Prevention of Heel Ulcers and Plantar Flexion Contractures

NPUAP’s Biennial Conference, February 27-28, 2009Prevention of Heel Ulcers and Plantar Flexion Contractures in High-RisPrevention of Heel Ulcers and Plantar Flexion Contractures in High-Risk Ventilated PatientsTina Meyers, BSN, RN, CWOCN, ACHRN – Conroe Regional Medical Center, ConrTina Meyers, BSN, RN, CWOCN, ACHRN – Conroe Regional Medical Center, Conroe TXChange in Heel/Patient StatusPatients in the intensive care unit (ICU) have a highrisk of developing heel pressure ulcers (hPUs) andplantar flexion contractures (PFCs), with prevalenceranging from 14% to 41%, and incidence rangingfrom 1% to 56%. 1 In one study, approximately 50% ofICU patients with severe sepsis experienced acutelyacquired neuromuscular dysfunction, 2 which is acomplex process leading to myopathy in the criticallyill,the morphology of which is well described inMillers Anesthesia 6th Edition. 3 In addition to thepathophysiological processes associated with highriskcritically-ill patients, such as polyneuropathy andmyopathy, the new reimbursement policies of theCenters for Medicare & Medicaid Services (CMS) area strong catalyst for refocusing efforts on preventingnegative outcomes and hospital-acquired conditionssuch as pressure ulcers. 4An IRB-approved study (waiver received) wasconducted to assess the impact of a heel protector*intervention on hPU rates and PFCs through the use ofa heel protector in a high-risk, sedated, intensive careunit (ICU) population. Patients who did not receive theheel protector for off-loading the heel, received a pillowfor heel offloading (per facility protocol).* Prevalon, Sage Products Inc.This intervention established hPU and PFC preventionprotocols in a high-risk patient population in order to ensureearlier recognition of heel skin issues and prevent PFCs ifpossible.In order to be treated with the intervention, the followinginclusion criteria were met:Patients were sedated in ICU >5 daysPatients may or may not have been intubatedBraden score of 16 or lessThe intervention provided to these high-risk patientsincluded the following:On admission to ICU, heel skin assessment and Bradenscale were administered to all patientsInitial ankle range of motion (ROM) was measured with aSource: Research Institute for Human Engineering for Quality Life, “Measurement andgoniometer on evaluation admission of the human dynamic and characteristics,” before application Joint Passive Resistance of the Database heela4, 2000. Available at: http://www.dh.aist.go.jp/bodyDB/a/HQL-00-04e.htmlprotectorGoniometric measurements were documentedevery other dayHeel assessments, Braden scale, and Ramsey sedationscale scores were recorded every shift, and recorded as partof study every other dayMeasurements continued until patient was eithertransferred, heel protector boot was discontinued by thephysician, or the patient had Braden scale greater than 16Patients who were treated with the pillows for offloadingreceived the same measurements and documentation aspatients who received the intervention.The study resulted in 100% prevention ofhPU development, 100% prevention of PFCdevelopment, enhanced caregiver compliancewith existing protocols, and several surprisingsecondary findings:Source: Research Institute for Human Engineering for Quality Life, “Measurement andevaluation of the human dynamic characteristics,” Joint Passive Resistance Databasea4, 2000. Available at: http://www.dh.aist.go.jp/bodyDB/a/HQL-00-04e.html9.4% showed improvement in heel status fromentry to discharge11.3% of existing heel skin conditions stayedSource: Research Institute for Human Engineering for Quality Life, “Measurement andevaluation of the human dynamic characteristics,” Joint Passive Resistance Databasea4,the2000.sameAvailable at:withhttp://www.dh.aist.go.jp/bodyDB/a/HQL-00-04e.htmlno change and no worseningin status50% of abnormal heels showed improvement130130 120120 110110 100Ankle Ankle angle at at rest rest (in degrees)Ankle angle at rest100 9090 8080707060605050Secondary Goniometric Findings:Improvements in Plantar Flexion ContracturesImprovements Secondary Goniometric in Plantar Findings:4.Improvements in Plantar Flexion ContracturesSecondary Goniometric