Sacs 2.0 a review of the original sacs scale WUWHS Florence 29.09.2016

About eight years have passed since the publication of the SACS Classification, the use of which has proved to be essential in Italy, not only on account of the particular characteristics of this instrument but also and above all as it is a point of reference for debate and discussion and aims to facilitate an objective awareness of peristomal skin lesions.

1. SACS 2.0
a review of theoriginalSACS scale
and a proposal of a new classification
ANTONINI Mario
Ostomy and Wound Care Specialist –Local Healthcare Toscana Centro -Empoli
Professor at University of Florence
[email protected]

2. “The Peristomal skin should be
intact with no evidence of
redness, loss of epidermis or
sensations such as itchiness,
warmth or pain ”
Colwell J, Beitz J. Survey of wound ostomy and continence (WOC) nurse clinicians on stomal and
peristomal complications: A content validation study. J Wound Ostomy Continence Nurs.
2007;34(1):57-69.

4. WHAT IS A PERISTOMAL SKIN DISORDERS?
-Anycompromise in the integrityof peristomalskin(definition)
-Wide rangeof incidencerates:
-10,2 –40% (reviewof 7 studies)
1
-18 –55%
2
-Lack of consensus concerning stomaland peristomalcomplications does not allow for comparison of
prevalence rates
1. SalvadalenaG. Incidence of complications of the stoma and peristomalskin among individuals with colostomy, ileostomy, and urostomy: a systematic review. J Wound Ostomy Continence Nurs.
2008;35(6):596-607.
2. Bosio G, Pisani F, Lucibello L, Fonti A, Scrocca A, MorandellC, Anselmi L, Antonini M, Militello G, Mastronicola D, Gasperini S. A proposalfor classifyingperistomalskindisorders: resultsof a multicenter
observationalstudy.OstomyWoundManage. 2007;53(9):38-43.
3. ColwellJ, BeitzJ. Surveyof woundostomyand continence(WOC) nurse clinicianson stomaland peristomalcomplications: A contentvalidationstudy. J WoundOstomyContinenceNurs. 2007;34(1):57-69.
ST. CYRETAL. (2012)
An evaluationof the
canadianassessmentguide
44%
BOSIOETAL. (2007)
A proposalforclassifyingperistomalskin
disorders: resultsof a multicenter
observationalstudy
52%
COLWELLETAL. (2001)
The state of the
sandarddiversion
56%
ANTONINIM, MILITELLOG (2013)
The incidenceof Stomaland Peristomal
Complicationsin Italy: resultsof a pilotstudy
56%
SCARPAETAL(2007)
Rod in loopileostomy: just an
insignificantdetailforileostomy-
relatedcomplications?
61%

5. REVIEW OF THE LITERATURE
Incidence of complications of the
stoma and peristomalskin
among individuals with
colostomy, ileostomy, and
urostomy: a systematic review.
SalvadalenaG. Journal Wound
Ostomy Continence Nurs. 2008
Nov-Dec;35(6):596-607; quiz 608-9.
Number of participants in each
phase of the analysis.
Differentlengthof the studies.
NO DEFINITIONSOF
SKINDISORDERS.
NO DESCRIPTIONOF
THE ASSESSMENT OF
THE SKINLESIONS.

6. Complications
Time OSTOMYCOMPLICATIONS PERISTOMALCOMPLICATIONS Cutaneoussigns
Immediate post-operative
complications(0 –72 hrs)
Oedema ContactAllergicDermatitis(CAD)Cutaneousalterations
Ischaemiaand necrosis Candidiasis Infection
Intra and peristomalhaemorrageFolliculitisor otherbacteria
Malpositioning Pseudo-verrocouslesion Proliferation
Poorcreationof a stoma Oxalatesdeposit
Late post-operative complicationsRetraction Neoplasia
Prolapse Mucocutaneousdetachment Ulcer
Fistula Pressure Ulcers
Stenosis ContactIrritative Dermatitis(CID)
Hernia PyodermaGangrenosum
Trauma Trauma
Pseudo-inflammatorypolypse DermatitisArtefact
Psoriasis Dermatologicaldisease
Eczema
Seborrheicdermatitis

