European Pressure Ulcer Advisory Panel

1. Recent trends in pressure ulcer management in Japan

Hiromi Sanada, RN, WOCN, PhD

Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo, Japan

In recent years, the government's concern about pressure ulcers has dramatically increased due to the heightened national interest of these life-threatening and QOL-lowering diseases.

In October 2002, the Japanese Government introduced a penalty system which imposes fines of approximately 0.35 Euro per patient per day to hospitals that have not established a committee that addresses the issues concerning pressure ulcer care and support surfaces. The Japanese Society for Pressure Ulcers conducted a large survey (N = 2,582 hospitals with response rate of 51.6%) on the change in prevalence of pressure ulcers in hospitals before and after the introduction of this penalty system to evaluate its effectiveness. We revealed a significant decrease in the prevalence one year after its introduction. Although this decrease in prevalence shows signs of success, a high proportion of severe pressure ulcers which extend to muscle and bone tissue still remains. To actualize a lower incidence of these severe pressure ulcers, the government is relying on the professional skills of Wound, Continence, and Ostomy Nurses (WOCNs), who are in charge of pressure ulcer management in hospitals. We conducted a prospective cohort study to evaluate the cost-effectiveness of WOCNs staffing. In 2005, questionnaires were mailed to all hospitals in Japan with more 200 beds (1,358 hospitals). We compared labour, material costs, and the healing status of patients suffering from Stage II or greater pressure ulcers amongst hospitals with and without WOCNs. This study period was three weeks in duration. 179 ‘with’ WOCNs and 482 ‘without’ hospitals responded to the questionnaire. Material costs of the ‘with’ group was significantly lower (<50%) than the ‘without’ group. With respect to the pressure ulcer healing process during the study period, significantly faster healing was observed in ‘with’ group. Multiple regression analysis revealed that the presence of WOCNs in a hospital was the most significant factor related to pressure ulcer healing. Based on this finding, the government established a reimbursement system for each high risk patient admission to hospitals that employ a full-time WOCN specializing in pressure ulcer management.

In this session, the introduction and evaluation of these two governmental systems; the penalty system and the new reimbursement system for high-risk patients will be presented.

2. DESIGN tool: to classify pressure ulcer severity and monitor the healing process

Takahiko Moriguchi MD, PhD.

Dept. of Plastic Surgery, Kawasaki Medical School, Kurashiki, Japan

There were several wound assessment tools, but there were no scales for nurses and physicians not only to classify but also to monitor healing progression. To develop a new assessment tool, the Japanese Society of Pressure Ulcers (JSPU) established a committee comprised of a facilitator, physicians from departments of internal medicine, surgery, dermatology, and plastic surgery, and two wound ostomy and continence specialist nurses. In 2000, the committee first completed a prototype model with reference to several former classifications and/or tools. After receiving feedback from delegates at the Annual Meeting of the JSPU, this prototype was revised, and the final version was published in March 2002.

The new assessment tool, which classifies the severity of pressure ulcers and monitors the wound healing process, was given the name DESIGN. The name is composed of the first letters of six items; Depth, Exudates, Size, Infection/Inflammation, Granulation and Necrosis. The severity is expressed by small letters and large letters. Small letters indicate slight damage and large letters indicate serious damage. Using this lettering system, the general condition of a wound can be quickly identified at a single glance. The healing progression uses scoring points for each item. Lower points indicate improvement.

Depth is classified in to ways. A small ‘d’ indicates extension to the dermis and a large ‘D’ indicates full thickness skin loss. In the healing progression, depth is divided into five steps. If a wound becomes shallower, the decreased depth should be reflected in the assessment. If there is black and hard necrotic tissue, the ulcer wound be expressed as a ‘D5’. Depth is the most important item. There is a big difference between a small ‘d’ and a large ‘D’. A small ‘d’ indicates a re-epithelization tendency. In the case of a small ‘d’, only a moist environment must be prepared. On the other hand, in the case of a large ‘D’, necrotic tissues must first be removed.

Exudates are of three degrees; slight, moderate and heavy. Classification depends on the number of daily dressing changes. ‘E3’ indicates a heavy amount of exudates requiring dressing changes at least twice a day.

Size is divided into six degrees. The wound size is measured by the perpendicular method, that is, the longest and widest aspect of the wound surface in centimeters. ‘S6’ indicates that the size is 100cm² or larger.

Infection and inflammation have scores ranging from ‘0-3’. ‘0’ is for no infection. ‘1’ is for inflammation, ‘2’ is for local infection, and ‘3’ is for systemic infection. This score is based on only visual observation, not a bacterial examination.

