03 RESOURCE REQUIREMENTS

To complete data collection as outlined in this toolkit, the following resources are required:

Time

Estimated time required for good clinical practice:

 No wounds - 5-10 minutes

 1-3 wounds - 10-20 minutes

 4+ wounds - 20-30 minutes

Equipment

 Pressure Ulcers Clinical Data Collection Form or your local hospital version with these questions integrated

 Paper, single-use (disposable) measuring tape

 Two sterile cotton swabs per wound

NOTE: This form is provided for convenience and meets the minimum requirements for RHSCIR data collection. Please integrate this information into your local hospital pressure ulcer assessment tool. If your facility does not have a data collection tool, please add any additional hospital specific information to this form to meet your facility's practice requirements. If you would like assistance to combine your existing local hospital information and this form, please contact us at clinical [AT] rickhanseninstitute [DOT] org.

RESOURCE REQ

04 FORMS

Clinical Data Collection Form 

Refer to the end of this document for definition of terms found on the form.

Looking for examples of other facilities' assessment forms and policies? Click here to login.

 

05 INSTRUCTIONS

PLEASE NOTE: The activities described, herein, do not replace your facility’s existing protocols or practices, but represent the minimum steps necessary to obtain the required information. These standards were developed to concur with other standards available in North America.

For the purposes of RHSCIR, you will perform two assessments:

 One Admission Assessment

 One Discharge Assessment

Step 1: Get Ready

1. Collect supplies:

 Pressure Ulcer Assessment Clinical Data Collection Form

 Single-use, paper measuring tape (dispose after use)

 Two sterile cotton swabs per wound (dispose after use)

2. Liaise with other staff, as required, to plan time to perform the assessment.

Admission: A skin assessment should be performed as soon as possible after admission (i.e. within 24 hours), but within seven days at a minimum. If you are unable to complete the admission assessment within seven days (e.g. the patient is too critically ill, or access is not possible due to surgery, etc.), please complete the skin assessment and Pressure Ulcer Assessment Clinical Data Collection Form as soon as possible.

Discharge: A skin assessment should be performed within seven days prior to discharge. Please complete the skin assessment and Pressure Ulcer Assessment Clinical Data Collection Form even if the discharge assessment is completed outside this window.

3. Inform the patient of the assessment and obtain consent to proceed.

Step 2: Complete a Head-To-Toe Visual Skin Inspection

1. To minimize patient burden, first inspect as many body areas as possible that do not require patient turning. Reposition the patient as needed at the beginning, during, and at the end of the assessment (follow physician orders and unit-specific protocols of care related to turning and positioning of individuals with known or suspected orthopedic injury and SCI).

2. Inspect the patient’s skin. Particular attention should be paid to vulnerable areas, especially over bony prominences and all (15) locations listed below must be inspected:

3. Note the presence of pressure ulcers of any severity. Include all pressure ulcers, regardless of stage of healing (i.e. open or closed). See NPUAP and CWAP resources in training resources for more information on staging.

Please note that a risk assessment (such as SCIPUS or Braden) and a head-to-toe skin assessment should be carried out with all patients at admission, and a head-to-toe skin assessment daily, thereafter, for individuals identified at risk for skin breakdown (usually performed by nursing staff during regular assessment)(10,11). The RHSCIR dataset does not include the specific data arising from the risk assessment, only whether or not it was completed and total score.

Go to the Pressure Ulcer Assessment Data Collection Form:

On Admission to Facility: Regardless of whether or not there is a pressure ulcer on admission to the facility, please complete the Pressure Ulcer Assessment Clinical Data Collection Form. Complete question 1 - Was a skin integrity risk assessment completed at admission? -          Yes. Indicate yes, and note which risk assessment tool was used (e.g., SCIPUS, Braden, Other) as well as their score. -          No. Indicate no, and proceed to the next question Complete question 2 Was a prealbumin level tested? -          Yes. Indicate yes, and note the level in g/L. This is a proxy for general nutritional status. -           No.  Indicate no, and proceed to the next question Complete question 3 - Any pressure ulcers identified from admission assessment? -          Yes. Indicate yes, and proceed with a detailed assessment. Complete only sections   A  and   B   (Steps 3 & 4 below) of the Pressure Ulcer Tracking Table for all pressure ulcers identified at admission to facility (section   C   should be completed only at discharge). Complete the date of assessment and your name. -          No. Complete the date of assessment and your name. Continue skin monitoring following hospital specific protocols or on a daily basis for those identified at risk for skin breakdown.