Findings:= improvementNeutral (normal)Goniometer used by trained andlicensed clinicians to assess forplantar flexion contracture 6-8Flexion Contracturesn = 106Individual anklesIndividual ankles*Individual anklesEntry MeasurementExit MeasurementEntry MeasurementExit Measurement* Of the 106 ankles measured with goniometer, 20 showed improvement from entry to exit..Goniometer used by trained andlicensed clinicians to assess forplantar flexion contracture 6-8Goniometer used by trained andlicensed clinicians to assess forplantar flexion contracture 6-8References1. Keller BP, Wille J, van Ramshorst B, van der Werken C.Pressure ulcers in intensive care patients: a review ofrisks and prevention. Intensive Care Med. 2002;28:1379-1388.2. Khan J, Harrison TB, Rich MM, et al: Early development ofcritical illness myopathy and neuropathy in patients withsevere sepsis. Neurology. 2006; 67:1421–1425.3. Miller R. Morphology. Miller’s Anesthesia, 6th ed.Orlando, FL:Churchill-Livingstone;2005.Centers for Medicare and Medicaid Services. FederalRegister Part II 42 CFR Parts 411, 412, 413, and 489:Changes to the Hospital Inpatient Prospective PaymentSystems and Fiscal Year 2008 Rates; Final Rule. FederalNew hPUsFinancial Benefits of hPU PreventioRegister. 2007;72(162):47201-47205.5. Whittington KT, Briones R. National prevalence andincidence study: 6-year sequential acute care data. AdvSkin Wound Care. 2004;17:490-494.6. Tourtual DM, Riesenbert LA, Korutz CJ, et al. Predictorsof hospital acquired pressure ulcers. Ostomy/WoundManage. 1997;43(9):24-40.7. Landi F, Onder G, Russo A, Bernabei R. Pressure ulcerand mortality in frail elderly people living in community.Arch Gerontol Geriatr. 2007;44 Suppl 1:217-223.8. Wong VK, Stolis NA. Physiology and prevention of heelulcers: the state of science. J Wound Ostomy ContinenceNurse. 2003;30:191-198.9. Hoppenfeld S. (1976). Physical Examination of the Spineand Extremities. Norwalk, CT:Prentice-Hall;1976.10. Kapandji IA. Ilustrated Physiology of Joints. Med Biol Illus.1964;14:72-81.11. Kendall FP, McCreary EK, Provance PG, et al. Muscles:Testing and Function with Posture and Pain. 5th ed.Baltimore, MD:Lippincott Williams and Wilkens;2005.[Avg census 260; 7.3%4 may develop PUs = 19; 28%4 may develop hPUs = 5; total hPU days (365) = 1825;avg LOS 4.6 (NIS Data) = 397 actual hPU days; 93% stage 1 or 2 4 = 369; 7% stage 3 or 4 4 = 28]4 Whittington KT, Briones R. Adv Skin Wound Care. 2004;17:490-494;9 Young ZF, Evans A, Davis J. J Nurs Adm. 2003;33:380-383.21202• 100% prevention ofNPUAP’s Biennial Conference, February 27-28, hospital-acquired 2009 hPUs• 100% prevention of plantarReferences1. Keller BP, Wille J, van Ramshorst B, van der Werken C. Pressure ulcers in intensive care patients: a reviewof risks and prevention. Intensive Care Med. 2002;28:1379-1388.2. Khan J, Harrison TB, Rich MM, et al: Early development of critical illness myopathy and neuropathy in5.6.

CWOCN, ACHRN – Conroe Regional Medical Center, Center, Conroe Conroe TX TXPlantar Flexion Contractures in High-Risk Ventilated Patientsnsure ensureCs ififtientsth ae heelaheelonas sedation partcorded as parts partherthe ed by theater n 16 than 16effloadingn ntation 16as asgasN, CWOCN, ACHRN – Conroe Regional Medical Center, Conroe TXentionder ing to ensureent g PFCs iffollowingdd Bradenred with an of the heelThe study resulted in in 100% prevention of ofhPU development, 100%100%preventionpreventionofofPFCPFCdevelopment, enhanced caregiver compliancedevelopment, enhanced caregiver complianceChange in Heel/Patient Statuswith existing protocols, and several surprisingwith The existing study resulted protocols, in 100% and prevention several surprisingofsecondary findings:hPUssecondary hPU development, findings: 100% prevention of PFC9.4%development,showedenhancedimprovementcaregiverin heelcompliancestatus from9.4% with existing showed protocols, improvement and several in surprisingentry heel status fromsecondaryto dischargefindings:entry to discharge11.3% 9.4% of showed existing improvement heel skin in conditions heel status stayed from11.3% the entry same of to with existing discharge no change heel skin and conditions no worsening stayedthe in status same with no change and no