Granulation has a score ranging from ‘0-5’, with a higher score repressing a lower percentage of visible healthy granulation tissue in the wound.

Necrosis has a score raging from ‘0-2’, with ‘1’ indicating the presence of ‘slough’ or soft necrotic tissue, and ‘2’ indicating the presence of ‘eschar’ which is hard thick necrotic tissue attached to the wound.

If a pocket is present, a large ‘P’ is added to the DESIGN assessment, and a score ranging from ‘1-4’ according to its size is assigned.

The concept of the guidelines of the JSPU is that, through treatment the large letters of the DESIGN should be become the small letters. In the presentation, the overall development process and concept of DESIGN tool will be discussed.

3. JSPU Guideline for Local Treatment of Pressure Ulcers

Shigeru Ichioka, MD.

Department of Plastic and Reconstructive Surgery, Saitama Medical University, Japan

The committee of Japanese Society of Pressure Ulcers (JSPU) developed a guideline for local treatment of pressure ulcers in 2005. This guideline has been intended to systematically provide clinicians with specific guidance upon local management of pressure ulcers. The recommendations offered in this guideline have been graded using the following systems:

• Source of evidence that underpins the recommendation

  1. Evidence obtained from systematic review or metaanalysis of randomised controlled trials
  2. Evidence obtained from at least one randomised controlled trial
  3. Evidence obtained from controlled trials without randomisation
  4. Evidence obtained from analytical epidemiologic studies, such as cohort studies and case-control studies.
  5. Evidence obtained from non-experimental descriptive studies, such as case reports and series of cases.
  6. Evidence from expert committee reports or opinions and/or clinical experience of respected authorities.

• Recommendation Grading

  1. Very strong recommendation
  2. Strong recommendation
  3. Weak recommendation, low-quality evidence
  4. Very weak recommendation, lack of evidence
  5. Not appropriate for recommendation.

Strength of recommendations has been comprehensively assigned taking various factors including types, quality, and consistency of evidence into considerations. The manual has addressed individual therapeutic strategy in accordance with DESIGN assessment tool released from JSPU for feasible application. The current guideline facilitates scientific clinical decisions for all care settings. We expect that it may contribute to improvement of global as well as domestic status of pressure ulcer treatment.

4. Risk factors of pressure ulcers in Japan

Takehiko Ohura MD, PhD

President of Pressure Ulcer and Wound Healing Research Center (Kojin-kai) Sapporo, Japan

Introduction

Risk factors of pressure ulcers should be detected by the case-control study. Risk factors should consist of only intrinsic factors, not including extrinsic factors which allow a comparison of prevalence between hospitals and past cases. These risk factors should be simple and easy to assess by anyone.

Detection procedure

Data from 132 patients with pressure ulcers, whose conditions at one month prior to onset of their pressure ulcers, were compared with 528 patients without pressure ulcers matched for ‘gender and age’, 81 PU - related variables were evaluated. Monovariate and multivariate analyses were carried out to detect PU risk factors. That is, deterioration of self-sustainable ability (possible (0 point), intermediate (1.5), impossible (3)), morbid bony prominence (none(0), intermediate (1.5), severe (3)), edema (negative (0), positive (3)) and articular contracture (negative (0), possible (1)) were assessed as intrinsic risk factors of PU. Moist skin and malnutrition were set up as warning factors. Furthermore, the estimated probability of PU development, based on the combination of these factors, and the risk factor score, were fixed according to ß values of analysis. Also, the duration of healing was assessed.

Relationship between OH Risk Factors, Onset Probability and Healing Period

	Level of OH Risk Factor	Onset probability	Healing period * 1
* 1 In 115cases of PUs patents were completely healed under adequate treatment * 2 P< 0.001
Incidental Pressure Ulcer (none of OH RF)	Temporal Risk Factor	Temporal Risk Factor Dependence	Temporal Risk Factor Dependence
Common Pressure Ulcer (OH RF)	(Low level) 1-3 points	less than 25%	40 days * 2
	(Middle level) 4-6 points	26 to 65%	57 days * 2
	(Severe level) more than 7 points	more than 66%	173 days * 2

Application

The OH scale could serve for assessing risk factors in patients, however, it can also be used for the other valid applications as follows:

1. It is possible to presume effectively how many mattresses are necessary in hospitals and facilities and also to evaluate the change of PU onset rate. This is dependent on the changing of mattress supply rate overtime at any given hospital,
2. It is also possible to compare and to evaluate the nursing quality from the viewpoint of PU care among hospitals. If the supply rate of mattresses in all hospitals is fixed, then the rate of PU onset per level of RF can be compared. This data will in turn show the level of nursing care.

