What Role Does Staging Play in Pressure Injury Care?

Crack the code to better healthcare! Ever wondered about pressure injury care? Uncover simple tips for effective wound management and empower your family to make informed healthcare decisions. In this week’s episode, nursing home abuse attorney Rob Schenk welcomes guest Dr. Tippett to talk about understanding the crucial role of staging in pressure injury care, ensuring your loved ones receive the best possible care.

What Role Does Staging Play in Pressure Injury Care?

Schenk: 

This week on the Nursing Home Abuse Podcast, what role does staging play in pressure injury care? Stick around.

Hey out there. Welcome back to the nursing home abuse podcast. My name is Rob. I’m an attorney and I will be your host for this episode. This week, we’re talking about staging and pressure injuries with Dr. Aletha Tippett. We get into a fantastic conversation about her views on staging, how staging relates to communications with providers.

And then we talk about an interesting story about her experience. Essentially consulting and administering pressure ulcer interventions in a particular nursing home that resulted in phenomenal outcomes for the residents there. So stick around we’re going to, we’re going to do some things first.

Let’s get into the substance of the episode. So we’re going to be talking with Dr. Aletha Tippett this week. Dr. Tippett has a B. S. in chemical engineering and she got her medical degree from the University of Cincinnati.

She’s renowned for her expertise in family medicine, palliative and hospice care, and wound care. A retired family physician from Ohio, Dr. Tippett specializes in wound care, particularly in limb salvage and pressure ulcer prevention, treating over 15, 000 wounds in her career. She’s a celebrated author, international speaker, and recipient of numerous Healthcare awards.

We are so happy to have her on the podcast this week. And actually we’re going to link in the show notes a copy of a study or an article that she wrote about her experience in consulting in a particular nursing home that led to Exceptional outcomes for the residents there in terms of pressure injuries, but be sure to check that out, read that check out her website.
Learn more about Dr. Tippett’s article How Do You Prevent Pressure Ulcers? 

She’s fantastic. If you have any questions for her you can absolutely reach out to her via her email and her email address is tip at a w at fuse. net. You can email her if you have any questions. Further questions or want to hear her story about that specific experience at that nursing home with the outrageous results.

Lovely talking to her. She’s awesome. We actually had her on a previous episode which we can talk about, but so she’s a veteran of the podcast and with that, Dr. Tippett, welcome to the show. 

Dr. Tippett: 

Thank you. Hello. 

Schenk: 

I told the audience a little bit about you before you came on and we were talking before the show that we, you and I spoke together, but this has been almost three years ago, three or four years ago is July of 2020.

What Are the Key Stages in Pressure Ulcer Development?

We talked about Pressure ulcers then and now we’re going to talk about pressure injuries again today. So I’m happy that you can be here just to kick it off. Regular listeners, regular watchers of this program, or this, I don’t even know what we call this a podcast program episode.

We talk about pressure injuries a lot, cause it’s a major problem in the long term care setting. But in terms of honing in on that particular topic today, we’re talking about staging. And what does it mean? So what in, in your understanding and your research and your knowledge, what does, what do pressure ulcer stages mean? What is that? When we say there’s a stage of pressure injury, 

Dr. Tippett: 

Stage really is just. At that point in time, how thick is your ulcer? That’s all it’s telling you. So you could have stages one through four. That’s just different levels of thickness. Like one is just, your skin might be red or pink if you’re a white person.

If you’re a dark person, it’s harder to tell what color that might be, but it might be lighter or darker. It’s mushy, maybe. That’s one. A two means if you just scrape the top of your skin off, that’s a two. And three means you’ve taken all the whole skin off and down here, down the muscle and four means you’ve gone all the way down to the bone.

Learn more about the Stages of Pressure Injuries.

Schenk: 

So I guess that’s probably why staging is important because we’re at different stages of the actual injury, the wound itself. And I would imagine that. Each stage probably has its own treatments. Maybe you’re doing things that you would do at stage one that you wouldn’t do at stage four and vice versa. So it talks about that. Is that kind of an important reason why we make distinctions between stages? 

Dr. Tippett: 

Your treatments are going to be different. You don’t need to know the stage in order to treat a wound. If I’m looking at a wound and I see it, I can figure out what it needs without knowing what the stage is.

The stage may help me communicate with other people that I’m working with. It’s stage is more of a communication tool than actual, doesn’t really mean anything to the wound. It doesn’t tell you how the wound got there. It doesn’t tell you where the wound is going. Just tells you where it is right now when you’re looking at it. 