worsening11.3% of existing heel skin conditions stayedin status50% the of same abnormal with no heels change showed and no improvementworseningNew hPUsin status50% of abnormal heels showed improvementNew hPUsSecondary Goniometric Findings:Secondary 50% of abnormalImprovementsGoniometric heels showed improvementin PlantarFindings:New hPUsFlexion ContracturesSecondary Goniometric Findings:Secondary Improvements Secondary Goniometric in Plantar Findings:Secondary GoniometricImprovements in Plantar Findings:Secondary Flexion Contractures130Flexion in Plantar ContracturesFlexion ContracturesImprovementsGoniometric in PlantarFindings:in Plantar Findings: Flexion ContracturesImprovements Secondary Goniometric in Plantar Findings:Financial Benefits of hPU Prevention130130 120 Improvements 130 Flexion in Plantar ContracturesFlexion ContracturesFinancial Benefits of hPU Prevention120 110 130 120PFCs130 120110 100 120 110120 110100 110 10090110 100 10090908010090 80807090 8070 80 70607080 6060 705060507050 6050Ankle Ankle angle Ankle at at Ankle rest angle rest (in at at degrees) rest rest (in degrees)Ankle angle Ankle at angle rest at restAnkle Ankle angle at at rest rest (in degrees)Ankle angle at rest605050= improvementn = 106Individual anklesIndividual ankles*Individual ankles= improvementNeutral Neutral (normal) (normal)= improvementEntry MeasurementExit Exit MeasurementEntry Measurementankles Entry measured Measurement with goniometer,Exit Measurementshowed improvement from * Of the 106 20 entry to exit..* Of the 106 ankles measured with goniometer, 20 showed improvement from entry to exit..Neutral (normal)Exit Individual Measurement anklesIndividual ankles*Individual anklesEntry MeasurementEntry MeasurementExit Measurement• 100% prevention ofn = 106n = 106Exit Measurement* Of the 106 ankles measured with goniometer, 20 showed improvement from entry to exit..• 100%hospital-acquiredprevention ofhPUshospital-acquired hPUs• 100% prevention of of plantar• 100% flexion prevention contractures of plantarhospital-acquired hPUsflexion contractures• 100% prevention of plantarflexion contracturesChange Change in Heel/Patient in Status StatushPUs hPUsPFCsFinancial Benefits of hPU PreventionPFCs[Avg census 260; 7.3%4 may develop PUs = 19; 28%4 may develop hPUs = 5; total hPU days (365) = 1825;avg LOS 4.6 (NIS [Avg Data) census = 397260; actual 7.3%4 hPU days; may 93% develop stage PUs 1 or = 2 419; = 369; 28%4 7% may stage develop 3 or 4 4 = hPUs 28]5; total hPU days (365) = 1825;avg LOS 4.6 (NIS Data) = 397 actual hPU days; 93% stage 1 or 2 4 = 369; 7% stage 3 or 4 4 = 28]4 Whittington KT, Briones R. Adv Skin Wound Care. 2004;17:490-494;9 Young ZF, Evans 4 Whittington A, Davis J. KT, J Nurs Briones Adm. 2003;33:380-383.R. Adv Skin Wound Care. 2004;17:490-494;9 Young ZF, Evans A, Davis J. J Nurs Adm. 2003;33:380-383.ReferencesReferences[Avg census 260; 7.3%4 may develop PUs = 19; 28%4 may develop hPUs = 5; total hPU days (365) = 1825;avg LOS 4.6 (NIS Data) = 397 actual hPU days; 93% stage 1 or 2 4 = 369; 7% stage 3 or 4 4 = 28]4 Whittington KT, Briones R. Adv Skin Wound Care. 2004;17:490-494;9 Young ZF, Evans A, Davis J. J Nurs Adm. 2003;33:380-383.Heel PUs are the second most common pressure ulcer in theHeel PUs are the second most common pressure ulcer in theclinical setting,clinical 5 and cansetting, 5 result in serious complications suchand can result in serious complications suchas osteomyelitis, cellulitis, septicemia, and limb amputation.as osteomyelitis, cellulitis, septicemia, and limb 6Septicemia is reported as the cause of death in 40% of pressureamputation. 6ulcer patients, Septicemia according is reported to national as multiple the cause cause-coded of death in death 40% of pressurerecords. 7 ulcer Fortunately, patients, with according appropriate to national preventative multiple measures, cause-coded hPUs deathcan be prevented, records. 