Final 2020 NPIAP CPG Deck pressure sore grade

Cpg wound

1. The 2019 International Guidelines What’s New

2. NPIAP CPG 2019 The  National Pressure Injury Advisory Panel (NPIAP)  released their 2019 Clinical Practice Guideline which provides the most comprehensive evidence-based recommendations on pressure ulcer/injury prevention and treatment. The guideline was developed through an international collaboration and is based on extensive research and expert opinion.  It includes evidence-based best practice recommendations for the prevention of pressure injuries

3. Clinical Question: Are parachutes effective in preventing injury when jumping from a plane at high altitudes? Wear a parachute when jumping from a plane at high altitudes. (Good Practice Statement) “ Parachutes reduce the risk of injury after gravitational challenge, but their effectiveness has not been proved with randomized controlled trials.” Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ (Clinical research ed ). 2003;327(7429):1459-1461. Cuddigan, Janet 2019 Methodology & Key Changes. NPIAP Guideline Launch Presentation

4. What are the key recommendations from the 2019 NPIAP guideline? Risk Assessment : Conduct a comprehensive risk assessment for all patients upon admission and reassess at regular intervals. Skin Inspection : Perform daily skin inspections for all patients at risk of pressure injuries. Support Surfaces : Use higher-specification foam mattresses rather than standard hospital mattresses for at-risk patients. Repositioning : Reposition at-risk patients at least every two hours to redistribute pressure. Nutrition : Provide nutritional support based on individual needs to prevent and treat pressure injuries. Education : Educate healthcare professionals, patients, and caregivers about pressure injury prevention and management.

5. Prevention of Pressure Injuries: Risk Factors and Risk Assessment

6. Risk Assessment Tools Three most commonly used scales: Norton Scale (1962) Waterlow Score (1985) Braden Scale for Predicting Pressure Sore Risk (1987) This is the most commonly used European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019. P.61 Scale images accessed July 2020 Why use them? They provide: A practical framework Operational definitions of risk factors that have clinical utility and can be reliably measured Focus on modifiable risk factors Subscale scores that can be used as a basis for risk-based intervention planning Clinical reminders (especially for novice nurses) A minimum auditable standard.

7. The BIG Question: When does the Risk Assessment have to be done? 1.21: Conduct a pressure injury risk screening as soon as possible after admission to the care service and periodically thereafter to identify individuals at risk of developing pressure injuries. (Good Practice Statement) 1.22: Conduct a full pressure injury risk assessment as guided by the screening outcome after admission and after any change in status. (Good Practice Statement) 1.23: Develop and implement a risk-based prevention plan for individuals identified as being at risk of developing pressure injuries. (Good Practice Statement) Repeat the risk assessment as often as required by the individual’s acuity . Undertake a reassessment if there is any significant change in the individual’s condition ( Expert opinion ). European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019. p.58. Image presentermedia. Account: 166165

8. Prevention of Pressure Injuries : Skin and Tissue Assessment

9. Skin and Tissue Assessment What: Comprehensive skin and tissue assessment Who: All individuals at risk of pressure injuries When: ASAP after admission/transfer to the health care facility As part of every risk assessment Prior to discharge from the care service Inspection Components: Inspect for areas of erythema Blanchable vs. non-blanchable Assess the skin and soft tissue for temperature - NEW Assess the skin and soft tissue for edema and change in consistency of the surrounding tissue, consider using a sub-epidermal moisture/edema measurement device - NEW Assess the skin and soft tissue for turgor and change in consistency of the surrounding tissue Use tangential light and slightly moisten skin to inspect darkly pigmented skin, consider using a skin color chart - NEW Take care to inspect skin folds of the obese individual European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019. p. 73-83 Image – presentermedia acct 166165

10. Preventive Skin Care: Prophylactic Dressings Implementation Considerations Continue to implement other measures such as regular repositioning and support surfaces to prevent pressure injuries when using a prophylactic dressing ( Expert opinion ). Continue to assess the skin under a prophylactic dressing at least daily to evaluate the effectiveness of the preventive care regimen. Many dressings have features that facilitate regular skin assessment ( Levels 1 and 3 ). 3.5: Use a soft silicone multi-layered foam dressing to protect the skin for individuals at risk of pressure injuries. (Strength of Evidence = B1; Strength of Recommendation = ↑) Replace the prophylactic dressing if it becomes dislodged, loosened or excessively moist, if the dressing or skin underneath become soiled, and according to the manufacturer’s instructions ( Levels 1 and 3 ). For individuals at high risk of pressure injuries, application of a prophylactic dressing should be initiated as early as possible in the care pathway when feasible, for example applied in the ambulance or emergency room) ( Level 1 ). In 2014 the section on Prophylactic Dressings was only an Emerging Therapy, In 2019 Prophylactic Dressings are classed as Evidenced-based Practice. 18 of the 22 sustaining research articles are on Mepilex ® Border Sacrum or Mepilex ® Border Heel NEW European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019. p. 84-93

