Clinical Guideline HAPU

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Clinical guide for Hospital Acquired Pressure Ulcers

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<ul><li><p>Health Care ProtocolPressure Ulcer Prevention and Treatment Protocol</p><p>How to cite this document:Perry D, Borchert K, Burke S, Chick K, Johnson K, Kraft W, Patel B, Thompson S. Institute for Clinical Systems Improvement. Pressure Ulcer Prevention and Treatment Protocol. Updated January 2012.</p><p>Copies of this ICSI Health Care Protocol may be distributed by any organization to the organizations employees but, except as provided below, may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc. If the organization is a legally constituted medical group, the ICSI Health Care Protocol may be used by the medical group in any of the following ways: </p><p> copies may be provided to anyone involved in the medical groups process for developing and implementing clinical protocols; </p><p> the ICSI Health Care Protocol may be adopted or adapted for use within the medical group only, provided that ICSI receives appropriate attribution on all written or electronic documents and </p><p> copies may be provided to patients and the clinicians who manage their care, if the ICSI Health Care Protocol is incorporated into the medical groups clinical protocol program.</p><p>All other copyright rights in this ICSI Health Care Protocol are reserved by the Institute for Clinical Systems Improvement. The Institute for Clinical Systems Improvement assumes no liability for any adaptations or revisionsormodificationsmadetothisICSIHealthCareProtocol.</p><p> Copyright 2012 by Institute for Clinical Systems Improvement </p><p>www.icsi.org</p></li><li><p>Health Care Protocol:Pressure Ulcer Prevention and Treatment Protocol</p><p>Third EditionJanuary 2012</p><p> Copyright 2012 by Institute for Clinical Systems Improvement 1 </p><p>Inpa</p><p>tient</p><p> Alg</p><p>orith</p><p>m</p><p>www.icsi.org</p><p> M</p><p>inim</p><p>ize/</p><p>elim</p><p>inat</p><p>e fr</p><p>icti</p><p>on </p><p>an</p><p>d s</p><p>hea</p><p>r </p><p> S</p><p>up</p><p>po</p><p>rt s</p><p>urf</p><p>aces</p><p> M</p><p>inim</p><p>ize </p><p>pre</p><p>ssu</p><p>re (</p><p>off</p><p>-lo</p><p>adin</p><p>g) </p><p> Ma</p><p>na</p><p>ge </p><p>mo</p><p>istu</p><p>re</p><p> Mai</p><p>nta</p><p>in a</p><p>deq</p><p>uat</p><p>e n</p><p>utr</p><p>itio</p><p>n/</p><p>hy</p><p>dra</p><p>tio</p><p>n </p><p> E</p><p>du</p><p>cate</p><p> pat</p><p>ien</p><p>t/ca</p><p>reg</p><p>iver</p><p>s</p><p>3</p><p>A </p><p>Is p</p><p>atie</p><p>nt </p><p>at </p><p>risk</p><p>?y</p><p>es</p><p>2 A </p><p>Ris</p><p>k a</p><p>sse</p><p>ssm</p><p>en</p><p>t a</p><p>nd</p><p> do</p><p>cum</p><p>en</p><p>tati</p><p>on</p><p> C</p><p>omp</p><p>lete</p><p> inp</p><p>atie</p><p>nt </p><p>asse</p><p>ssm</p><p>ent</p><p> u</p><p>po</p><p>n ad</p><p>mis</p><p>sio</p><p>n </p><p> - A</p><p>du</p><p>lt </p><p> Bra</p><p>den</p><p> -</p><p> Ped</p><p>iatr</p><p>ic </p><p> Bra</p><p>den</p><p> Q</p><p> Re-</p><p>eval</p><p>uat</p><p>e d</p><p>aily</p><p> or </p><p>as in</p><p>dic</p><p>ated</p><p> f</p><p>or </p><p>care</p><p> set</p><p>tin</p><p>g</p><p>1</p><p>A </p><p>Sk</p><p>in i</p><p>nsp</p><p>ect</p><p>ion</p><p> an</p><p>d d</p><p>ocu</p><p>men</p><p>tati</p><p>on</p><p> C</p><p>omp</p><p>lete</p><p> sk</p><p>in </p><p> insp</p><p>ecti</p><p>on </p><p>up</p><p>on</p><p> ad</p><p>mis</p><p>sio</p><p>n</p><p> Re-</p><p>insp</p><p>ect </p><p>an</p><p>d p</p><p>alp</p><p>ate </p><p>skin</p><p> ev</p><p>ery</p><p> 8</p><p>-24</p><p> ho</p><p>urs</p><p>4</p><p>A </p><p>Is t</p><p>her</p><p>e ev</p><p>iden</p><p>ce o</p><p>f sk</p><p>in </p><p>alte</p><p>rati</p><p>on</p><p>/w</p><p>ou</p><p>nd</p><p>?