 

Step 3: Collect general information about the pressure ulcer(s)

1. If you answered 'Yes' to question 3, determine the location and onset information of all pressure ulcer(s) present. Assess each pressure ulcer separately.

 Location: Determine where on the body a pressure ulcer(s) is present. Uniquely identify each pressure ulcer using the location codes.

 Onset: Did this pressure ulcer begin at a different facility, or after admission to your facility?

 Date of appearance: A pressure ulcer usually presents with minor alteration to the skin and progresses later. The date of appearance should be the date when the first alteration to the skin was observed by any staff member (at any point on the continuum of care). This information may be found in the medical record or determined from the patient or health care team.

Go to the Pressure Ulcer Assessment Data Collection Form:

On Admission to Facility AND on Discharge from Facility: Complete Section   A    of the Pressure Ulcer Assessment Clinical Data Collection Form. Complete a separate row for each pressure ulcer. -          Location o   Only one location code (taken from the legend located on the first page of the Pressure Ulcer Clinical Data Collection Form) may be entered. For example, a pressure ulcer located on the right iliac crest is identified as O; a mid-line sacral pressure ulcer is identified as R. -          Onset o   Onset - Prior to admission. Any pressure ulcer with onset prior to admission to your facility. o   Onset - During stay. Any pressure ulcer with onset after admission to your facility and before discharge from your facility (including other care areas in your facility). -          Date of appearance o   Partial dates may be entered if exact date is unknown (e.g. YYYY/MM). §  Note: Date of appearance is the date when this pressure ulcer was first noted by a care provider at any facility or at any point of care including: EHS transport, Emergency Department, ICU, etc., not the day when your assessment is performed. -          Date of Appearance – Unknown. Unknown must be selected when the date of pressure ulcer appearance is not known and cannot be determined via medical record review, from patient or health care team interview.

 

Step 4: On admission, stage each pressure ulcer and determine the appropriate qualifier (i.e. whether it is healing or closed)

1. Determine the stage of each pressure ulcer as per the NPUAP Guidelines. See the Pressure Ulcer Assessment reference tables (reference table/legend, first page of the Pressure Ulcer Clinical Data Collection Form), the definitions section in this booklet (Section 6: Definitions), and training materials (Section 7: Training Resources) for more information about staging.

2. Determine whether the ulcer has changed since onset. "Successful ulcer management requires a parameter to judge the effectiveness of the treatment plan. For the clinician to say, "The ulcer is healing," requires comparison between the present state and previous state of the ulcer and evidence that the ulcer has improved." (5). On admission, the previous state of the pressure ulcer may not be available; in that case, it is appropriate to use "unknown". The following qualifiers should be used to provide this comparison where possible:

 If Stage is II, III, or IV, determine the appropriate Qualifier at Admission:

A) Use the following criteria to determine if the pressure ulcer is closed:

 Closed – Yes. Ulcer is 100% covered with epithelium (even a very thin layer) with no drainage.

 Closed – No. Ulcer is not 100% covered with epithelium (even a very thin layer) and/or drainage is present.

 Closed – Unknown. Unknown must be selected when unable to determine if the pressure ulcer is closed through any source (e.g. medical record review, patient, or health care team).

B) If the pressure ulcer closed status is 'No' or 'Unknown', use the following criteria to determine if the pressure ulcer is healing:

 Healing – Yes. Ulcer is decreasing in size, depth, amount of necrotic tissue or exudates, or increasing granulation tissue, etc.

 Healing – No. Ulcer is not decreasing in size, depth, amount of necrotic tissue or exudates, or increasing granulation tissue, etc. A pressure ulcer that remains the same is considered not to be healing.

 Healing – Unknown. Unknown must be selected when unable to determine if the pressure ulcer is healing through any source (e.g. medical record review, patient, or health care team).

Go to the pressure Ulcer Assessment Data Collection Form:

Complete the corresponding Admission Assessment Section   B   for each pressure ulcer -          Stage at Admission to Facility o   Indicate the NPUAP stage of the pressure ulcer as determined by your assessment. -          Qualifier at Admission If Stage is II, III, or IV o   Indicate the Closed and Healing status using the criterion above Your Admission Assessment is now finished.