7. WHAT IS THE SACS INSTRUMENT?
-An evidence-based instrument developed out of a clinical need
-A systematic literature review revealed that no universal system existed to objectively classify peristomal
lesions according to type and location
-The SACS™ Instrument was developed to help establish a standard language for the assessment and
classification of peristomallesions
-Provides operational definitions for the consistent interpretation of peristomalskin lesions
-An objective classification system to document the incidence of peristomalskin lesions

8. L1 –Erythematouslesion
(peristomalerythemewithout
lossof substance
L2 –Erosive lesionwith lossof
substanceasfar asand non
beyondthe basalmembrane
L3 –Ulcerative lesionbeyond
the basalmembrane
L4 –Ulcerative
fibrinous/necroticlesion
LX –Proliferative lesion
(neplasia, granulomas, osalate
deposit)
ORIGINAL SACS CLASSIFICATION

9. The SACS 2.0 Study: objectives
1. Completionof the classificationto include an additional
levelof severity(L5)
2. Classificationof alltypesof peristomalskinchanges
present, eliminatingthe notionof «mostseriouslesion»

10. Empoli
Prato
Rimini
Catania
Beginningof the
SACS 2.0 Study
(January2013)
End of the SACS 2.0
Study
(December2014)
Comingsoon…..
WCET Journal

11. Ostomy Patient
S.A.C.S. 2.0
Study
ENROLLMENT
Time frames
T0T1T2 T6T5T4T3
ASSESSMENT
7 DAYS
14 DAYS
1 MONTH 2 MONTHS
3 MONTHS
6 MONTHS
Consensus
Conference
SACS 2.0 Classification

12. The SACS 2.0 Study: Results
PATIENTSENROLLED
SkinIntegrity
171
PeristomalSkin
Disorders
255
Incidence
59,86%
47%
53%
Gender
Males ♂Females ♀
43%
40%
17%
OstomyTypes
ColostomyIleostomyUrostomy
61
74
23
66
13
18
01020304050607080
L1: Erythematous lesion
L2: Erosive lesion
L3: Ulcerative lesion
L4: Ulcerative with fibrin/necrotic lesion
L5: Ulcerative involving planes beyond the
fascia
LX: Proliferative lesion
Peristomal Skin Disorders

13. L1 –Erythematouslesion
(peristomalerythemewithout
lossof substance
L2 –Erosive lesionwith lossof
substanceasfar asand non
beyondthe basalmembrane
L3 –Ulcerative lesionbeyond
the basalmembrane
L4 –Ulcerative
fibrinous/necroticlesion
L5 –ULCERATIVELESIONINVOLVING
PLANESBEYONDTHEMUSCOLAR
FASCIA(WITHORWITHOUTFIBRIN,
NECROSIS, PUSORFISTULA)
LX –Proliferative lesion
(neplasia, granulomas, osalate
deposit)
SACS CLASSIFICATION 2.0
Objectiven.1: Completionof the classificationto include an additionallevelof severity(L5)

14. THE SACS STUDY: TOPOGRAPHY (T)
TOPOGRAPHY(T)
Perspectiveof theHCP
-I=UpperLeftQuadrant
-II=UpperRightQuadrant
-III=LowerRightQuadrant
-IV=LowerLeftQuadrant
-V=AlltheQuadrants
Patientstanding in front of the
HCP
The orderof thequadrantsaroundthe stoma
startsin theUpper Leftcorner (TI) andends
in theLowerLeftcorner (TIV) clockwise.

15. Objectiven.1: Completionof the classificationto include an additionallevelof severity(L5)
L5 –ULCERATIVELESIONINVOLVINGPLANESBEYONDTHE
MUSCOLARFASCIA(WITHORWITHOUTFIBRIN, NECROSIS, PUSOR
FISTULA)
We therefore proposed the
sole inclusion of the condition
relating to the detection of a
new non-classifiable lesion (L5)
—even though it has a low
presence in our study (5%)
4. Sandy-HodgettsK, CarvilleK, Leslie GD. Determiningrisk factors for surgical wound dehiscence: a literature review. IntWoundJ 2015;12:265-75.
5. DealeyC. The management of patients with acute wounds. In: DealeyC. The Care of Wounds: A Guide for Nurses. Fourth edition. Hoboken, NJ: John Wiley & Sons; 2012.