</p><p>5</p><p>no</p><p>Is t</p><p>he </p><p>skin</p><p> al</p><p>tera</p><p>tio</p><p>n/</p><p>wo</p><p>un</p><p>d a</p><p> p</p><p>ress</p><p>ure</p><p> ulc</p><p>er?</p><p>yes</p><p>6</p><p>Co</p><p>mp</p><p>reh</p><p>en</p><p>siv</p><p>e p</p><p>ati</p><p>en</p><p>t a</p><p>sse</p><p>ssm</p><p>en</p><p>t in</p><p>clu</p><p>din</p><p>g w</p><p>ou</p><p>nd</p><p> ev</p><p>alu</p><p>ati</p><p>on</p><p> an</p><p>d </p><p>do</p><p>cum</p><p>en</p><p>tati</p><p>on</p><p> H</p><p> &amp; P</p><p> W</p><p>ou</p><p>nd</p><p> des</p><p>crip</p><p>tio</p><p>n/</p><p>stag</p><p>ing</p><p> E</p><p>tio</p><p>log</p><p>y o</p><p>f p</p><p>ress</p><p>ure</p><p> N</p><p>utr</p><p>itio</p><p>nal s</p><p>tatu</p><p>s</p><p> Bac</p><p>teri</p><p>al c</p><p>olo</p><p>niz</p><p>atio</p><p>n/</p><p>infe</p><p>ctio</p><p>n</p><p> Psy</p><p>cho</p><p>soci</p><p>al n</p><p>eed</p><p>s</p><p>8</p><p>A </p><p>Iden</p><p>tify</p><p> tre</p><p>atm</p><p>ent </p><p>goa</p><p>ls</p><p>9</p><p>A </p><p>Imp</p><p>lem</p><p>en</p><p>t a</p><p>nd</p><p> do</p><p>cum</p><p>en</p><p>t in</p><p>terv</p><p>en</p><p>tio</p><p>ns</p><p> M</p><p>ois</p><p>t wo</p><p>un</p><p>d h</p><p>eali</p><p>ng</p><p> W</p><p>ou</p><p>nd</p><p> cle</p><p>ansi</p><p>ng</p><p> T</p><p>op</p><p>ical</p><p> tre</p><p>atm</p><p>ents</p><p> D</p><p>ebri</p><p>dem</p><p>ent</p><p> A</p><p>dju</p><p>nct</p><p> th</p><p>erap</p><p>ies</p><p> P</p><p>ain</p><p> man</p><p>ag</p><p>emen</p><p>t</p><p> Nu</p><p>trit</p><p>ion</p><p> S</p><p>urg</p><p>ical</p><p> rep</p><p>air</p><p> E</p><p>du</p><p>cati</p><p>on1</p><p>0</p><p>A </p><p>Wo</p><p>un</p><p>d E</p><p>va</p><p>lua</p><p>tio</p><p>n a</p><p>nd</p><p> Tre</p><p>atm</p><p>en</p><p>t</p><p>Inte</p><p>rdis</p><p>cip</p><p>lin</p><p>ary</p><p> an</p><p>d i</p><p>nte</p><p>r-fa</p><p>cili</p><p>ty c</p><p>om</p><p>mu</p><p>nic</p><p>ati</p><p>on</p><p> an</p><p>d </p><p>do</p><p>cum</p><p>en</p><p>tati</p><p>on</p><p> D</p><p>isch</p><p>arg</p><p>e or</p><p> tra</p><p>nsf</p><p>er o</p><p>f </p><p> car</p><p>e</p><p>11</p><p>Not</p><p>e: t</p><p>his </p><p>alg</p><p>ori</p><p>thm</p><p> dep</p><p>icts</p><p> th</p><p>e re</p><p>quir</p><p>ed d</p><p>ua</p><p>l p</p><p>roce</p><p>sses</p><p> of </p><p>risk</p><p> ass</p><p>essm</p><p>ent </p><p>an</p><p>d s</p><p>kin</p><p> insp</p><p>ecti</p><p>on </p><p>for </p><p>the </p><p>ho</p><p>spit</p><p>aliz</p><p>ed p</p><p>atie</p><p>nt </p><p>an</p><p>d a</p><p>lso</p><p> d</p><p>emo</p><p>nst</p><p>rate</p><p>s th</p><p>e p</p><p>ara</p><p>lle</p><p>l p</p><p>roce</p><p>sses</p><p> th</p><p>at </p><p>exis</p><p>t b</p><p>etw</p><p>een </p><p>the </p><p>pre</p><p>ven</p><p>tion</p><p> pla</p><p>n a</p><p>nd</p><p> wo</p><p>un</p><p>d </p><p>eval</p><p>uat</p><p>ion </p><p>an</p><p>d t</p><p>reat</p><p>men</p><p>t, in</p><p> th</p><p>e p</p><p>rese</p><p>nce</p><p> of </p><p>a </p><p>pre</p><p>ssu</p><p>re