 

Step 5: On discharge, stage each pressure ulcer and determine the appropriate qualifier (i.e. whether it has resolved, is healing or is closed)

1. Determine 'Stage at Discharge from Facility' and the 'Date Stage' determined as outlined for admission assessment above (Step 4).

 If Stage is SDTI or Stage I, determine whether the pressure ulcer has resolved using the following criteria:

 Resolved – Yes. Skin surface (epithelium) is intact, and deeper tissues are not red, purple, indurated, painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

 Resolved – No. Skin surface (epithelium) is intact, but deeper tissues show red or purple markings, are indurated, painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

 Resolved – Unknown. Unknown must be selected when unable to determine if the pressure ulcer has resolved through any source (e.g. medical record review, patient, or health care team).

 If Stage is II, III, or IV, determine if the pressure ulcer is closed using the same criteria defined in Step 4.

Note: Pressure ulcers should not be reverse staged. For example, a Stage IV pressure ulcer at admission cannot become a lower staged pressure ulcer at discharge. Instead, use the “closed” or “healing” qualifiers as appropriate to modify its status as a Stage IV pressure ulcer. For more information see Section 6: Definitions - NPUAP Pressure Ulcer Stages.

Go to the Pressure Ulcer Assessment Data Collection Form:

At Discharge from Facility: Complete question 4 - Any pressure ulcers following admission to the facility (i.e. during stay)? -          No. Complete the date of assessment and your name. -          Yes. Indicate yes, and proceed with a detailed assessment to complete sections   A   ,   B   and   C    of the Pressure Ulcer Tracking Table for all pressure ulcers identified at discharge from facility: Steps 3, 5, 6 and 7. Complete a separate row for each pressure ulcer. Complete the date of assessment and your name. o   NB: for pressure ulcers that develop following admission, choose “N/A (No ulcer at admission) for “stage at admission to facility” in part  B  . Accordingly, leave blank the Qualifier at Admission (In section   B  ). Additionally, for any pressure ulcer present on admission to facility where sections   A    and   B  were completed, complete the corresponding Discharge Assessment (Section   C  ). -          Stage at D/C from Facility o   Enter the NPUAP stage of the pressure ulcer as determined by your assessment o   If stage is SDTI or I, complete the Qualifier at Discharge by marking whether the pressure ulcer is resolved using the criteria above o   If stage is II, III, or IV, complete the Qualifier at Discharge by marking whether the pressure ulcer is closed using the criteria in step 4. §  If closed status “no” or “unknown” is selected, mark whether the pressure ulcer is healing using the criteria in step 4.

 

Step 6: At discharge, determine if the pressure ulcer was ever treated non-surgically or surgically

1. Determine if the pressure ulcer was treated non-surgically at any time. Non-surgical treatments are described in five categories:

 Biophysical: including ultrasound and electrical stimulation, among other similar treatments.

 Pressure redistribution: including the changing of any surface that touches the affected area, including sleeping, toileting, washing/showering and seating surfaces.

 Dressings: including all types of occlusive, regular and specialized dressings; including negative pressure wound therapy.

 Minor/bedside debridement: including any removal of tissue at the bedside or in a specialized area but does not include treatment performed in an operating room.

 Other.

2. Determine if the pressure ulcer was surgically treated at any time. Surgical treatment includes major surgical methods such as: direct closure, skin grafting, rotation flaps or debridement of pressure ulcers that occur in an operating room (bedside debridements are not considered surgical and should not be included in this category).

Go to the Pressure Ulcer Assessment Data Collection Form:

Complete the corresponding Discharge Assessment (Section   C  ) for each pressure ulcer -          What type of non-surgical treatment was used? -          If applicable, choose all the non-surgical treatment used, as defined above. -          Has the ulcer been surgically treated? o   Surgically treated – Yes. o   Surgically treated – No. o   Surgically treated – Unknown. Unknown must be selected when unable to determine if surgical treatment was provided through any source; e.g. medical record review, patient, or health care team. -          If yes, date surgically treated o   Date surgically treated is the calendar date (yyyy/mm/dd) on which the surgical treatment occurred.

 

Step 7: Finish pressure ulcer assessment

Review the information you have collected to make sure other care providers can use it to re-assess this pressure ulcer later (e.g. are able to identify the location and stage of the pressure ulcer in future).

Go to the Pressure Ulcer Assessment Data Collection Form:

Ensure all data is complete, accurate, and legible. Place the original form in the medical record.