11. Preventive Skin Care: Prophylactic Dressings When selecting a prophylactic dressing consider: Potential benefit of using a dressing Appropriateness of the size and design of the dressing Ability to manage the microclimate Ease of application and removal Ability to maintain the dressing in situ Ability to regularly assess the skin under the dressing The individual’s preferences , comfort and any allergies Coefficient of friction at the skin-dressing interface Cost-effectiveness and accessibility of dressings ( Expert opinion ). Mepilex ® Border Sacrum Mepilex ® Border Heel Mepilex ® Border Flex European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019. p. 84-93

12. Preventive Skin Care: Prophylactic Dressings MHC 270567 10.17 p2

13. Prevention of Pressure Injuries : Repositioning & Early Mobilization

14. Repositioning & Early Mobilization The Top 4 Recommendations 5.1: Reposition all individuals with or at risk of pressure injuries on an individualized schedule, unless contraindicated. (Strength of Evidence = B1; Strength of Recommendation = ↑↑) 5.4: Implement repositioning reminder strategies to promote adherence to repositioning regimens. (Strength of Evidence = B1; Strength of Recommendation = ↑) 5.9: Keep the head of bed as flat as possible. (Strength of Evidence = B1; Strength of Recommendation = ↔ ) 5.10: Avoid extended use of prone positioning unless required for management of the individual’s medical condition. Strength of Evidence = B1; Strength of Recommendation = ↔) 5.11: Promote seating out of bed in an appropriate chair or wheelchair for limited periods of time. (Strength of Evidence = B1; Strength of Recommendation = ↑) European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019. p. 115 - 144

15. Prevention of Pressure Injuries : Heel Pressure Injuries

16. Heel Pressure Injuries 6.2: For individuals at risk of heel pressure injuries and/or with Category/Stage I or II pressure injuries, elevate the heels using a specifically designed heel suspension device or a pillow/ foam cushion. Offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon and the popliteal vein. (Strength of Evidence = B1; Strength of Recommendation = ↑↑) 6.4: Use a prophylactic dressing as an adjunct to heel offloading and other strategies to prevent heel pressure injuries. (Strength of Evidence = B1; Strength of Recommendation = ↑) European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019. p. 145 – 154 Image: Boneandspine.com Blood supply to the calcaneus. Accessed 8/9/2020

17. Prevention of Pressure Injuries : Support Surfaces

18. Support Surfaces - Review Categories of Support Surfaces Reactive: A powered or non-powered support surface with the ability to change its load distribution properties only in response to an applied load. Active: A powered support surface that has the ability to change its load distribution properties with or without an applied load. What is a Support Surface? A Support Surface is a specialized device for pressure redistribution designed for management of tissue loads, microclimate, and/or other therapeutic functions. Types of Support Surfaces: any mattress, integrated bed system, mattress replacement, mattress overlay, or seat cushion, or seat cushion overlay European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019. p. 155 - 180

19. Prevention of Pressure Injuries : Device Related Pressure Injuries

20. Device Related Pressure Injuries Identified potential sources of pressure injuries increased from 19 equipment sources in the 2014 to 31 equipment sources, list not limiting, in 2019 Categories: Respiratory Equipment Orthopedic Equipment Urinary & Fecal Equipment Tubes & Drains IVs & Cuffs/Compression Systems Non-Medical Devices Classify non-mucosal pressure injuries according to the staging system, Stage 1-4, DTI, Unstageable European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019. p. 181-193 Images: MHC-2015-3642

21. Key Points to Remember: There is direct evidence in a range of populations that application of a prophylactic dressing at the skin-device interface reduces the incidence of medical device related pressure injuries. - Select a dressing that can manage microclimate, absorb moisture and manages friction at the skin – dressing interface Avoid excessive layering of prophylactic dressings under a device because layering may in fact increase pressure Ensure the functionality of the medical device is not compromised by the prophylactic dressing Regularly inspect the skin under the device, as feasible If appropriate and safe, alternate the oxygen delivery device between correctly fitting mask and nasal prongs to reduce the severity of nasal and facial pressure injuries for neonates receiving oxygen therapy. Device Related Mucosal Pressure Injury European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019. p. 181-193

22. Stage 1 Non blanchable erythema of intact skin Stage 2 Partial thickness skin loss, with exposed dermis Stage 3 Full thickness skin loss, slough may be present Stage 4 Full thickness skin and tissue loss, with exposed bone, tendon, muscle Unstageable Obscured full-thickness skin and tissue loss, with s lough and/or eschar Deep Tissue Injury Persistent non- blanchable deep red, maroon or purple discoloration Stage 1 Stage 2 Stage 3 Stage 4 Unstageable DTI All wounds classified based upon Depth of tissue destruction NPIAP Pressure Injury Classification System