u</p><p>lcer</p><p>no</p><p>yes</p><p>Do</p><p>cum</p><p>ent </p><p>wh</p><p>en w</p><p>ou</p><p>nd</p><p> is</p><p> ou</p><p>tsid</p><p>e of</p><p> sco</p><p>pe:</p><p> d</p><p>iffe</p><p>rent</p><p>ial d</p><p>iag</p><p>no</p><p>sis</p><p>7</p><p>A </p><p>noPre</p><p>ssu</p><p>re U</p><p>lce</p><p>r P</p><p>rev</p><p>en</p><p>tio</p><p>n P</p><p>lan</p><p> Do</p><p>cum</p><p>en</p><p>tati</p><p>on</p><p> an</p><p>d E</p><p>du</p><p>cati</p><p>on</p><p> of </p><p>Pa</p><p>tie</p><p>nt </p><p>an</p><p>d C</p><p>are</p><p>giv</p><p>ers</p><p>Pat</p><p>ien</p><p>t ad</p><p>mit</p><p>ted</p><p>A </p><p>A = Annotation</p><p>All algorithm boxes with an "A" and those that refer to other algorithm boxes link to annotation content.</p><p>Text in blue throughout the document also provides links.</p><p>Return to Table of Contents</p></li><li><p>Institute for Clinical Systems Improvement </p><p>www.icsi.org</p><p>2</p><p>Pressure Ulcer Prevention and Treatment Protocol Third Edition/January 2012</p><p>Out</p><p>patie</p><p>nt A</p><p>lgor</p><p>ithm</p><p> M</p><p>inim</p><p>ize/</p><p>elim</p><p>inat</p><p>e fr</p><p>icti</p><p>on a</p><p>nd</p><p> sh</p><p>ear </p><p> Su</p><p>pp</p><p>ort </p><p>surf</p><p>aces</p><p> M</p><p>inim</p><p>ize </p><p>pre</p><p>ssu</p><p>re (</p><p>off-</p><p>load</p><p>ing)</p><p> Man</p><p>age </p><p>moi</p><p>stu</p><p>re</p><p> Mai</p><p>nta</p><p>in a</p><p>deq</p><p>uat</p><p>e n</p><p>utr</p><p>itio</p><p>n/</p><p>hyd</p><p>rati</p><p>on </p><p> Ed</p><p>uca</p><p>te p</p><p>atie</p><p>nt/</p><p>care</p><p>give</p><p>rs </p><p>3</p><p>A </p><p>Is p</p><p>atie</p><p>nt </p><p>at </p><p>risk</p><p>?</p><p>2 A </p><p>Ris</p><p>k a</p><p>sses</p><p>smen</p><p>tan</p><p>d d</p><p>ocu</p><p>men</p><p>tati</p><p>on</p><p>1</p><p>A </p><p>Is t</p><p>her</p><p>e ev</p><p>iden</p><p>ce o</p><p>f sk</p><p>in </p><p>alte</p><p>rati</p><p>on/</p><p>wou</p><p>nd</p><p>?</p><p>5</p><p>Is t</p><p>he </p><p>skin</p><p> al</p><p>tera</p><p>tion</p><p>/w</p><p>oun</p><p>d a</p><p> p</p><p>ress</p><p>ure</p><p> ulc</p><p>er?</p><p>yes</p><p>6</p><p>Com</p><p>pre</p><p>hen</p><p>sive</p><p> pat</p><p>ien</p><p>t as</p><p>sess</p><p>men</p><p>t in</p><p>clu</p><p>din</p><p>gw</p><p>oun</p><p>d e</p><p>valu</p><p>atio</p><p>n a</p><p>nd</p><p> d</p><p>ocu</p><p>men</p><p>tati</p><p>on</p><p> H &amp;</p><p> P</p><p> Wou</p><p>nd</p><p> d</p><p>escr</p><p>ipti</p><p>on/</p><p>stag</p><p>ing</p><p> E</p><p>tiol</p><p>ogy </p><p>of p</p><p>ress</p><p>ure</p><p> N</p><p>utr</p><p>itio</p><p>nal s</p><p>tatu</p><p>s</p><p> Bac</p><p>teri</p><p>al c</p><p>olon</p><p>izat</p><p>ion/</p><p> in</p><p>fect</p><p>ion</p><p> P</p><p>sych</p><p>osoc</p><p>ial n</p><p>eed</p><p>s</p><p>8</p><p>A </p><p>Iden</p><p>tify</p><p> tre</p><p>atm</p><p>ent </p><p>goal</p><p>s</p><p>9</p><p>A </p><p>Imp</p><p>lem</p><p>ent </p><p>and</p><p>doc</p><p>um</p><p>ent </p><p>inte</p><p>rven</p><p>tion</p><p>s</p><p> Moi</p><p>st w</p><p>oun</p><p>d h</p><p>eali</p><p>ng</p><p> W</p><p>oun</p><p>d c</p><p>lean</p><p>sing</p><p> T</p><p>opic</p><p>al t</p><p>reat</p><p>men</p><p>ts</p><p> Deb</p><p>rid</p><p>emen</p><p>t</p><p> Ad</p><p>jun</p><p>ct t</p><p>hera</p><p>pie</p><p>s</p><p> Pai</p><p>n m</p><p>anag</p><p>emen</p><p>t</p><p> Nu</p><p>trit</p><p>ion</p><p> S</p><p>urg</p><p>ical</p><p> rep</p><p>air</p><p> E</p><p>du</p><p>cati</p><p>on10</p><p>A </p><p>Wou</p><p>nd</p><p> Eva</p><p>luat</p><p>ion</p><p> an</p><p>d T</p><p>reat</p><p>men</p><p>tIn</p><p>terd</p><p>isci</p><p>pli</p><p>nar</p><p>yan</p><p>d i</p><p>nte</p><p>rfac</p><p>ilit</p><p>y co</p><p>mm</p><p>un</p><p>icat</p><p>ion</p><p> an</p><p>d </p><p>doc</p><p>um</p><p>enta</p><p>tion</p><p> D</p><p>isch</p><p>arge</p><p> or</p><p> t</p><p>ran</p><p>sfer</p><p> of </p><p>care</p><p>11</p><p>A </p><p>Not</p><p>e: t</p><p>his </p><p>algo</p><p>rith</p><p>m d</p><p>epic</p><p>ts t</p><p>he </p><p>par</p><p>alle</p><p>l p</p><p>roce</p><p>sses</p><p> th</p><p>at e</p><p>xist</p><p> bet</p><p>wee</p><p>n th</p><p>e p</p><p>reve</p><p>ntio</p><p>n p</p><p>lan </p><p>and</p><p> wou</p><p>nd</p><p> eva</p><p>luat</p><p>ion </p><p>and</p><p> tre</p><p>atm</p><p>ent </p><p>in t</p><p>he </p><p>pre</p><p>sen</p><p>ce o</p><p>f a </p><p>pres</p><p>sure</p><p> ulc</p><p>er</p><p>no</p><p>yes</p><p>Doc</p><p>um</p><p>ent </p><p>wh</p><p>en w</p><p>oun</p><p>d </p><p>is o</p><p>uts</p><p>ide </p><p>of s</p><p>cop</p><p>e: </p><p>dif</p><p>fere</p><p>ntia</p><p>l dia</p><p>gnos</p><p>is</p><p>7</p><p>A </p><p>no</p><p>En</p><p>d</p><p>Sk</p><p>in i</p><p>nsp</p><p>ecti</p><p>on </p><p>and</p><p> doc</p><p>um</p><p>enta</p><p>tion</p><p>4</p><p>A </p><p>Pre</p><p>ssu</p><p>re U</p><p>lcer</p><p> Pre</p><p>ven</p><p>tion</p><p> Pla</p><p>n D</p><p>ocu</p><p>men</p><p>tati</p><p>on a</p><p>nd</p><p> Ed</p><p>uca</p><p>tion</p><p> of </p><p>Pat</p><p>ien</p><p>t an</p><p>d C</p><p>areg</p><p>iver</p><p>s</p><p>En</p><p>dno</p><p>yes</p><p>Pat</p><p>ien</p><p>t p</p><p>rese</p><p>nts </p><p>as </p><p>outp</p><p>atie</p><p>nt</p><p>A = Annotation</p><p>All algorithm boxes with an "A" and those that refer to other algorithm boxes link to annotation content.</p><p>Text in blue throughout the document also provides links.</p><p>Return to Table of Contents</p></li><li><p>Institute for Clinical Systems Improvement </p><p>www.icsi.org</p><p>3</p><p>Pressure Ulcer Prevention and Treatment Protocol Third Edition/January 2012</p><p>Table of ContentsWork Group LeaderDeb Perry, RNNursing, Olmsted Medical Center</p><p>Work Group MembersCertified Wound Care SpecialistKathleen Borchert, MS, RN, CWOCN, ACNS-BCHealthEast Care System</p><p>Internal MedicineBhavin Patel, MDHealthPartners Medical Group and Regions Hospital</p><p>NursingSandy Burke, RNOlmsted Medical CenterKatherine Chick, RN, CNSMayo ClinicWendy Kraft, RN, BSN, CWOCNNorth MemorialSusan Thompson, MS, RNMayo Clinic</p><p>FacilitatorKari Retzer, RNICSI</p><p>Algorithms and Annotations ....................................................................................... 1-41Inpatient Algorithm ............................................................................................................ 1Outpatient Algorithm .......................................................................................................... 2</p><p>Disclosure of Potential Conflict of Interest ........................................................................ 4</p><p>Description of Evidence Grading ....................................................................................... 