 

Step 8: Address facility specific care protocols

This assessment and documentation process fulfills only the minimum requirements for good practice and data collection for the RHSCIR process. Site specific protocols may require additional assessment, intervention, and documentation which are not included in this document.

06 DEFINITIONS

Admission: The date the individual is admitted to the care facility, regardless of where in the facility the individual is first admitted or where he/she may be internally transferred between care areas.

Admission assessment: A skin assessment should be performed as soon as possible after admission (i.e. within 24 hours), but within seven days at a minimum. If the admission assessment cannot be completed within seven days (e.g. the patient is too critically ill, or access is not possible due to surgery, etc.) then it should be completed as soon as possible.

Closed: The previously open ulcer is covered with epithelium (even a very thin layer) with no drainage.

Date of appearance: A pressure ulcer usually presents with a minor alteration to the skin and progresses later. The date of appearance should be the date when the first alteration to the skin was observed. If the date is unknown this should be documented (source: international SCI Skin and Thermoregulation Basic Data Set)

Date stage determined: The calendar date (yyyy/mm/dd) on which the pressure ulcer was first staged as per NPUAP Pressure Ulcer Staging Guidelines.

Date surgically treated: The calendar date (yyyy/mm/dd) on which the surgical treatment occurred.

Discharge assessment: A skin assessment should be performed within seven days prior to discharge. Please complete the skin assessment and Pressure Ulcer Assessment data collection form even if the discharge assessment is completed outside this window.

Healing: The ulcer is decreasing in size, depth, amount of necrotic tissue or exudates, or increasing in granulation tissue, etc.

NPUAP Pressure Ulcer Stages:

SDTI (Suspected Deep Tissue Injury): Purple or maroon localized area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area.

Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

Unstageable/Unclassified (U): Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed.

Note: Do not use reverse staging to document a healing pressure ulcer. Pressure ulcers heal to progressively more shallow depth; they do not replace lost muscle, subcutaneous fat, or dermis before they re-epithelialize. Instead, the ulcer is filled with granulation (scar) tissue composed primarily of endothelial cells, fibroblasts, collagen and extracellular matrix. A Stage IV pressure ulcer cannot become a Stage III, Stage II, and/or subsequently Stage I. When a Stage IV ulcer has healed it must be classified as a healed Stage IV pressure ulcer; no other description is applicable. Therefore, reverse staging does not accurately characterize what is physiologically occurring in the ulcer (12). For more information, see NPUAP Position Statement on reverse staging.

Onset - prior to admission: Any pressure ulcer with onset before admission to your facility.

Onset - during stay: Any pressure ulcer with onset after admission to your facility and before discharge from your facility (including other care areas in your facility).

Resolved: A SDTI or Stage I pressure ulcer is considered resolved when the skin surface (epithelium) is intact, and deeper tissues are not red, purple indurated, painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Surgical treatment: Surgical treatment may include any treatment ranging from small debridement of the ulcer surface to rotation flaps. In this context, this variable includes only major surgical methods such as direct closure, skin grafting, or rotation flaps. Minor debridement is defined as conservative treatment and should not be documented here but under conservative treatment (13).

07 TRAINING RESOURCES

-         Canadian Best Practice Guidelines for the Prevention and Management of Pressure Ulcers in People with Spinal Cord Injury

o   Chapter 8 is a comprehensive explanation of assessment after developing a pressure ulcer

o   Other chapters in the document cover all topics related to the prevention, monitoring and treatment of pressure ulcers.

o For your patients, they have developed a consumer guide to pressure ulcers based on the guideline

-         National Pressure Ulcer Advisory Panel (NPUAP)  

o Information about staging

o Pressure ulcer photos including real life images of pressure ulcer at all stages: ankle, buttocks, ear, elbow, etc.

-        Canadian Association of Wound Care  

o Wound Assessment Pocket Guide, includes:
• NPUAP updated staging system (2007)
• Wong-Baker FACES© pain scale
• Calculation to determine percentage healing over time
• BWAT© Pictorial Guide with enhanced descriptors
• Braden Scale for Predicting Pressure Sore Risk©

o Pressure ulcer photos including real life images of pressure ulcer at all stages: ankle, buttocks, ear, elbow, etc.

-         Assessment Forms and Chart Inserts  here you'll find examples of pre-printed orders, policies and guidelines as well as assessment and charting sheets relating to skin integrity assessment and treatment.