Discover Different Stages of Pressure Ulcer Development in detail.

Schenk: 

But I guess. I guess that makes sense. So staging at least in part is important in terms of how you communicate that to the next shift or to the next provider. Correct. But I guess, would it be important to you to get the stage at least somewhat approximated correctly? Like you wouldn’t want to come to a resident or a patient where you’ve been told it’s a stage four but it’s a stage one. So I guess there would be some importance in how that’s communicated. 

Dr. Tippett: 

Oh, sure. You’d be expecting something very different if that happened. Of course, you’d have to alter what you were planning to do, but change everything, but the stage by itself is not, it’s not important as a thing.

You can’t design a plan around staging because that doesn’t work. Staging is just, How thick that is at the time and different things may affect that, the actual person, maybe their skin doesn’t break down. Maybe someone else breaks down right away. You just don’t know. 

What Are Common Misconceptions About Pressure Ulcer Staging?

Okay, that makes sense. So tell me then what are some misconceptions that the public has about staging? What are some things that you would see? You’re like, you hear and you’re ah, like this is wrong. Tell me about that. 

Dr. Tippett: 

The biggest thing that’s come to understand in say the last 15 years is deep tissue injury. Now that is really important. Let me ask this, do you know how long it takes to create an ulcer? 

Schenk: From my anecdotal experience, it can take as little as a few hours to develop an ulcer. 

Dr. Tippett: 

Two hours is all it takes. 

Schenk: 

Yeah. 

Dr. Tippett: 

To get an ulcer. So say you were, say you fell off your ladder and you were laying on the ground and it took a while for someone to find you and call the nine on one and all that.

Maybe you were laying there for eight hours. That’s a lot of pressure on your backbone and on the butt bones that you’re laying there. Now you’re not going to see anything right away. You say, Oh, he looks all right, and he goes in and whatever they do. And about two weeks later, they say, gosh, it looks like a bruise developing on his butt and then it’s not open.

It’s just a dark discoloration. And then a couple of days later, there’s a wound there. And they’re all gone. How would that come from? Where’d that come from? That came from him laying on the ground. when he was first injured. And you don’t see it for maybe six weeks even before it happens. Now, the trouble is, nursing homes, or whoever is taking care of this guy, get in trouble because the wound, no matter what they do, keeps getting bigger and bigger.

And everyone thinks, Oh, they’re not doing the right thing. They’re doing wrong. They’re not. The wound is going to the bottom of that injury. It goes all the way down to the bone, then it’ll start healing. So you’re just wasting your time if you’re thinking that you’re not doing the right thing. If you’re treating it.

For more insights on pressure injuries, check out the National Pressure Injury Advisory Panel.

You’re doing the best you can do, but it’s. You’re not gonna make it go away. It’s gonna, not until the physiologic process happens, where the wound goes to the bottom, and then they’ll start healing. But that’s deep tissue injury, and I have had a lot of experience with that in legal cases. Because it’s a big deal.

Schenk: 

Sure. Because it’s, I guess from what I understand you to say, that a deep tissue injury, as opposed to maybe a standard pressure injury, is that it almost starts from the bottom and goes to the top. 

Dr. Tippett: 

Yes, That’s exactly right. 

Schenk: 

So it’s not as easily observable as not observable at all. 

Dr. Tippett: 

You don’t see it. For maybe weeks, 

Schenk: 

You would, but I guess if you suspected a deep tissue injury, there are ways to observe for it. For example, you could do a skin test in terms of looking for blanchable skin, things like that in your experience. Is that what, is that something? 

Dr. Tippett: 

I don’t think that would help you as much.

The most important thing is to understand the history of what happened to this patient. And if you know about deep tissue injury, then you know that if he was laying there for hours, He’s probably going to have some deep tissue injury. So you can watch for that. You can note in your notes that probable deep tissue injury, and then people will be alert and watching for it.

Schenk: 

And of course you would, if you suspect the tissue injury, one of the primary interventions in that respect would be to offload that area. 

Dr. Tippett: 

Oh, absolutely. That’s the trick always to prevent any pressure injury is to offload and if you have deep tissue injury, you better be offloading.

What Role Does Awareness Play in Preventing Pressure Injuries?

