubation, physical care, and documentation. The main interventions for pressure ulcer prevention are assessing risk for pressure ulcers, turning and positioning, use of moisture barriers and skin protectants, use of specialty beds, nutrition screening, managing incontinence and initiating skin rounds. Marrying critical care nursing actions with pressure ulcer prevention in a combined care map forces the interdisciplinary team to give the integumentary system the attention that it needs early in the patient’s ICU stay.The new protocol also provides the ICU staff with a decision-making structure that allows immediate response to patients identified as at high risk for pressure ulcers (see Figure).Being able to differentiate a pressure ulcer from fungal rash, incontinence-related dermatitis, a diabetic ulcer, an arterial wound, and a venous wound is extremely important to determine subsequent treatment options.6 According to the National Pressure Ulcer Advisory Panel (NPUAP), “a pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or in combination with shear and/or friction.”7 In 1989, NPUAP developed a 4-stage classification system for pressure ulcers. This system did not recognize unstageable and deep tissue injury. In 2007, NPUAP updated the staging system by addressing the causes of wounds. This method has improved the understanding of pressure ulcers and the treatment of wounds caused by pressure. The classification system is described as follows.7Stage I is characterized by intact skin with localized redness that does not blanch when light pressure is applied specifically over a bony prominence. When skin is darkly pigmented, blanching might not be visible, but the sore’s color may appear different from the surrounding area.Stage II is characterized by a partial loss of thickness of the dermis. A stage II pressure ulcer is shallow and open, with a red or pink wound bed, and has no slough. It may also manifest as an intact or ruptured serum-filled blister.Stage III pressure ulcers are characterized by a loss of the full thickness of tissue; subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed, and undermining or tunneling may be present.Stage IV pressure ulcers are characterized by a loss of the full thickness of tissue, with exposed bone, tendon, or muscle. Undermining, tunneling, or both are often present.In addition to these 4 stages, NPUAP has added 2 more classifications: (1) unstageable, described as a loss of full thickness of tissue but with the wound covered by slough and/or eschar and (2) suspected deep tissue injury, an area of localized, discolored (purple or maroon) intact skin resulting from damage of the underlying soft tissue caused by pressure or by shear.Despite the improvements in the classification system, disagreements still exist among staff nurses and WOC nurses in identification of pressure ulcers and different types of wounds.8Historically, in nursing schools, the integumentary system has been the last organ about which students learned. In case presentations, it is the organ least presented or addressed. Even today, at hand-off communication, the integumentary system is often the last system mentioned. In ICUs, if the patient is in critical condition and dependent on life-support measures, the condition of the patient’s skin might not even be mentioned. When life and death decisions are being made in the care of critically ill patients, it is easy to put aside skin care and pressure ulcer prevention as a nonpriority item in ICUs. However, the degree of patients’ suffering, the dissatisfaction among family members, the prolonged length of stay, and the increase in the cost of care are enough reasons to keep the issue of skin care and pressure ulcer prevention constantly in our minds. We need to continuously look for innovative ways to make sure we keep the occurrence of pressure ulcers to a minimum.Recent articles have suggested that not all pressure ulcers can be prevented.9 Furthermore, CMS acknowledges that not all pressure ulcers are unavoidable in long-term care settings.9Interventions used in ICUs are sometimes contradictory to good skin care practices. For instance, prevention of ventilator-associated pneumonia recommends that the head of a patient’s bed be raised to a 40º angle. Pressure ulcer prevention, however, states that keeping the head of a bed that high predisposes the patient to sliding down the bed, causing shearing and friction, and leading to development of pressure ulcers. As a compromise, protocols in our institution now recommend that the head of the bed be elevated no higher than 30º. Further complicating matters are the comorbid conditions that many ICU patients have that predispose them to skin breakdown and the procedures that prevent the staff from turning patients at the accepted and prescribed frequency of every 2 hours.New technology and new products will certainly help prevent pressure ulcers. However, key factors to reduce the incidence of pressure ulcers include changing our perspective of the importance of the integumentary system and strong collaboration among multidisciplinary team members.The authors would like to thank Catherine Halliday, Director of Cardiac Services at New York Presbyterian Hospital-Columbia University, for her support, encouragement, and advice during the writing of this article. The authors also thank all fellow skin champions for their inspiration and hard work in the prevention of pressure ulcers." @default.
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• W2142121749 title "Pressure Ulcers in the Intensive Care Unit: New Perspectives on an Old Problem" @default.
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