78 Fortunately, and the clinical with implications appropriate of preventative a successful measures, hPUsprevention can protocol be prevented, for hPUs 8 in and high-risk the clinical sedated implications patients can of result a successfulin the following: prevention protocol for hPUs in high-risk sedated patients can resultin the following:Decreased morbidity and mortality related to hPUPrevention Decreased of possible morbidity pain and and discomfort mortality related related to hPUs to hPUPotential Prevention for indirect of cost possible savings pain (decreased and discomfort length of stay, related to hPUssavings on Potential cost of treatment, for indirect decreased cost savings nursing (decreased staff time, length etc.) of stay,Prevention savings of a hospital-acquired on cost of treatment, condition decreased nursing staff time, etc.)Prevention of a hospital-acquired conditionHeel PUs are the second most common pressure ulcer in theclinical setting, 5 and can result in serious complications suchas osteomyelitis, cellulitis, septicemia, and limb amputation. 6Septicemia is reported as the cause of death in 40% of pressureulcer patients, according to national multiple cause-coded deathrecords. 7 Fortunately, with appropriate preventative measures, hPUscan be prevented, 8 and the clinical implications of a successfulprevention protocol for hPUs in high-risk sedated patients can resultin the following:Decreased morbidity and mortality related to hPUPrevention of possible pain and discomfort related to hPUsPotential for indirect cost savings (decreased length of stay,savings on cost of treatment, decreased nursing staff time, etc.)Prevention of a hospital-acquired conditionCentral nervous system disease or injury, and/or spinal corddisease or injury can lead to PFC. 9-11 Damage to the peronealnerve, myopathy Central nervous due to critical system illness, disease or immobility or injury, which and/or results spinal cordin shortening disease of the or Achilles injury can tendon lead (foot to PFC. drop 9-11 due Damage to contracture) to the peronealare all etiologic nerve, myopathy factors which due can to contribute critical illness, to PFCs. or immobility Risk factors which resultsfor PFCs include shortening pharmacologic of the Achilles sedation tendon or paralysis, (foot drop coma, due leg to contracture)weakness, are and/or all etiologic heavy and factors tight which bed linens can contribute which hold to the PFCs. foot in Risk factorsprolonged for plantar PFCs include flexion (extension). pharmacologic Physical sedation therapy or can paralysis, reverse coma, legtendon contracture, weakness, but and/or prevention heavy is and preferable tight bed as linens PFCs can which become hold the foot inpermanent prolonged deformities. plantar Clinical flexion implications (extension). of a Physical successful therapy PFC can reversepreventiontendonprotocolcontracture,include:but prevention is preferable as PFCs can becomeImproved permanent quality of deformities. life Clinical implications of a successful PFCPrevention prevention of potentially protocol permanent include: deformitiesPotential Improved for indirect quality cost savings of life (decreased length of stay,savings onPreventionrehabilitationof potentiallycosts for PFC,permanentetc.)deformitiesPrevention of a hospital-acquired conditionPotential for indirect cost savings (decreased length of stay,savings on rehabilitation costs for PFC, etc.)Central nervous system disease or injury, and/or spinal corddisease or injury can lead to PFC. 9-11 Damage to the peronealnerve, myopathy due to critical illness, or immobility which resultsin shortening of the Achilles tendon (foot drop due to contracture)are all etiologic factors which can contribute to PFCs. Risk factorsfor PFCs include pharmacologic sedation or paralysis, coma, legweakness, and/or heavy and tight bed linens which hold the foot inprolonged plantar flexion (extension). Physical therapy can reversetendon contracture, but prevention is preferable as PFCs can becomepermanent deformities. Clinical implications of a successful PFCprevention protocol include:Improved quality of lifePrevention of potentially permanent deformitiesPotential for indirect cost savings (decreased length of stay,savings on rehabilitation costs for PFC, etc.)Prevention of a hospital-acquired condition1. Keller BP, Wille J, van Ramshorst B, van der Werken C. Pressure ulcers in intensive care patients: a review 5. Whittington KT, Briones R. National prevalence and incidence study: 6-year sequential acute care data. 9. Hoppenfeld S. (1976). Physical Examination of the Spine and Extremities. Norwalk, CT:Prentice-Hall;1976.of risks and prevention. Intensive Care Med. 2002;28:1379-1388.Adv Skin Wound Care. 2004;17:490-494.10. Kapandji IA. Ilustrated Physiology of Joints. Med Biol Illus. 