Schenk: 

Okay. That I mean I would agree with you I think that the concept of deep tissue injury is not very well known in the public and in some instances in my field of the plaintiff’s bar, but Whatever their, what other misconceptions do you see possibly with families of loved ones and that have somebody in a nursing home?

What are some misconceptions that they might have that maybe they need to be turned every 15 minutes or something like that in your experience? Are there Renee? 

Dr. Tippett: 

That I could answer that really. I don’t know what kind of misconceptions. People, families have for their loved ones in the nursing home.

I’ve worked in a lot of nursing homes, but I guess I don’t have that much interface with families about what they’re concerned about or what misconception they might have. Typically the nurse nurses should be talking to the patient. Families and telling them what’s going on, and sometimes the families are there when they’re taking care of wounds or doing something like that.

And that helps to keep them up to speed, it’s really interesting. I’ve worked with one nursing home. In Delhi and they were, they had a horrible pressure injury rate and the federal government was just about to close them down. They had a G level citation or whatever it was anyway, and they were about to be closed down.

They called me, I went out there and I helped them and they went six years without an ulcer. Not one ulcer in six years. So I thought that was a pretty dramatic change, but they were very committed to getting rid of pressure ulcers. 

Learn more about Comprehensive Pressure Ulcer Prevention in Nursing Homes.

Schenk: 

That’s an extremely wonderful story. Like no pressure injuries in six years. 

Dr. Tippett: 

Six years, six years.

Schenk: 

That’s amazing. So what, what was implemented? What are some things that in terms of pressure injury prevention that may be actually there.

Dr. Tippett: 

It’s actually very simple. And, first when I proposed the program, we all worked together and we got the program started and after about a month or two into the program.

I’d be walking through the hall and I’d be stopped by different aides who would come up to me and say, gosh, this is so easy compared to what we used to do. Thank you so much. So the people doing it found it very simple and very easy and would even tell me how easy it was and they were really happy, but it’s the pressure support.

You talk about offloading. The key is the proper pressure support. And we went with a product, it’s a static air, inflated air, and we put it on every bed and every chair, for every person, it didn’t matter, we didn’t stratify them at all, everyone who’s there is at risk, and we put them an air mattress on their bed, and put an air pad on their chair, and if their feet were in trouble, we got air boots for their feet, and that’s it.

We lubricated their skin every day. I think we used bag bombs all over their skin every day. If you don’t, can’t use a bag bomb, you can use A and D ointment, something like that. But we lubricated and we had pressure support and we had zero pressure injuries. 

Explore further by checking out the episode about Preventing Pressure Ulcers in Nursing Homes.

Schenk: 

I think that if I can throw this out there, like the, just the concept that everyone is at risk for pressure injury is probably revolutionary.

Dr. Tippett: 

Yes, it is. Yes. We did not stratify at all. We didn’t have to do a brain scale. We didn’t do anything. If you’re here, you’re at risk in the story and we’re going to protect you. That was the attitude and that worked. That’s how we went to zero. 

Schenk: 

Did you receive any pushback from staff, from administration in terms of Whoa, Whoa.This is going to raise labor costs or whatever. 

Dr. Tippett: 

Nope. Nope. They were. 100 percent for it. We started with the whole group. We, it wasn’t just me. I had, they were all in the team and I showed them everything and we talked about it and debated it and they picked to go with the static air.

Now, the interesting thing is this: They had just gotten a massive citation and were about to be closed down. What they had on every bed before that was alternating pressure pads, which I hate alternating pressure because they create more injury than they prevent. But they’re promoted big time and so they were sold a bill of goods.

They put alternating pressure pads on all their beds. And guess what? They had a lot of ulcers from alternating pressure pads. They didn’t know that. But when I went in and took pictures and looked at everybody, I said, these beds are causing you a lot of problems. 

Gain more insights by listening to Five Ways to Prevent Pressure Ulcers in Nursing Homes.

Schenk: 

And why is that? Is it because that you believe in your mind that because of the alternating pressure that you don’t have to actually still physically turn a reposition? Is that why, or is there some other reason why they’re not effective? 

Dr. Tippett: 

It’s because the pads, one will have pressure and one won’t. One has pressure, it’s causing injury. And you can, if you have someone that’s on an alternating pressure pad and you look, take pictures, you can compare the pictures to where they’re laying on the bed. Pad and see where it happened. It’s where the pressure is up on the pad. 

Schenk: 

I see. 