08 REFERENCES

1. Craven C, Verrier M, Balioussis C, Wolfe D, Hsieh J, Noonan V, Rasheed A, Cherban E. Rehabilition Environmental Scan Atlas: Capturing Capacity in Canadian SCI Rehabilitation. Vancouver: Rick Hansen Institute; 2012.

2. Rivers C, Noonan V, Trenaman L, Krueger H. Economic impact of traumatic spinal cord injury in Canada: total economic burden and potential cost-avoidance by preventing secondary complications. Can J Surg. 2013;56(4 Suppl 2):S67.

3. Chan BC, Nanwa N, Mittmann N, Bryant D, Coyte PC, Houghton PE. The average cost of pressure ulcer management in a community dwelling spinal cord injury population. Int Wound J. 2013 Aug;10(4):431–40.

4. Krause JS. Skin sores after spinal cord injury: relationship to life adjustment. Spinal Cord. 1998 Jan;36(1):51–6.

5. NPUAP. NPUAP Pressure Ulcer Stages/Categories [Internet]. NPUAP. 2007 [cited 2014 Aug 15]. Available from:www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/.

6. Cobb J, Belanger L, Park S, Shen T, Rivers C, Dvorak M, Street J, Noonan V. Evaluation of a pilot Pressure Ulcer Prevention Initiative (PUPI) for patients with spinal cord injury. J Wound Care. 2014;12(5):211–26.

7 Nogueira PC, ODE ulcers, decubitus IN, IN A, H University, Ulcer EODE, Em DEP, UM Hospital. Profile of Patients with Spinal cord injuries and occurrences of Pressure Ulcers at a university hospital. Rev Lat Am Nursing. 2006, 14 (3): 372-7.

8. Accreditation Canada. Qmentum Program: Spinal Cord Injury Acute Services. 2014;

9. Accreditation Canada. Qmentum Program: Spinal Cord Injury Rehabilitation Services. 2014;

10. RNAO. Risk Assessment & Prevention of Pressure Ulcers Guidelines [Internet]. [cited 2014 Aug 15]. Available from:http://rnao.ca/sites/rnao-ca/files/storage/related/639_BPG_Pressure_Ulcers_v2_summary.pdf.

11. Houghton P, Campbell K, CPG Panel. Canadian Best Practice Guidelines for the Prevention and Management of Pressure Ulcers in People with Spinal Cord Injury. A resource handbook for Clinicians [Internet]. ONF. 2013 [cited 2014 Aug 15]. Available from: http://onf.org/system/attachments/168/original/Pressure_Ulcers_Best_Practice_Guideline_Final_web4.pdf

12. NPUAP. Position Statements [Internet]. NPUAP. [cited 2014 Aug 15]. Available from:www.npuap.org/resources/position-statements/.

13. International SCI Skin and Thermoregulation Function Basic Data Set Version 1.0 English [Internet]. ISCoS. [cited 2014 Aug 15]. Available from: here.

REFERENCES

09 ADDITIONAL RESOURCES

NPUAP has the Pressure Ulcer Scale for Healing (PUSH), which is a non-SCI specific way to measure the healing of wounds.

The Braden Scale is used by most sites for the assessment of pressure sore risk.

A SCI-specific pressure ulcer risk assessment, the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS), is also available.

The Spinal Cord Injury Rehabilitation Evidence Project has evidence-based information on the assessment and treatment of pressure ulcers

The International Spinal Cord Society produced eLearnSCI, a set of education modules covering a wide variety of topics for all health-care professionals.

 Street JT, Thorogood NP, Cheung A, Noonan VK, Chen J, Fisher CG, Dvorak MF. Use of the Spine Adverse Events Severity System (SAVES) in patients with traumatic spinal cord injury. A comparison with institutional ICD-10 coding for the identification of acute care adverse events. Spinal Cord. Nature Publishing Group; 2013 Jun;51(6):472–6.AL RESOURCES

10 RHSCIR – ADDITIONAL PRESSURE ULCER DATA

Additional pressure ulcer data is collected in the RHSCIR from all participants who consent. This data is collected via self-report at all community follow-up time points (1 year, 2 year, 5 year and every 5 years following the date of SCI) as a part of the collection of secondary complications information.

Participant Self-Report

 

 

Questions or comments about this toolkit? Email us at clinical [AT] rickhanseninstitute [DOT] org