Acute Skin Failure from Sepsis: Preventing Injury with Early

MobilityAugust 31, 2017

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WELCOME AND INTRODUCTIONS

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Lisandra Cuadrado, MPH, Program Manager| HRET

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Agenda for Today

HIIN HAPI DATA REVIEWMariana Lesher, Data Analyst | HRET

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Overall HRET HIIN Progress

Data submitted to HRET as of: 8/1/2017

FRAMING: WHY THIS IS IMPORTANT

Jackie Conrad RN, BSN, MBAImprovement Advisor, Cynosure Health

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SKIN FAILURE

Diane Langemo, PhD, RN, FAANPres, Langemo & Associates

Professor Emeritus, U of North DakotaFormer NPUAP Board Member and President

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Objectives

• Discuss the current evidence on the pathophysiology of skin failure and multiorganfailure

• Delineate the best practices for caring for individuals with skin failure & multiorganfailure

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SKIN• Comprises 10-15% of body weight

• Receives approximately 1/3 of the circulating blood volume

• Complex organ with multiple functions, yet dependent on other organs for function

• Primary functions: water balance, body temperature control, immunocompetence, maintenance of vasomotor tone

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Mean Arterial Pressure

• Average BP in a single cardiac cycle• Varies between 65-110mmHg• 70 mgHg is believed to be needed to maintain

organ function

SKIN FAILURE

• Associated with hemodynamic changes, impaired thermoregulatory control, and metabolic complications

• Hypo perfusion of skin due to shunting to vital organs

o

o

Hypothermia resulting from hypo perfusion

Metabolic abnormalities of toxic metabolites from catabolism

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STUDY OF ACUTE SKIN FAILURE IN ICU PATIENTS

• N=552 ICU patients• 5 variables significantly & independently associated with skin failure:

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PAD (vascular compromise): (OR=3.8)Respiratory failure (OR=3.2)Mechanical ventilation >72 hr (OR=3.0)Liver failure (OR=2.9)Severe sepsis/septic shock (OR=1.9)(Delmore et al, 2015)

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Skin Failure

• “An event in which the skin and underlying tissue die due to the hypoperfusion that occurs concurrent with severe dysfunction or failure of other organ systems” (Langemo, 2005; Langemo & Brown, 2006)

Acute • Hypoperfusion

with critical illness• Sepsis• MI

Chronic• Hypoperfusion

from chronic disease state• Neuropathy• PVD• Nephropathy• MS

End Stage• Hypoperfusion

at end of life• Cancer• ALS• MS

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TYPES OF SKIN FAILURE (LANGEMO & BROWN, 2006)

EVIDENCE IN SUPPORT OF THE DEFINITION

• Multiorgan failure: leading cause of morbidity & mortality resulting from organ dysfunction or failure

• Based on SCALE (2008) statements and NPUAP positions (2011, 2014), the 2 conditions necessary for establishing the diagnosis of skin failure are – skin hypoperfusion – severe organ dysfunction or failure – (White-Chu & Langemo, 2012)

• ICD-10 diagnosis of skin failure: L98.9 Disorders of the skin

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WHY THE TERM SKIN FAILURE

Benefits

• Skin failure is a subset of multiple organ dysfunction syndrome (MODS) (Bone et al., 1992)

• Distinguishes it from a PU (Langemo, 2005; Langemo & Brown, 2006; White-Chu & Langemo, 2012; Delmore et al., 2015)

Consequences• It is not a PU (Langemo, 2005;

Langemo & Brown, 2006; White-Chu & Langemo, 2012; Delmore et al., 2015)

• No other term at present to describe phenomena

DISTINGUISHING PI & SKIN FAILURE

• SF and PI are 2 distinct phenomena, yet interrelated & canoccur simultaneously.

• Inadequately perfused skin is susceptible to pressure & shear forces

• PI can occur in relatively healthy individual; SF can occur in acutely or chronically ill individuals or at end of life.

Sepsis Continuum

• Continuum of Infection Septic shock

©2014 National Pressure Ulcer Advisory Panel | www.npuap.org

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Local infection

SepsisSIRS

Severe sepsis

Septic shock

End of Life: Skin Failure/Multiorgan Failure/Multiorgan Dysfunction Syndrome

• Patients critically ill w/MOF or MODS & sepsis are at hi risk for hypoperfusion from microvascular dysfunction, ↑ demand for 02, & vasoconstriction (Langemo & Brown, 2006).