Dr. Tippett: 

And it was really interesting. But once the data was there, we looked at it and the head of the nursing home said, get rid of all these. And go with this. She just said, that’s it. Of course, she knew that they were looming.

Schenk: 

The federal government was breathing down their neck, And I might have missed it. I apologize. But what was that? What are the support services that are used instead of alternating the mattresses? 

Dr. Tippett: 

We use the static air set of care.

Schenk: 

Okay. So you guys. Yeah, I was going to say, you’ve got, Everyone’s a risk. Everyone stays somewhat lubricated, at least the pressure points. 

Deepen your understanding of pressure ulcer staging by checking out Understanding Pressure Ulcer Staging.

Dr. Tippett: 

Every day. No, every day. The whole body. We did that, we started hearing from old timers, old time nurses. We used to do that all the time. We lubed everyone up and no one ever had a sore. And I said, That’s all time coming back. We lubed everyone up and I knew when I would take my rounds, if I could see that someone had dry skin, I knew that also was going to happen. So I tell him you better lube that skin. Cause it’s going to be an ulcer if you don’t, 

Schenk: 

This is amazing. You got, like you said, like the lubrication, everybody’s a risk, the proper support service, jettisoning the support surfaces that don’t work, what else was applied to every single resident? What other, what would the, what are some other interventions that you made sure happened? 

Dr. Tippett: 

That’s all we did. That’s it. Pressure support. And lubrication. 

Schenk: 

What do you think about the concept of everybody’s at risk? How does that translate to the overall philosophy or the overall like mindset of the staff? So for example, like in your stand up meetings in the morning, is that always a topic? Hey, listen, now we’re at the part of the meeting. Tell me about so and so residents. Tell what we’re doing today. Lubricating everybody or whatever. I guess the question is to translate that it’s a constant, everyone’s constant job is to think about this in terms of preventing the ulcers every day.

Dr. Tippett: 

It should be now I wasn’t at stand up meetings cause I only went. Once a week I went home and did training for everybody and stuff. And so my training, we talked about that, assumed that they did that at their standup meetings, it really, when you get down to it, any person that goes into any facility.

hospital, nursing home, assisted living, that you should assume that they are at risk. You don’t, you do not need to stratify the risk. You could do a Brayden scale, but so what? Might as well flip a coin. The Braden scale is right 50 percent of the time. So how are you going to know that they’re at risk if half the time it doesn’t even tell you?

Tell you that they’re at no risk and they get an ulcer, so what I, when I read that report on the Braden scale, I said, huh, what good is a Braden scale? It’s just, everyone’s at risk and you do everything, you do the whole thing for everybody and then you’ll be alright. 

Schenk: I see. That’s again, that’s a fantastic story. Have you approached this from an academic standpoint in terms of trying to draw something up and convince other administrations or not?

Dr. Tippett: 

I haven’t done that. I’ve published, I published the article and and I presented it at symposiums but I don’t think, I don’t think people, it didn’t turn people on.

Schenk: 

Why do you think that is 

Dr. Tippett: 

I don’t know. I really don’t know. Cause I’m thinking, how can you ignore going to zero? Six years, How can you ignore that? How can you just say, oh, you should have done this. And I said, I don’t know. I don’t know if it’s. The bed manufacturers that control it. I don’t know because the static air is cheap, 60 bucks for a bed. 

Schenk: 

Have you been able to repeat that success anywhere else? 

Dr. Tippett: 

I haven’t had the opportunity. 

Schenk: 

I see. 

Dr. Tippett: 

But, individually. Sure. We can do it individually. But I haven’t worked with another facility at that level.

What Inspired Your Research on Pressure Ulcer Staging, and Why Is It a Crucial Topic?

Schenk: 

Yeah. Okay. What do you in your, speaking of that, then what inspired you to go to this direction with wound care and wound treatment? What didn’t put you down that path? 

Dr. Tippett: 

I guess my engineering background. I just, I understood pressure injury and, I just, and I looked at the mechanics.

One of my heroes is Paul Brandt. He was a doctor that did. worked in Africa, but he always said it’s the mechanics. It’s not anything else. It’s all about mechanics. And I said, Dr. Brandt, you are so right. Because I am an engineer, I knew that it was all about the mechanics, so a lot of times people, how is this wound like this?

