Sacs score from sacs to sacs 2.0 and beyond oral presentation_mario antonini

SACS 2.0 Classification

1. ANTONINI Mario
Ostomyand WoundCare Specialist–Local Healthcare Toscana Centro -Empoli
[email protected]
SACS Score
FROMSACS TOSACS 2.0 ANDBEYOND
14THCONFERENCEOFTHEEUROPEANCOUNCILOFENTEROSTOMALTHERAPISTS
ROMA, 23 –26 GIUGNO2019

2. SACS Score: From SACS to SACS 2.0 and Beyond
“The Peristomal skin should be
intact with no evidence of
redness, loss of epidermis or
sensations such as itchiness,
warmth or pain ”
Colwell J, BeitzJ. 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.

3. SACS Score: From SACS to SACS 2.0 and Beyond
«The rehabilitationof people living with an ostomydepends
mainlyon the integrityof theirperistomalskin»
«Maintaininga healthyperistomalskinisthereforethe main
objectiveof anyhealthcare professionalthattakes care about
ostomates»

4. SACS Score: From SACS to SACS 2.0 and Beyond

5. SACS Score: From SACS to SACS 2.0 and Beyond
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%

6. SACS Score: From SACS to SACS 2.0 and Beyond
COMPLICATIONS
Time OSTOMYCOMPLICATIONS PERISTOMALCOMPLICATIONS Cutaneoussigns
Immediate post-operative
complications(0 –72 hrs)
Oedema ContactAllergicDermatitis(CAD)Cutaneousalterations
Ischaemiaand necrosis Candidiasis Infection
Intra and peristomalhaemorrage Folliculitisor 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. SACS Score: From SACS to SACS 2.0 and Beyond
PREVENTION ASSESSMENTANDCLASSIFICATION TREATMENT
TherapeuticRelationship Assessand recognizeskinlesions
Knowledge aboutStoma BagTypesand
accessories
Stoma-siting
Use of a PeristomalSkinDisorders
Rating Score
Advanced Dressingsand theirCorrect
Use
Stoma surgery
Knowledge aboutStoma Complications
and PeristomalSkinDisorders
Knowledge aboutStoma BagTypesand
accessories
Prevention Assessmentand Classification Treatment

8. SACS Score: From SACS to SACS 2.0 and Beyond
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 peristomallesions 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

9. SACS Score: From SACS to SACS 2.0 and Beyond
The Objectivesof the OriginalSACS Study
1.ASSESS AND CLASSIFYPERISTOMALSKINDISORDERS
The Study group agreedon nottakingintoconsideration:
•The aetiologyof peristomal skin disorders
•The Therapeuticaltreatment
2.EVALUATETHE CORRELATIONBETWEEN BOODCHEMISTRY
AND SEVERITY OF PERISTOMAL LESIONS.

10. SACS Score: From SACS to SACS 2.0 and Beyond
The SACS Study: DEFINITIONS
PERISTOMALAREA:
Theterm“peristomal”ismeanttoincludethe
wholeskinaroundthestomaevenifitisnot
directlylinkedwiththestoma.

11. SACS Score: From SACS to SACS 2.0 and Beyond
The SACS Study: DEFINITIONS
THEPREDOMINANTSIGN:
Itwasdecidedthattheclassificationshouldonly
refertothePredominantSign(themostserious
one)andtheTopography(T)ofthelesion;the
classificationwillincludeonlyone«L»andin
casemorethanone«T».