23. Treatment of Pressure Injuries: Pressure Injury Assessment & Monitoring Healing

24. 3 Key Reminders: Conduct a comprehensive reassessment of the individual, if the pressure injury does not show some signs of healing within two weeks despite appropriate local wound care, pressure redistribution, and nutrition. Select a uniform, consistent method for measuring pressure injury size and surface area to facilitate meaningful comparisons of wound measurements across time. Consider using a validated tool to monitor pressure injury healing. Treatment of Pressure Injuries: Pressure Injury Assessment & Monitoring Healing European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019. p. 209-223

25. Treatment of Pressure Injuries: Pain Assessment & Treatment

26. Conduct a comprehensive pain assessment for individuals with a pressure injury - Assess pain prior and during wound procedures - Including but not limited to: Character, intensity and duration Consider applying a topical opioid to manage wound-related pressure injury pain, if required and when there are no contraindications. - Topical opioids generally have minimal systemic effect - Topical opioids and other topical analgesia are more effective when applied 20 to 30 minutes, and up to 60 minutes, prior to wound care Pain Assessment & Treatment European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019. p. 224-234

27. Treatment of Pressure Injuries: Supporting Healing

28. T Tissue Management, remove devitalized or necrotic tissue I Infection and Inflammation control, reduce bacterial count M Moisture Balance, promoting a warm, moist wound bed to prevent desiccation E Epithelial Edge Advancement, a non-advancing edge due to T-I-M not being controlled can delay healing Plus update R Repair and Regeneration, support of therapies that stimulate wound healing S Social and Individual-Related Factors, the patient’s intrinsic and extrinsic risk factors that cause a pressure injury may also be those that need remediation for healing Treatment of Pressure Injuries: Supporting Healing European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019. p. 235-236

29. Treatment of Pressure Injuries: Cleansing & Debridement

30. 12.3: Cleanse the skin surrounding the pressure injury. Strength of Evidence = B2; Strength of Recommendation = ↑ 12.4: Avoid disturbing stable, hard, dry eschar in ischemic limbs and heels, unless infection is suspected . Strength of Evidence = B2; Strength of Recommendation = ↑ ↑ 12.5: Debride the pressure injury of devitalized tissue and suspected or confirmed biofilm and perform maintenance debridement until the wound bed is free of devitalized tissue and covered with granulation tissue. Strength of Evidence = B2; Strength of Recommendation = ↑ ↑ Cleansing & Debridement European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019. p. 237 – 250

31. Treatment of Pressure Injuries: Wound Dressings & Surgeries for Treatment

32. Wound Dressings for Treatment Selection based on goal for the treatment Selection based on the self-care ability of the patient or caregiver Selection based on the clinical assessment of the wound: Diameter, shape and depth of the pressure injury Need to address bacterial bioburden Ability to keep the wound bed moist Nature and volume of wound exudate Condition of the tissue in the wound bed Condition of the peri-wound skin Presence of tunneling and/or undermining Pain Selection criteria for a wound dressing: European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019. p. 267-278

33. Wound Dressings for Treatment Mepilex ® Lite or Mepilex ® Border Lite dressings for non-infected Stage II pressure injuries as indicated by the clinical condition of the pressure injury. Normlgel Ag dressing for non-infected or infected Stage II pressure injuries as indicated by the clinical condition of the pressure injury Mepilex ® or Mepilex ® Border Flex dressings for non-infected Stage II pressure injuries as indicated by the clinical condition of the pressure injury Advanced Wound Care Dressings: Stage 1 and Stage 2 Pressure Injuries

34. Surgical Management Debridement : During surgery, the wound is cleaned (debrided) to remove any dead or infected tissue. This process creates a larger wound, but the remaining healthy tissue is more likely to heal. Flap Reconstruction : Partial Flap : A section of healthy skin and tissue near the wound is partly detached and pulled over the wound. Part of the flap remains attached to blood vessels connected to healthy tissue, ensuring nourishment for the skin and tissue over the wound. Full Flap : Healthy skin and tissue are completely detached (harvested) from areas like the back, buttocks, or thigh and moved to cover the wound. Common Sites for Treatment : Ischium : The bony area above the back side of the thigh and beneath the buttocks. Sacrum : The bone in the center of the lower back, just above the buttocks. Trochanter : The bony area on the side of the hip. Benefits of Surgical Treatment : Surgical closure significantly improves quality-of-life scores for patients with traumatic spinal cord injuries. Healing of severe wounds often requires surgical intervention.