5. New Concepts of PU from the Perspective of Shear Force and Pressure (1) Mechanism and measurements

Makoto Takahashi, Dr Eng.

Bioengineering and Bioinformatics Graduate School of Information Science and Technology Hokkaido University, Sapporo, Japan

The force applied on the skin is measured as a mixture of two components, one in the perpendicular direction and the other is in the tangential direction. Tangential force is defined as shear force.

When a pressure ulcer occurs, traditionally, only the surface phenomenon has been spot lighted and been evaluated. However, there have been many clinical phenomenons that could not be simply described by that model. A good example would be a deep tissue injury - why would an injury develop within the subcutaneous layers of the skin?

Here, we have provided many new ways to look and evaluate a pressure ulcer. By looking into how forces on the skin surface transforms beneath the surface and above the bony prominence, in between layers of skin, muscles, fat and bones, we have given new ways to think how a pressure ulcer is generated. The keyword is shear, and it is not just surface friction.

Shear force on the skin surface is caused mainly by friction and movement. However, the inner shear force is quite difficult to recognize. To understand the forces within - its direction and also its magnitude - the concept of "stress" is important. As a result of the stress, a great "strain" impacts the skin layers beneath its surface and triggers pressure ulcer development. Even if the perpendicular force is applied to the skin without any tangential factors, shear force may appear within the tissue.

To understand in more detail how and what forces impact the skin beneath its surface, measuring that force exactly how it is - is essential.

One approach to this is to measure the force that has been applied on to the skin, measurement with the six degrees of freedom. However at present, we can measure with only two or three degrees freedom with current measuring instruments available in market. Recently, apparatus for measuring one dimensional shear force on the skin has been made available.

Another approach is to measure the force within the inner tissue. However this is difficult even if it just pressure. Current, we must conjecture that forces in consideration with the surface applied force and the anatomical structures, together with other possibilities. Moreover, computer simulation using a finite element model (FEM) is beneficial for numerical speculation inner or deep tissues and it gives us some clues without invading the human skin.

Here in my presentation, I would like to 1) make ‘shear’ clear and 2) provide future ways to clarify the mechanisms of pressure ulcers as an engineer.

6. Clinical Evidence regarding Shear Force and Pressure Ulcers

Takehiko Ohura MD, PhD.

Pressure Ulcer and Wound Healing Research Center (Kojin-kai) Sapporo, Japan

Introduction

When the combined factors of pressure and shear force act on the body, they will generate a larger pressure inside the tissue than either of the factors acting on their own. Furthermore if a bony prominence is involved as well then the two forces will combine to cause extensive damage in the vicinity of the soft tissue around the bony prominence. This can give rise to the development of specific clinical conditions and I will focus on three of these in this presentation.

Clinical Evidence

1. Hourglass shape necrosis. Deep Tissue Injuries (Initial Phase type of undermining)

   When the combined three factors of bony prominence, shear force and pressure generate a larger pressure in the tissue close to a bony prominence, extensive ischemia may already have been induced at the onset of pressure ulcer and the affected soft tissue will become gradually and increasingly necrotic over a period of 6 to 10 weeks. The shape of this necrosis will be like an hourglass in cross-section. The clinical development of a pressure ulcer will be very slow which gives the impression of a gradual deterioration. This however is misleading since the affected soft tissue had been destined to become necrotic during the initial stage and this is part of a natural wound development process which occurs beneath intact skin.

2. External force type of undermining

   This type of undermining is caused by a combination of shear force, pressure and a bony prominence. Development of this type of undermining should be preventable through good nursing care. Also clinicians should know that it can not be healed unless shear force is eliminated by careful treatment. When a patient is moved laterally or vertically over a bony prominence point, the soft tissue is compressed together on that point, causing damage due to the weight of the patient, acting as a vertical load. When the patient is then returned to the original position, undermining damage will have occurred in the previously compressed soft tissue.

3. Residual Shear Force

   This type of shear force can be induced during movements of the bed, not only when the head side is raised but also when it is lowered and after postural changes. Recent findings have shown that a residual shear force exists even after the head side of the bed is lowered. Nursing staff need to be aware about residual shear forces and they should be able to eliminate its effects through innovative nursing care.