4</p><p>Foreword</p><p>Introduction ................................................................................................................... 5Scope and Target Population ......................................................................................... 6Aims .............................................................................................................................. 6Clinical Highlights ..................................................................................................... 6-7Implementation Recommendation Highlights ......................................................... 7-11Related ICSI Scientific Documents .............................................................................11Definitions .............................................................................................................. 12-13Special Considerations ................................................................................................ 13</p><p>Protocol ....................................................................................................................... 14-16</p><p>Annotations ................................................................................................................. 17-41</p><p> Quality Improvement Support ................................................................................ 42-73Aims and Measures ..................................................................................................... 43-45</p><p>Measurement Specifications .................................................................................. 46-65Implementation Recommendations ............................................................................. 66-70Resources .......................................................................................................................... 70Resources Table ........................................................................................................... 71-73</p><p>Supporting Evidence.................................................................................................... 74-86References ................................................................................................................... 75-80</p><p>Appendices .................................................................................................................. 81-86Appendix A Braden Scale for Predicting Pressure Sore Risk (Braden Scale) ........................................................................................................ 81Appendix B Braden Q Scale ......................................................................................82Appendix C Outpatient Risk Assessment Plan ...............................................................83Appendix D Pressure Ulcer Prevention Plan ............................................................ 84-85Appendix E Mnemonics for Critical Colonization .........................................................86</p><p>Document History and Development ..................................................................... 87-88Document History ............................................................................................................ 87ICSI Document Development and Revision Process ....................................................... 