• Individuals w/MOF have abnormal capillary vasomotion, → ↓ sympathetic vasomotor tone & endothelial dysfunction → vasodilation & hypotension (Holloway et al, 1985; Young & Cameron, 1995).

• Tissue blood flow may be ↑, yet 02 delivery to & uptake by the cells is ↓ (Beal & Cerra, 1994).

©2014 National Pressure Ulcer Advisory Panel www.npuap.org

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End of Life: Skin Failure/Multiorgan Failure/Multiorgan Dysfunction Syndrome

• Critically ill individuals w/MOF are susceptible to tissue breakdown and failure, “regardless of the quality of care received” (Curry et al, 2012).

• These patients have altered tissue perfusion which, in combination with failed organ systems, results in the inability to maintain homeostasis, leading to skin and underlying structures dying (Curry et al, 2012; Keller et al, 2002).

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End of Life: Skin Failure/Multiorgan Failure/Multiorgan Dysfunction Syndrome

• Study of 29 pts w/skin failure (age M=59yr) (Curry et al, 2012)

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All patients had failure of at least 2 organ systems or an organ system + sepsis

90% had failure of > 1 organ system besides the skin

Renal & respiratory systems failed most often (89.7% each), followed by cardiac (34.5%), & hepatic (27.6%)

Sepsis was present in 62.1% of patients

Non-skin organ system failure & skin failure can be expected to be observed at the same time

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Study of Acute Skin Failure in ICU Patients

• Respiratory failure was significantly associated with skin failure in 2 other studies (Curry et al, 2012; Levine et al, 2009)

• Curry et al. also found that 2 or > failed organ systems resulted in skin failure.

Interpreting Relative Infrared Images• A selection of a baseline control area allows for the visualization of relative temperature differentials.

• Minimizes the always present intrinsic and extrinsic variables (ambient temperature or comorbidities).• When analyzing tissue a clinician should not be concerned with absolute temperature value.• Instead, focus on relative temperature differences between the affected/at-risk tissue and the control.

Copyright 2017 WoundVision EHOB

Raw Thermal Image (no-control)Image is interpretable but cannot be quantified

without bias from variables.

Relative Color (w/ control)Image is easier to interpret and can be quantified

into a temperature range.

Copyright 2017 WoundVision | EHOB

Perfusion Deficiency: Example #1

Perfusion Deficiency: Example #2

Copyright 2017 WoundVision | EHOB

Perfusion Deficiency: Example #3

Copyright 2017 WoundVision | EHOB

Oxygen Challenge: Before, During, and After

Copyright 2017 WoundVision | EHOB

Future• Animal model studies of comprised perfusion and resulting skin failure

• Identification of biomarkers placing an individual at risk

• Thermographic images of various body locations of severely impaired perfusion

• Early identification of underlying disorder

• More concise diagnostic criteria could provide clarity on the etiology of SF (Delmore et al, 2015)

Incremental Positioning of Critically Ill Patients

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Kathleen M. Vollman MSN, RN, CCNS, FCCM, FAANClinical Nurse Specialist / Educator / Consultant

ADVANCING NURSING

Do Not Turn

• If a patient requires a “no turn” order it basically means do not touch or move.

• A no-turn order should be generally self-limiting

• A no-turn order should have a mandatory reassessment ever 4 hrs.

Does hemodynamic instability need to be a reason for “ to unstable to turn”

HemodynamicInstability

Is it a Barrier to Positioning?

???

Patient related barriers = 50% of barriers to mobility

Dubb R, et al. Ann Am Thorac Soc. 2016 May;13(5):724-30

• Lateral turn results in a 3%-9% decrease in SVO2, which takes 5-10 minutes to return to baseline

• Appears the act of turning has the greatest impact on any instability seen

• Risk factors that contribute to imbalances in oxygen supply and demand

The Role of Hemodynamic Instability in Positioning

Winslow EH, et al. Heart Lung. 1990;19:557-561Price P. Dynamics. 2006;17:12-19.Vollman KM. Crit Care Nurs Q. 2013;36:17-27White, KM. AACN Clin Issues Crit Care Nurs. 1993 Feb;4(1):134-47