16. L5 –ULCERATIVELESIONINVOLVINGPLANES
BEYONDTHEMUSCOLARFASCIA(WITHOR
WITHOUTFIBRIN, NECROSIS, PUSOR
FISTULA)
L5, TI-III-IV

17. Objectiven.2: Classificationof alltypesof peristomalskinchangespresent, eliminatingthe notionof «most
seriouslesion»
L2, TV: EROSIVELESIONWITHSUPERFICIALLOSSOFSUBSTANCE
(LESIONS1, 2 AND3); L4, TII-III-IV –FIBRINOUS/NECROTIC
ULCERATIVELESION(LESIONS5 AND6); LX, TIII-IV -
PROLIFERATIVELESION(LESION4)
WHENUSINGTHESACS 2.0 INSTRUMENT:
-Documenteachlesionobserved
-Documentthe topographicallocation(s) for eachlesionobserved
The sole classification of the prevailing sign (most serious lesion) is reductive in most cases
and not explanatory for the health professional. For example, ‘redness’ may exist as a
single lesion (simple redness -L1) or co-exist together with an ulcerative fibrinous/necrotic
lesion (L4) as a sign of inflammation/infection, but may also not be present in an
ulcerative lesion (L3) as it is in the healing phase. In literature such situations may be
referred to as primary skin lesions present at the onset of the disorder or as secondary
skin lesions as a result of modifications over time caused by the progression of the
disorder, manipulation, medications or the healing process
5
. During the course of the
development of consensus it was thus decided that each lesion present in the peristomal
quadrant should be classified.
5. DealeyC. The management of patients with acute wounds. In: DealeyC. The Care of Wounds: A Guide for Nurses. Fourth edition. Hoboken, NJ: John Wiley & Sons; 2012.
CLASSIFICATIONOFTHELESIONSINTHEPHOTO(EXAMPLE):
-L2, TV (lesions1,2 and 3)
-L4, TII-III-IV (lesions5 and 6)
-LX, TIII-IV (lesion4)

18. L2, TV: erosive
lesionwith
superficialloss
of substance
L4, TII-III-IV –
fibrinous/necr
oticulcerative
lesion
LX, TIII-IV -
proliferative
lesion
L2, TV: EROSIVELESIONWITHSUPERFICIALLOSSOFSUBSTANCE
L4, TII-III-IV –FIBRINOUS/NECROTICULCERATIVELESION
LX, TIII-IV -PROLIFERATIVELESION

19. CONCLUSION
The inclusion of an additional descriptive clinical
picture of a lesion such as L5 and the possibility to
classify any lesion present in the peristomal
quadrant makes the classification more precise for
the health professional.
We have maintained the basic characteristics of
the original SACS Study, on the basis of which it is
objective, reproducible and easy to use.
This upgrade tool offers, at all clinicians, a
complete guideline for a correct interpretation and
diagnosis of skin disorders, characteristics not
present in other types of classification.
The use of the SACS instrument is important in
terms of determining and documenting skin
lesions, that it would contribute to the exact
measurement of the prevalence and incidence of
skin lesions, and that it would provide assistance in
clinical decision making.
The low rate of lesion L5 is a limitation of this study, but only for
the numerosityof the sample. However, the numerosityof this
type of lesion is strongly influenced by risk factors such as:
Abdominal operative procedure, operative time, emergency
procedure and clean wound classification.
Consequently the need to implement the existing classification
with a type of clinical picture that interested the abdominal
structures beyond the dermis.
FUTURESTEPS
•The study group is currently working on a NEW
DIAGNOSTICPROPOSALFOREACH‘L’ CONDITION,
which, in all likelihood, we will refer to as ‘LD’
(LESIONDIAGNOSIS)and to which will necessarily
correspond a TOPICALORSYSTEMICTHERAPEUTIC
PROPOSALreferred to as ‘R’ (RESOLUTION).

20. THANK YOU
FOR YOUR
ATTENTION
ANTONINI Mario
Ostomyand WoundCare Specialist–Local Healthcare Toscana Centro -Empoli
Professor atUniversityof Florence
[email protected]