88</p></li><li><p>Institute for Clinical Systems Improvement </p><p>www.icsi.org</p><p>4</p><p>Disclosure of Potential Conflict of InterestIn the interest of full disclosure, ICSI has adopted a policy of revealing relationships work group members have with companies that sell products or services that are relevant to this protocol topic. It is not assumed that these financial interests will have an adverse impact on content. They are simply noted here to fully inform users of the protocol.</p><p>Kathy Borchert, MS, RN, CWOCN, ACNS-BC, reviews documentation and provides expert testimony related to pressure ulcer cases.</p><p>No other work group members have potential conflicts of interest to disclose.</p><p>Return to Table of Contents</p><p>Description of Evidence Grading A consistent and defined process is used for literature search and review for the development and revision of ICSI Protocols. Literature search terms for the current revision of this document include device-related pressure ulcers in pediatric patients, occipital pressure ulcers in pediatric patients, pressure ulcer prevention, pressure ulcer prevention with devices, biofilm, hyperglycemia and pressure ulcers, deep tissue injury and stageable pressure ulcers from January 2010 through July 2011.</p><p>Individual research reports are assigned a letter indicating the class of report based on design type: A, B, C, D, M, R, X.</p><p>Evidence citations are listed in the document utilizing this format: (Author, YYYY [report class]; Author, YYYY [report class] in chronological order, most recent date first). A full explanation of ICSI's Evidence Grading System can be found on the ICSI Web site at http://www.icsi.org.</p><p>Class Description </p><p>Primary Reports of New Data Collections </p><p>A Randomized, controlled trial </p><p>B Cohort-study </p><p>C Non-randomized trial with concurrent or historical controls Case-control study Study of sensitivity and specificity of a diagnostic test Population-based descriptive study </p><p>D Cross-sectional study Case series Case report </p><p>Reports that Synthesize or Reflect upon Collections of Primary Reports </p><p>M Meta-analysis Sytematic review Decision analysis Cost-effectiveness analysis </p><p>R Consensus statement Consensus report Narrative review </p><p>X Medical opinion </p><p> Return to Table of Contents</p><p> Pressure Ulcer Prevention and Treatment ProtocolThird Edition/January 2012</p></li><li><p>Institute for Clinical Systems Improvement </p><p>www.icsi.org</p><p>5</p><p>ForewordIntroduction </p><p>Pressure ulcers have been associated with an extended length of hospitalization, sepsis and mortality. In fact, nearly 60,000 United States hospital patients are estimated to die each year from complications due to hospital-acquired pressure ulcers. The estimated cost of managing a single full-thickness pressure ulcer is as high as $70,000, and the total cost for treatment of pressure ulcers in the United States is estimated at $11 billion per year (Reddy, 2006 [M]; Redelings, 2005 [C]).</p><p>The prevalence of pressure ulcers in health care facilities is increasing. Pressure ulcer incidence rates vary considerably by clinical setting, ranging from 0.4% to 38% in acute care, from 2.2% to 23.9% in long-term care, and from 0% to 17% in home care (Lyder, 2003 [R]).</p><p