• Dressing change 10%• Physical exam 20%• Agitation 18%• Bath 23%• Chest X-ray 25%• Suctioning 27%• ↑ work of breathing 40%• Weigh on sling scale 36%• Position change 31%• Linen change 22%• Chest physiotherapy 35%

Activities That Increase VO2

Balance the Risk & Benefit

• Determining the timing of the turn in relation to other care activities

• Monitoring for tolerance 5 to 10 minutes after the mobilization• If using the left lateral position

– Potential for greater cardiovascular compromise– May necessitate a temporary decision to use supine (head-

of-bed elevation) and the right lateral position until able to tolerate

Vollman KM. Crit Care Nurs Q. 2013;36:17-27

The Role of Hemodynamic Instability in Positioning

37 Vollman KM. Crit Care Nurs Q. 2013;36:17-27

•• Elderly• Diabetes with neuropathy• Prolonged bed rest• Low hemoglobin and cardiovascular reserve• Prolonged gravitational equilibrium

Factors that put patients at risk for intolerance to positioning:

Training to Turn• Continuous Lateral Rotation

Therapy– Driven by a protocol-

hemodynamically stable or unstable

– Stop rotation every q 2 & assess– Yearly competencies

• Incremental Turns– Use of wedges– Microturns?– Start as 10%, gradually increase

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Brindle TC, et al. WOCN, 2013;40(3):254-267Vollman KM. Crit Care Nurs Q. 2013;36:17-27Krapfl, LA, et al. Wound Ostomy Continence Nurs. 2017;44(4):319-323

Decision-Making Tree for Patients Who Are Hemodynamically Unstable With Movement1,2

Screen for mobility readiness within 8 hrs of admission to ICU & daily initiate in-bed mobility strategies as soon as possible

Is the patient hemodynamically unstable with manual turning?•O2 saturation < 90%•New onset cardiac arrhythmias or ischemia•HR < 60 <120•MAP < 55 >140•SPB < 90 >180•New or increasing vasopressor infusion

Is the patient still hemodynamically unstable after allowing 5-10 minutes’ adaption post-position change before determining tolerance?

Has the manual position turn or HOB elevation been performed slowly?

Initiate continuous lateral rotation therapy via a protocol to train the patient to tolerate turning

Begin in-bed mobility techniques and progress out-of-bed mobility as the patient tolerates

Allow the patient a minimum of 10 minutes of rest between activities, then try again to determine tolerance

Begin in-bed mobility techniques and progress out-of-bed mobility as the patient tolerates

Try the position turn or HOB maneuver slowly to allow adaption of cardiovascular response to the inner ear position change

No

No

No

No

Screen for mobility readiness within 8 hrs of admission to ICU & daily initiate in-bed mobility strategies as soon as possible

Yes

Yes

Yes

Yes

HOB=head of bed; HR=heart rate; MAP=mean arterial pressure; SPB=systolic blood pressure.Vollman KM. Crit Care Nurse. 2012;32:70-75.Vollman KM. Crit Care Nurs Q. 2013;36:17-27.

Thank you

• Kathleen Vollman– kvollman@comcast.net– www.Vollman.com

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Progressing Mobility

Theresa Murray R.N. M.S.N. C.C.R.N, C.C.N.S Critical Care Clinical Nurse Specialist

Community Health Network, Indiana41

ABOUT US

• Eight Hospital Health System in IN• 65 year old facility with experienced staff. • Up in cardiac chair as standard of care already

established before intervention.

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RASS -5 to - 3 RASS -3 & up RASS -1 & up

*Mobility is the responsibility of the RN, with the assistance from the RT’s Unlicensed Assistive Personnel and PT/ OT. PT and OT may assist the team with placement to the appropriate mobility level of activity, always prioritizing patient and provider safety. Placement is based on clinical judgment.