1964;14:72-81.2. Khan J, 1. Harrison Keller TB, Rich BP, Wille MM, et J, al: van Early Ramshorst development B, van of critical der Werken illness myopathy C. Pressure and neuropathy ulcers in intensive care 6. patients: Tourtual a review DM, Riesenbert 5. LA, Korutz Whittington CJ, et al. Predictors KT, Briones of hospital R. National acquired prevalence pressure and ulcers. incidence Ostomy/ study: 6-year 11. sequential Kendall FP, acute McCreary care EK, data. Provance PG, et 9. al. Muscles: Hoppenfeld Testing S. and (1976). Function Physical with Posture Examination and Pain. of 5th the Spine and Extremities. Norwalk, CT:Prentice-Hall;1976.patients with severe sepsis. Neurology. 2006; 67:1421–1425.Wound Manage. 1997;43(9):24-40.of risks and prevention. Intensive Care Med. 2002;28:1379-1388.Adv Skin Wound Care. 2004;17:490-494.ed. Baltimore, MD:Lippincott Williams and Wilkens;2005.Prevention of a hospital-acquired 10. Kapandji IA. Ilustrated Physiology of Joints. Med conditionBiol Illus. 1964;14:72-81.3. Miller R. Morphology. Miller’s Anesthesia, 6th ed. Orlando, FL:Churchill-Livingstone;2005.7 . Landi F, Onder G, Russo A, Bernabei R. Pressure ulcer and mortality in frail elderly people living in2. Khan J, Harrison TB, Rich MM, et al: Early development of critical illness myopathy and neuropathy in6. Tourtual DM, Riesenbert LA, Korutz CJ, et al. Predictors of hospital acquired pressure ulcers. Ostomy/4. Centers for Medicare and Medicaid Services. Federal Register Part II 42 CFR Parts 411, 412, 413, andcommunity. Arch Gerontol Geriatr. 2007;44 Suppl 1:217-223.11. Kendall FP, McCreary EK, Provance PG, et al. Muscles: Testing and Function with Posture and Pain. 5thpatients with severe sepsis. Neurology. 2006; 67:1421–1425.Wound Manage. 1997;43(9):24-40.489: Changes to the Hospital ReferencesInpatient Prospective Payment Systems and Fiscal Year 2008 Rates; Final 8. Wong VK, Stolis NA. Physiology and prevention of heel ulcers: the state of science. J Wound Ostomyed. Baltimore, MD:Lippincott Williams and Wilkens;2005.Rule. Federal 3. Register. Miller R. 2007;72(162):47201-47205.Morphology. Miller’s Anesthesia, 6th ed. Orlando, FL:Churchill-Livingstone;2005. Continence Nurse. 2003;30:191-198. 7 . Landi F, Onder G, Russo A, Bernabei R. Pressure ulcer and mortality in frail elderly people living in4. Centers for Medicare and Medicaid Services. Federal Register Part II 42 CFR Parts 411, 412, 413, andcommunity. Arch Gerontol Geriatr. 2007;44 Suppl 1:217-223.489: Changes1. Kellerto theBP,HospitalWille J,Inpatientvan RamshorstProspectiveB, vanPaymentder WerkenSystemsC.andPressureFiscal Yearulcers2008in intensiveRates; Finalcare patients:8.a reviewWong VK, Stolis5.NA. PhysiologyWhittingtonandKT,preventionBrionesofR.heelNationalulcers:prevalencethe state ofandscience.incidenceJ Woundstudy:Ostomy6-year sequential acute care data.Rule. Federal of Register. risks and 2007;72(162):47201-47205.prevention. Intensive Care Med. 2002;28:1379-1388.Continence Nurse. 2003;30:191-198.Adv Skin Wound Care. 2004;17:490-494.10. Kapandji IA. Ilustrated Physiology of Joints. Med Biol Illus. 1964;14:72-81.2. Khan J, Harrison TB, Rich MM, et al: Early development of critical illness myopathy and neuropathy in6. Tourtual DM, Riesenbert LA, Korutz CJ, et al. Predictors of hospital acquired pressure ulcers. Ostomy/patients with severe sepsis. Neurology. 2006; 67:1421–1425.Wound Manage. 1997;43(9):24-40.3. Miller R. Morphology. Miller’s Anesthesia, 6th ed. Orlando, FL:Churchill-Livingstone;2005.7 . Landi F, Onder G, Russo A, Bernabei R. Pressure ulcer and mortality in frail elderly people living incommunity. Arch Gerontol Geriatr. 2007;44 Suppl 1:217-223.9. Hoppenfeld S. (1976). Physical Examination of the Spine and Extremities. Norwalk, CT:Prentice-Hall;1976.11. Kendall FP, McCreary EK, Provance PG, et al. Muscles: Testing and Function with Posture and Pain. 5thed. Baltimore, MD:Lippincott Williams and Wilkens;2005.