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PERFORMANCE IMPROVEMENT PROJECT Objective: Determine whether novel pressure-relieving Fluid Immersion Simulation (FIS) OR Table Pads reduce the incidence of perioperative HAPU among patients undergoing cardiac surgery (CS) Timeline: September 1, 2013 through November 30, 2013 BACKGROUND AND SIGNIFICANCE DRIVING FORCES — INSTITUTIONAL 2006: zEstimated cost of Stage 3 and 4 pressure ulcers (PU) in the United States – $11 billion/year 4 zManaging a single full-thickness PU may cost ≥ $70,000 2007: zCenters for Medicare and Medicaid Services (CMS) identified Stage 3 and 4 PU as "never events" 2008: zCMS implemented nonpayment for treatment DRIVING FORCES — INSTITUTIONAL zHAPU Stage II above goal of 0% - < 1%** Survey Date Patients Surveyed (N) Hospital Acquired Pressure Ulcers (HAPU) (N) HAPU ≥ Stage 2 (%) Patients Surveyed in CSICU (N) Patients with| HAPU in CSICU (N) Stage % of Total Patients with HAPU in CSICU (%) 09/2012 800 18 1.9% 7 1 DTI (1) (5.5%) 12/2012 701 22 2.7% 14 5 II (3) DTI (2) (23.0%) 03/2013 777 25 3.0% 14 1 DTI (1) (4.0%) 06/2013 766 26 3.2% 4 4 II (2) DTI (2) (15.3%) Legend: HAPU: Hospital-acquired pressure ulcers CSICU: Cardiac Surgical Intensive Care Unit ** No Stage III or Stage IV HAPU reported in these quarterly surveys RISK FACTORS FOR PU DEVELOPMENT IN CARDIAC SURGICAL PATIENTS zExtended time/immobilization on the OR table zOlder age zExtracorporeal circulation zTemperature manipulation zVasoactive drugs zHypotensive periods zReduced hemoglobin and hematocrit levels. IMPLEMENTATION zFIS OR Table Pad placed continuously on the table in all four cardiac surgical operating rooms (OR) zSkin inspected by OR nurse before surgery and at end of case z Skin inspected daily by nurse in CSICU and/or progressive care unit, if patient's condi- tion permitted repositioning z Safety report filed if evidence of new PU ≥ Stage 2 FLUID IMMERSION SIMULATION (FIS) OR TABLE PAD FLUID IMMERSION SIMULATION TM (FIS) 7 zA state-of-the-art pressure redistribution technology zAn advanced microprocessor-driven system - analyzes the pressure waveform generated by the patient while sinking into the mattress surface - then, precisely adjusts air density in the mattress to simulate immersion in a fluid medium. zMimics floating in water and dynamically reduces undesired soft tissue deformation. CONCLUSION This patient series suggests that the FIS OR Pad is effective at preventing tissue deformation and consequent deep tissue injury in a subset of patients who are at very high risk of PU. REFERENCES 1 Feuchlinger J, Halfens RJ, Dassen T. Pressure ulcer risk factors in cardiac surgery; a review of the research literature. Heart Lung. 2005 Nov-Dec; 34 (B); 375-85 2 Sowchuk D, Padula C, Osborne E. Prevention and early detection of pressure ulcers in patients undergoing cardiac surgery. AORN J. 2006 Jul; 84 (1), 75-96. 3 Kahanzadeh S. Breithaupt A. Bondarchuk, Bhavsar D, Evers L. Effectiveness of the Dolphin Bed as a Tool to Improve Tissue Perfusion in Points of Compression (Poster presented at Symposium on Advanced Wound Care, San Diego, CA.) Available at: http://www.biologics900t.com/news. html (Accessed December 17, 2013.) 4 Federal Register 73 (161). Tuesday August 19 2008, Rules and Regulations, p. 48471. Available at: http://edocket.access.gpo.gov/pdf/E8-17914.pdf 5 Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: A systematic review JAMA 2000; 290: 974-984 6 Russo CA, Steiner C, Spectof W: Hospitalizations related to pressure ulcers, 2006. HCUP Statistical Brief #64, December 2008. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb64. pdf. Accessed May 10, 2012 7 Biologics Pressure Relief Systems. Available at: http://www.biologics900t.com/news.html (accessed April 6, 2014.) This project was undertaken as a Quality Improvement initiative at Massachusetts General Hospital, and as such was not formally supervised by the Institutional Review Board per their policies. Questions? Contact vcapasso@partners.org EFFECT OF FLUID IMMERSION SIMULATION* OR TABLE PADS ON PRESSURE ULCER PREVENTION IN CARDIAC SURGICAL PATIENTS – EARLY RESULTS Virginia Capasso, PhD, ANP-BC, ACNS-BC, CWS; Charlene O'Connor, RN, MSN, CNOR: Sandra Silvestri, MS, RN, CNOR; Dawn Tenney, RN, MSN; Amanda Coakley, RN, PhD; Christine Gryglik, PhD(c), RN, ACNB-BC; Vivian Donahue, RN, MS, ACNS-BC; Theresa Gallivan, RN, MS; Gaurdia Banister, RN, PhD, FAAN Massachusetts General Hospital, Boston, Massachusetts ABSTRACT Problem: Between 9/2012 and 6/2013, our quarterly pressure ulcer (PU) prevalence surveys demonstrated that one (4.3%) to five (23%) patients with PU per quarter had undergone cardiac surgery (CS). Length of surgery ranged from three to cumulative 16 hours during multiple surgical procedures. Background and Significance: Our results are consistent with published reports of higher PU incidence for CS patients of up to 29.5%. 1 Risk factors include duration of immobiliza- tion on the OR table, older age, temperature manipulation, vasoactive drugs, hypotensive periods, and reduced hemoglobin and hematocrit levels. 1-2 Novel approaches to prevent PU from prolonged immobilization include Fluid Immersion Simulation (FIS) OR Pad – a pressure redistribution surface pad that uses a patented microprocessor and dynamic waveform analysis software to adjust internal air density based on the mass and surface area. The end result is a support medium with less molecular density than the supported body, maintaining normal tissue symmetry. Studies demonstrate preservation of 87% of baseline microvascular blood flow on FIS Pad versus 16% on static OR table pads. 3 Implementation: From 9/1/2013 to 11/30/2013, FIS OR Pads were placed continuously on the four CS OR tables. Results: 398 patients underwent CS on the FIS OR Pad, including 230 men (58%). Ages ranged from 24 years to 88 years (mean: 63 years.) Surgeries included coronary artery bypass graft (CABG) (28%), aortic valve replacement (AVR) (13%), mitral valve replacement (8%), thoracic aortic procedures (7.2%), CABG plus VR (4.5%), lung transplant (1%), heart transplant (0.5%). Duration of the procedures was shortest for CABG and longest for tho- racic aortic repair. In the series, the incidence of new pressure ulcers was 0%. Conclusion: The FIS OR Pad is effective at preventing tissue deformation and deep tissue injury (DTI) in a subset of patients who are at very high risk of PU. Implications for Practice: Use will be expanded to other patients at high risk of perioper- ative DTI. 1 Dolphin Mat Fluid Immersion Simulation (Clearwater, FL Biologics, Inc.) RESULTS (N=398) Gender Age Male 230 Range 24 years - 88 years Female 168 Mean 63 years Type of Surgery Percentage Coronary Artery Bypass Graft (CABG)* 28.0% Aortic Valve Replacement (AVR) 13.0% Mitral Valve Replacement 8.0% Thoracic Aortic Procedure** 7.2% CABG plus VR 4.5% Lung Transplant 1.0% Heart Transplant 0.5% Incidence of HAPU: 0% *Shortest duration of surgery **Longest duration of surgery IMPLICATIONS Practice - Extend use of FIS OR Table Mat to other patients at high risk of perioperative deep tissue injury Research - Conduct comparative effectiveness trial(s) comparing FIS OR Table Pad with other pressure relieving OR table pads/products/strategies