Is it time to consider doing ultrasounds of the skin upon admission to the emergency department?

Karen Farid, RN

The March 2017 of Ostomy Wound Management includes our pilot study regarding the use of hospital-grade ultrasound (US) technology to discover deep tissue injuries (DTI) not yet visible on the skin. I know of at least 1 long-term care facility that uses an US unit no bigger than a loose-leaf binder to obtain grainy images of the epidermis/dermis on the heels and sacrum of new admissions, specific only for skin edema to at least document abnormalities of the skin on those areas. However, the small US units can penetrate only to the dermis and would not pick up the full-thickness pressure injuries (PIs) that destroy large amounts of soft tissue and that are implicated in increased morbidity. Our pilot study used hospital-grade US units with highly specific transducers that clearly image DTIs that are not yet visible on the skin. Because acute care centers offer diagnostic US to their patient populations, it makes great sense to me to use this technology to diagnose pre-existing DTI that have not yet (but very well might) surfaced on the skin. If we turn a blind eye to these pre-existing DTIs and they subsequently surface after admission, we become liable for full-thickness pressure injuries NOT “present on admission!”

Because the triage nurses in our study facility, a community university teaching hospital, do Braden scores on all patients entering the emergency department (ED), we were able to focus on the patients at high risk for PIs (Braden score <18). Unlike with CT and MRI scans, the Radiology Department can deliver US operated by licensed, certified technicians to the bedside of the patient. This also makes it possible for the technician to describe the skin surface and avoid scanning on and document areas that are already ulcerated or otherwise damaged. 

What is very interesting about our study results is that our US transducers are so sensitive we can see early DTI not only at the level of the bone, but we also noted multiple subcutaneous lesions that had not yet appeared on the skin. In fact, these subcutaneous pressure lesions were most common on the sickest patients. We know this because we also recorded the number of skin failure risk factors for each participant. There are 5 skin failure risk factors: fever, hypotension, weight loss, coagulopathy, acidosis/respiratory failure. These risk factors are found predominately on patients with a Braden score of 15 or less. These factors were identified by a highly specialized group of medical, vascular specialists, CWONs from all patient venues, nursing home directors of nursing, and the New York State Department of Health New York Patient Advisory and Safety Enhancement (NYPASE) initiative clinical directors. These risk factors are spot on, which is evident when you read the US study.

Our study US scans not only discovered potential skin PIs, but in 1 patient they were instrumental in diagnosing a calciphylaxis! Read the study and find out the results! You also will learn the differences between the conditions of the PI-negative patients and the PI-positive patients and the differences between the level of acuity between persons who had PI that appeared on the skin versus those who did not develop PIs on the skin. Other soft tissue abnormalities besides DTI may affect people from the waist down (eg, diabetic muscle infarctions, calciphylaxis, hematomas, and tumors). Out of all these possibilities, DTI are the most common. It behooves us to use the cutting-edge technology that is at the facility’s disposal to defend ourselves against liabilities and reimbursement fines.