RASS 0 & up

***If the patient is intolerant of current mobility level activities, reassess and place in appropriate mobility level***For each position/activity change allow 5-10 minutes for equilibration before determining the patient is intolerant

RASS 0 & up

Tolerates Level IIActivities

ToleratesLevel IVActivities

Tolerates Level IIIActivities

Ambulate progressively longer distances with less

assistance x2 or x3/day with

RN/PT/RT/UAP

Tolerates Level I

Activities

Refer to the following criteria to assist in

determining mobility level

YESNO

Start at level II and progress*

Start at level I*

o PaO2/FiO2 > 250

o Peep <10

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oa

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Progressive Mobility Continuum

O2 Sat > 90%

RR 10-30

No new onset cardiac rrythmias or ischemia

HR >60 <120

MAP >55 <140

SBP >90 <180

No new or increasing vasopressor infusion

o RASS > 3

Perform Initial mobility screen w/in 8 hours of ICU

admissionReassess mobility level at

least every 24 hours(Recommended at shift Δ)

Goal: upright sitting; increased strength and

moves arm against gravity

PT consultation prnOT consultation prn

Goal: Increased trunk strength, moves leg against gravity and

readiness to weight bear

PT: Active Resistance Once a day, strength

exercises

OT consultation prn

ACTIVITY:Self or assisted Q 2 hr turning

1.Sitting on edge of bed w/RN, PT, RT assist X 15 min.

2.Progressive bed sitting PositionMin.20 min. 3X/d

OrPivot to chair position 2X/d

ACTIVITY:Self or assisted Q 2 hr turning

1.Bed sitting PositionMin.20 min. 3X/d;

2.Sitting on edge of bed; stand w/ RN, PT, RT assist

3.Active Transfer toChair (OOB) w/ RN/PT/RT assist Min. 3X/d

PT x 2 daily & OT x1 daily

ACTIVITY:Self or assisted Q 2 hr turning

1.Chair (OOB) w/ RN/PT/RT assist Min. 3X/day

2.Meals consumed while dangling on edge of bed or in chair

Goal: stands w/ min. to mod. assist, able to

march in place, weight bear and transfer to chair

PT x 2 dailyOT consult for ADL’s

Goal: clinical stability; passive ROM

ACTIVITY:Q 2 hr turning

*Passive /Active ROM 3x/d

1. HOB 45º X 15 min.2. HOB 45º,Legs

in dependant position X 15 min.

3. HOB 65º,Legs in dependantposition X 15 min.

4. Step (3) & full chair mode X20 min. 3X/d

Or Full assist into cardiac

chair 2X/day

ACTIVITY:

HOB > 30º*Passive ROM 2X/d performed by RN, or

UAP_________________

CLRT/Pronation initiated if patient

meets criteria based on institutional

practiceOR

Q 2 hr turning

Goal: Increase distance in ambulation

& ability to perform some ADLs

START HERELEVEL I LEVEL II LEVEL III LEVEL IV LEVEL V

Includes complex, intubated, hemodynamically unstable and stable intubated patients; may include non-intubated

Includes intubated, non intubated hemodynamically stable/stabilizing, no contraindications

TESTS OF CHANGE AND WHAT WE LEARNED

• Secured .6 FTE of OT and PT dedicated to the ICU in the morning to work with the study patients.

• Randomized even rooms for consent into study.

• Worked toward walking vented patients.

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Patients in the study

• Control Group• 50 patients

– 34 vents

• Intervention group• 47 patients

– 32 vents

Both groups had similar age ranges, admitting diagnoses, sex

What about falls during the study?

47.%

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Total Falls of Patients who have been transferred from the ICU

2015

2016

Only 2 patients in the study group fell

Length of Stay ResultsControl group vs. Study group

10.5

8.3

CONTROL STUDY

Hospital LOS

5.8

7.1

CONTROL STUDY

ICU LOS

7.3

5.3

CONTROL STUDY

Vent LOS

Discharge Disposition

BARRIERS AND HOW THEY WERE RESOLVED

• Nursing , respiratory and OT, PT communication could have been better.

• We were surprised that RT was not more engaged.

• We will do focus groups when we move this to north.

• Already have two RT’s at north who are interested in the program

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ADVICE FOR OTHERS

• Frequent sharing of progress and data with the team including the medical staff.

• Bigger unit needs lifts and the OT and PT support.

• Our next steps…. move to North campus.

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Thank you

• Questions?• tmurray@ecommunity.com• 1-317-355-4258

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Questions for the Panelists

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BRING IT HOME

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Lisandra Cuadrado, MPH, Program Manager| HRET

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Resources

• 2017 HAPI Change Package• HAPI / Sepsis Top 10 Checklist• Progressive Mobility Continuum

(in files pod)

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Thank You!

Find more information on our website: www.hret-hiin.org

Questions or Comments: HIIN@aha.org

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