Why is it like this? And then I’ll go in and look at the wound and I’ll see the saying there, and I’ll talk to the aid. I said, This patient is up in her chair. Does she stay sitting up in her chair? And you’ll say, no, she slides down. Bingo. That’s how the wound is where it is. But you have to. Hunt out. You have to look and you have to ask, you can’t just assume anything. 

Schenk: 

That’s interesting. You say it’s the mechanics. I’m sure that your mind is thinking of these things in such a different way. Like more of an analytical I don’t know, like scientific and physics and how is the body, sitting, 

Dr. Tippett: 

Exactly.

Schenk: 

Yeah. Speaking of that interaction with that aid, What kind of role does awareness of those types of things play in the prevention and management of pressure wounds? Like, how important is it for that? See that CNA to know that. You’re going to get shear forces and friction when somebody slides and maybe they need to not be sitting there for so long.

Dr. Tippett: 

If you take two minutes and explain it to them, they’ll understand. People intuitively understand. When you’re talking about the physics of it, they get it. They really do. And families typically will understand better. The nurses, I I talked to them, they understand and they can figure out ways to do it, but yeah, if I wanted to change her views, I would just spend a couple minutes and train her about it.That’s all. 

Why Does Pressure Injury Staging Not Tell You Where the Wound Is Going?

Schenk: 

As we wrap up I just wanted to circle back on something that you said a little bit earlier and that staging is a communication tool. And that it doesn’t tell you where the wound is going. Can you tell me about that? What does that mean to you?

What does that mean that your staging doesn’t tell you where the wound is going? 

Dr. Tippett: 

Staging is. right now at this point in time as I’m looking at this wound, I can tell you what stage it is. And that’s just the thickness of the wound. It’s one, two, three or four. All right. So that’s just the thickness of the wound.

It doesn’t tell me how it got there. It doesn’t tell me where it’s going. Now, if it’s a four, it doesn’t have anywhere else to go, right? If it’s one, I don’t want it to go any further. So I better make sure I’m preventing pressure, doing offloading, doing all that, everything I can to prevent it, lubricating it with calmoseptine or whatever, and if it’s a two, eh.

You can almost treat it like one, really. You could still use common septine, but if it goes to a three, then you’re going to have to start using a dressing on it. But you don’t want it to progress. Your goal is, my goal is always zero, and I think your goal should be zero. You don’t want a wound.

You don’t want a wound. None of us want a wound on our body. It’s a horrible thing. And you know, I guess too, because I work in hospice, so I’m, I know that wounds are a terrible thing for people to live with. They’re, it’s an awful burden. So if you can prevent them, that’s really valuable.

That’s important and very valuable. But staging by itself doesn’t help me prevent a wound, tells me where it is, but doesn’t help me prevent it. 

Schenk:

Let me ask this. Are you like, is there anything in your mind? Like some people I’ve seen proposed the idea of only saying partial thickness or full thickness, meaning that it’s still at the epidermis or it’s actually gone to the muscle or tissues.

And that’s how we document pressure injuries. Have you given any thought to let’s get rid of the state, the staging and. That’s documented another way. 

Dr. Tippett: 

The partial thing is the full thing is reasonable. That’s stage 2 and stage 3. But that’s alright. But, yeah. Partial and full, that’s reasonable. People can understand that. If you’re using it as communication, that’s fine. 

Further reading on bedsores can be found here:

• Bed Sore Stages with Pictures
• What Are Bedsore Stages?
• What Are Bedsore Warning Signs?
• How Do You Prevent Bedsores?

Schenk: 

Gotcha. Dr. Tippett, I really appreciate it. Once again, I really enjoy talking to you about this stuff. It’s been a while. Maybe we won’t wait another 4 years to talk again, but I appreciate it so much.

Dr. Tippett: 

Thank you very much. It was fun being here. 

Schenk: 

Again, folks, if you want to learn more about. Her experience of that specific nursing home with the tremendous outcomes there’s a link in the description to that article. Also feel free to shoot her an email or visit her website.

Really interesting story with her. Again, thank you so much. This is, again, I feel like every week we’re trying to get a little bit better, trying to understand the world. Now it’s been a long time since we did our last podcast, at least a few years. So, I’m still trying to get the bugs out.

So appreciate everybody’s patience. Hope you learned something this week. And with that folks be sure to like, and subscribe wherever you’re listening or watching this episode with that. We’ll see you next week.

For legal advice and representation concerning bedsores in nursing homes, visit Atlanta Nursing Home Abuse Bedsores Lawyer.