12. SACS Score: From SACS to SACS 2.0 and Beyond
The SACS Study: DEFINITIONS
TOPOGRAPHY
▪TI=UpperLeftQuadrant
▪TII=UpperRightQuadrant
▪TIII=LowerRightQuadrant
▪TIV=LowerLeftQuadrant
▪TV=AlltheQuadrants
The orderof the quadrantsaroundthe stoma starts
in the UpperLeft corner (TI) and endsin the Lower
Left corner (TIV) clockwise.
Patient’shead
Patient’sfeet

13. SACS Score: From SACS to SACS 2.0 and Beyond
OriginalSACS Classification
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)

14. L1
HYPEREMICLESION
Peristomalrednesswith intactskin
SACS Score: From SACS to SACS 2.0 and Beyond
The SACS Study: CLASSIFICATION
SACS Classification
LESION(L)

15. L2
EROSIVELESION
OpenlesionNOTextendingintosubcutaneoustissue;
partialthicknessskinloss
SACS Score: From SACS to SACS 2.0 and Beyond
The SACS Study: CLASSIFICATION
SACS Classification
LESION(L)

16. L3
ULCERATIVELESION
Open lesionextendingintosubcutaneoustissueand
below; full thicknessskinloss
SACS Score: From SACS to SACS 2.0 and Beyond
The SACS Study: CLASSIFICATION
SACS Classification
LESION(L)

17. L4
ULCERATIVELESION
Full thicknessskinlosswith non-viable, dead tissue
(necrotic, fibrinous)
SACS Score: From SACS to SACS 2.0 and Beyond
The SACS Study: CLASSIFICATION
SACS Classification
LESION(L)

18. LX
PROLIFERATIVELESION
Abnormalgrowthspresent(i.e. hyperplasia,
granulomas, neoplasms)
SACS Score: From SACS to SACS 2.0 and Beyond
The SACS Study: CLASSIFICATION
SACS Classification
LESION(L)

19. The Objectivesof SACS 2.0 Study
SACS Score: From SACS to SACS 2.0 and Beyond
1.Completionof the classificationto include an additionallevel
of severity(L5)
2.Classificationof alltypesof peristomalskinchangespresent,
eliminatingthe notionof «mostseriouslesion»

20. SACS Score: From SACS to SACS 2.0 and Beyond
The Objectivesof SACS 2.0 Study
Objectiven.1: Completionof the classificationto include an additionallevelof severity(L5)
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)

21. SACS Score: From SACS to SACS 2.0 and Beyond
The Objectivesof SACS 2.0 Study
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.

22. L5
DEPTHLOSSOF
SUBSTANCE
Ulcerative lesioninvolvingplanesbeyondthe muscolar
fascia (with or withoutfibrin, necrosis, pus or fistula)
SACS Score: From SACS to SACS 2.0 and BeyondSACS Score: From SACS to SACS 2.0 and Beyond
The SACS 2.0 Study: CLASSIFICATION
SACS Classification
LESION(L)

23. SACS Score: From SACS to SACS 2.0 and Beyond
SACS 2.0 Classification
Objectiven.2: Classificationof alltypesof peristomalskinchangespresent, eliminatingthe notionof «mostserious
lesion»
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):
▪L1, TV: HyperemicLesion-PeristomalRednesswith IntactSkin
▪L2, TV: Erosive Lesion–SuperficialLossof Substance
▪L4, TII-III-IV Ulcerative Lesion-Full thicknessskinlosswith non-viable, dead tissue
(necrotic, fibrinous)
▪LX, TIII-IV Proliferative Lesion-Abnormalgrowthspresent(i.e. hyperplasia,
granulomas, neoplasms)

24. SACS Score: From SACS to SACS 2.0 and Beyond
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
•Development of a PeristomalSkinDisorders
measuringSystem (asystem to size the stoma area
affected from a wound and to assess it the severity)
•Guideline for the use of the various types of ostomy
devices based on the type of wound and associated
treatment

25. THANK YOU FOR YOUR ATTENTION
ANTONINI Mario
Ostomyand WoundCare Specialist–Local Healthcare Toscana Centro -Empoli
[email protected]
14THCONFERENCEOFTHEEUROPEANCOUNCILOFENTEROSTOMALTHERAPISTS
ROMA, 23 –26 GIUGNO2019