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/ Appendix
Pressure Ulcer Prevention
Breakthrough Series
Change Package
Sponsored by VA National Center for Patient Safety in partnership with the Office of Nursing Services (ONS); the Office of Nursing Services Hospital Pressure Ulcer Prevention Workgroup; The Inpatient Evaluation Center (IPEC) and the Office of Patient Centered Care and Cultural Transformation

VA SKIN BUNDLE

V-Veteran’s Skin Bundle Evidence(description on page 14)

A- Assessment of Skin and Risk2,3

  • Risk Assessment on admission and/or per policy (Braden, SCI, Surgery, medical device)
  • Risk and skin assessment is defined by policy with clear recommendations for timing, reassessment, documentation and communication.2 (SOE= C)
  • Presence of a current PU or a history of a prior ulcer places veterans at increased risk. 3 (SOE = C)
  • Veterans who have surgical procedures may be at higher risk for developing a HAPU.2-4 (SOE = C)
  • Skin Assessment on admission and per policy
  • Ensure that a complete skin assessment is part of the risk assessment screening policy in place in all health care settings. 2,3 (SOE = C)
  • Examine skin during each position change and cleansing.1
  • Educate professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration (hardness).2 (SOE = B)
  • Observe skin for medical device related HAPU. 2 (SOE= C)
  • Use skin emollients to hydrate dry skin. 2 (SOE= B)
  • Do not massage for HAPU prevention. 2 (SOE= B)

Develop and implement a prevention plan when individuals have been identified as being at risk of developing PUs.2

S-Select Surfaces and Devices to Redistribute/Relieve Pressure

  • Choose a support surface (on beds and chairs) that is compatible with the care setting. 2,3(SOE = C)
  • Pressure redistribution support surfaces are adjuncts to, but not replacements for manual repositioning. 3(SOE= C)
  • Heel-protection devices should elevate the heel completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. The knee should be in slight flexion.2 (SOE= C)
  • Use a pressure-redistributing mattress on the operating table for all veterans identified as being at risk of PU development.2 (SOE= B)

K-Keep Turning and Repositioning

  • Repositioning should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body.2 (SOE = A)
  • Repositioning frequency should be influenced by the support surface used.2 (SOE = A)
  • Repositioning frequency will be determined by the veteran’s tissue tolerance, their level of activity and mobility, their general condition, overall treatment objectives and assessment of skin condition. 2 (SOE = C)
  • Use lift equipment to reposition or transfer veterans. 2 (SOE= C)
  • Avoid positioning veteran directly on medical devices, such as tubes. 2 (SOE = C)
  • Avoid positioning veteran directly on bony prominences with existing PU. 2 (SOE = C)
  • Minimize/eliminate pressure from medical devices such as oxygen masks and tubing, restraints, cervical collars, feeding tubes, casts through padding/cushioning and repositioning where feasible. 2 (SOE = C)

I-Incontinence Management

  • Establish a bowel/bladder management program for the veteran with incontinence.3 (SOE = C)
  • Cleanse skin gently at each time of soiling with pH-balanced cleansers.3
  • Use incontinence skin barriers such as creams, ointments, pastes and film forming skin protectants as needed to protect and maintain intact skin.2,3 (SOE = C)
  • Consider a fecal pouching or fecal management system to contain excessive liquid effluent. 3

N-Nutrition and Hydration Assessment and Intervention

  • Screen and assess the nutritional status of every veteran at risk of PUs in each health care setting 2,3(SOE = C)
  • Offer high-protein mixed oral nutritional supplements and/or tube feeding, in addition to the usual diet, to veterans with nutritional risk and PU risk because of acute or chronic diseases, or following a surgical intervention.2 (SOE = A)
  • Refer veterans with nutritional and/or PU risk to a dietician and also if needed to an interprofessional nutrition team and when necessary a dentist. 2

References

1Sackett DL. Rules of Evidence and clinical recommendations on the use of antithrombotic agents. Chest. 1989; 95 (2 Suppl): 25-45.

2Pressure ulcer prevention recommendations. In: Prevention and treatment of pressure ulcers: clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel; 2009; 21-50.

3Guideline for prevention and management of pressure ulcers. WOCN clinical practice guideline; no. 2.Mount Laurel NJ: Wound, Ostomy, and Continence Nurses Society (WOCN); 2010;14-26.

4Cowan LJ, Stechmiller JK, Rowe M, Kairalia JA. Enhancing Braden pressure ulcer risk assessment in acutely ill adult veterans. Wound Rep Regen 2012; 20 137-148.

5Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. AHRQ Publication No. 11-0053-EF, Agency for Healthcare Research and Quality. Accessed April 15, 2012.

6Gibbons W, Shanks H, Kleinhelter P, Jones P. Eliminating facility-acquired pressure ulcers at Ascension Health. Joint Comm J Qual Patient Safety2006; 32: 299–30. Accessed April 15, 2012.

7 Healthcare Improvement Scotland. SSKIN Care Bundle. Accessed April 15, 2012.

Description of the Strength of Evidence (SOE) used in the Skin Bundle: (Sackett)

A: The recommendation is supported by direct scientific evidence from properly designed and implemented controlled trials in humans (or humans at-risk), providing statistical results that consistently support the guideline statement (Level 1 studies required)

B: The recommendation is supported by direct scientific evidence from properly designed and implemented clinical series in humans (or humans at-risk), providing statistical results that consistently support the recommendation. (Level 2, 3, 4, 5 studies).

C: The recommendation is supported by indirect evidence (e.g., studies in normal human subjects, humans with other types of disorders, or animal models) and/or expert opinion.

Level of Evidence of Individual Studies:

Level 1: Large randomized trial(s) with clear-cut results (and low risk of error)

Level 2: Small randomized trial(s) with uncertain results (and moderate to high risk of error)

Level 3: Non randomized trial(s) with concurrent or contemporaneous controls

Level 4: Non randomized trial(s) with historical controls

Level 5: Case series with no controls. Specify number of subjects.

Copyright Veterans Health Administration. Reprinted by permission, VHA Pressure Injury Prevention, VA Office of Nursing Services, 2016.

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