Faculty Bibliography

GENERAL PURPOSE: To provide information on risk factors for surgical site infections (SSIs) and actions to mitigate that risk. TARGET AUDIENCE: This continuing education activity is intended for surgeons, surgical teams, physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:1. Identify modifiable risk factors associated with the development of SSIs.2. Select steps to mitigate the risks for and morbidity from SSIs. ABSTRACT: Given the current reimbursement structure, the avoidance of a surgical site infection (SSI) is crucial. Although many risk factors are associated with the formation of an SSI, a proactive and interprofessional approach can help modify some factors. Postoperative strategies also can be applied to help prevent an SSI. If an SSI becomes a chronic wound, there are recommended guidelines and strategies that can foster healing.

PURPOSE: The purpose of this learning activity is to provide information regarding the differentiation between pressure ulcers and acute skin failure (ASF) in critically ill patients. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to:1. Describe the purpose, methodology and impact of this research.2. Differentiate the pathophysiology of pressure ulcers and ASF.3. Identify risk factors and diagnostic criteria for ASF. ABSTRACT: To develop a statistical model to predict the development of acute skin failure in patients admitted to the intensive care unit (ICU) and to validate this model.Retrospective case-control, logistic regression modeling552 ICU patientsIntensive care unit patients with and without pressure ulcers (PrUs) were studied and compared on key variables sorted into the following categories: (1) disease status, (2) physical conditions, and (3) conditions of hospitalization.The variables, peripheral arterial disease (odds ratio [OR], 3.8; P = .002), mechanical ventilation greater than 72 hours (OR, 3.0; P < .001), respiratory failure (OR, 3.2; P < .001), liver failure (OR, 2.9; P = .04), and severe sepsis/septic shock (OR, 1.9; P = .02), were found to be statistically significant and independent predictors of acute skin failure in ICU patients. These variables created a predictor model for acute skin failure in the ICU.Lack of objective criteria to define acute skin failure presents a clinical conundrum for practitioners-the acknowledgment that skin failure exists, but no clear-cut diagnostic criteria in which to support its existence as a result of a paucity of empirical evidence. In certain populations, such as the critically ill patient, the phenomenon of acute skin failure may be occurring, and with the current level of evidence, these ulcers may be incorrectly identified as PrUs. Accurately distinguishing risk factors that lead to a PrU from factors that result in a lesion due to acute skin failure is crucial in the quest to provide evidence-based practice to patients.

PURPOSE: To develop and validate a method of predicting whether patients will develop a heel pressure ulcer during their hospital stay. DESIGN: This retrospective case-control study used 2 separate data sets, one for an initial analysis followed by a second data set for validation analysis. SUBJECTS AND SETTING: From 2009 to 2011, medical records of discharged patients with a DRG code for heel pressure ulcers in our urban, tertiary medical center were retrospectively reviewed. Using age as the matching criterion, we then reviewed cases of patients without heel pressure ulcers. The initial analysis comprised 37 patients with hospital-acquired heel pressure ulcers and 300 without. The validation analysis included 12 patients with heel pressure ulcers and 68 without. METHOD: In order to develop this method of identifying patients with heel pressure ulcers, logistic regression modeling was used to select a set of patient characteristics and hospital conditions that, independently and in combination, predicted heel pressure ulcers. Logistic modeling produced adjusted and unadjusted odds ratios for each of the significant predictor variables. The validation analysis was employed to test the predictive accuracy of the final model. RESULTS: Initial analysis revealed 4 significant and independent predictors for heel pressure ulcer formation during hospitalization: diabetes mellitus, vascular disease, immobility, and an admission Braden Scale score of 18 or less. These findings were also supported in the validation analysis. CONCLUSION: Beyond a risk assessment scale, staff should consider other factors that can predispose a patient to heel pressure ulcer development during their hospital stay, such as comorbid conditions (diabetes mellitus and vascular disease) and immobility.

This case study will describe the journey of a patient admitted to an urban, tertiary medical center for bariatric surgery and the unexpected challenges encountered by the clinical staff in caring for him. Despite having awell-established bariatric surgical program, it took only one patient who deviated from the "norm" to cause thestaff to reexamine the way that bariatric patients are cared for in the facility, particularly with regard to their mobility and safe patient handling needs. The lessons learned from this experience and the patient’s own perspective have enabled a more informed approach to how bariatric patients are cared for throughout the hospital and led to an adjustment of protocols in this area of practice

The Centers for Medicare & Medicaid Services' regulations regarding nonpayment for hospital-acquired conditions such as pressure ulcers have prompted a marked increase in focus on preventive care. Our hospital also used this change in payment policy as an opportunity to strengthen our pressure ulcer prevention practices. We used an 8-spoke prevention wheel to develop and implement practice changes that reduced pressure ulcer incidence from 7.3% to 1.3% in 3 years. Because it is about the journey, we will describe the mechanisms we designed and implemented, and identify strategies that worked or did not work as we promulgated a quality improvement process for pressure ulcer prevention in our large urban hospital center.