Grade 1 pressure ulcers: we only see what we know.

An expert panel was established to formulate aconsensus statement on Skin Changes At Life’s End(SCALE). The panel consists of 18 internationallyrecognized key opinion leaders including clinicians,caregivers, medical researchers, legal experts,academicians, a medical writer and leaders ofprofessional organizations. The inaugural forum washeld on April 4-6, 2008 in Chicago, IL, and wasmade possible by an unrestricted educational grantfrom Gaymar Industries, Inc. The panel discussed thenature of SCALE, including the proposed concepts ofthe Kennedy Terminal Ulcer (KTU) and skin failurealong with other end of life skin changes. The finalconsensus document and statements were edited andreviewed by the panel after the meeting. The documentand statements were initially externally reviewed by49 international distinguished reviewers. A modifiedDelphi process was used to determine the finalstatements and 51 international distinguished reviewersreached consensus on the final statements. The skin is the body’s largest organ and like anyother organ is subject to a loss of integrity. It has anincreased risk for injury due to both internal andFinal Consensus Statement external insults. The panel concluded that: our currentcomprehension of skin changes that can occur at life’send is limited; that SCALE process is insidious anddifficult to prospectively determine; additional researchand expert consensus is necessary; and contrary topopular myth, not all pressure ulcers are avoidable. Specific areas requiring research and consensusinclude: 1) the identification of critical etiologicaland pathophysiological factors involved in SCALE,2) clinical and diagnostic criteria for describingconditions identified with SCALE, and 3)recommendations for evidence-informed pathways ofcare. The statements from this consensus documentare designed to facilitate the implementation ofknowledge-transfer-into-practice techniques forquality patient outcomes. This implementation processshould include interprofessional teams (clinicians, laypeople and policy makers) concerned with the careof individuals at life’s end to adequately address themedical, social, legal, and financial ramifications ofSCALE. The statements from this consensus document are designed to facilitate the implementation of knowledge-transfer-into-practice techniques forquality patient outcomes. This implementation process should include interprofessional teams (clinicians, lay people and policy makers) concernedwith the care of individuals at life’s end to adequately address the medical, social, legal, and financial ramifications of SCALE. The content of this document is based on the results of a two-day round table discussion held on April 4-6, 2008 in Chicago, IL, and was madepossible by an unrestricted educational grant from Gaymar Industries, Inc. Additional input was received from an internationalfrom internationalpanels of 49 and 51 distinguished reviewers using a modified Delphi Method process. The information contained herein does not necessarilyrepresent the opinions of all panel members, distinguished reviewers, or Gaymar Industries, Inc. Disclaimer: The content of this document is intended for general information purposes and is not intended to be a substitute for medical or legaladvice. Do not rely on information in this article in place of medical or legal advice. Copyright 2009 Skin Changes At Life’s End (SCALE) Expert Panel. All rights reserved SCALE Final Consensus Statement, October 1, 2009Page 1 Co-ChairpersonsR. Gary Sibbald, BSc, MD, FRCPC (Med, Derm),MACP, FAAD, MEd, FAPWCA University of Toronto,Toronto, Canada, [email protected] Diane L. Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN, Wound & Skin Care Consultant, York, PA,USA, [email protected] Corresponding Author: 212 East Market Street, York, PA 17403 USA Medical WriterJames Lutz, MS, CCRA, Lutz Consulting, LLC, Medical Writing Services, Buellton, CA, USA, [email protected] Panel FacilitatorCynthia Sylvia, MSc, MA, RN, CWOCN, Gaymar Industries, Inc., Orchard Park, NY, USA, [email protected] Additional Panel MembersOscar Alvarez, PhD, CCT, FAPWCA, Center for Curative and Palliative Wound Care, Calvary Hospital,Bronx, NY, USA, [email protected] Elizabeth A. Ayello, PhD, RN, ACNS-BC, ETN, FAPWCA, FAAN, Excelsior College School of Nursing,USA, elizabeth @ayello.com Sharon Baranoski, MSN, RN, CWOCN, APN, DAPWCA, FAAN, Wound Care Dynamics, Inc.,Shorewood, IL, USA, [email protected] William J. Ennis, DO, MBA, FACOS, University of Illinois, Palos Heights, IL, USA, [email protected] Nancy Ann Faller, RN, MSN, PhD, ETN, CS, Carlisle, PA, USA, [email protected] Jane Hall, Medical Malpractice Defense Attorney, Huie, Fernambucq & Stewart, LLP, Birmingham, AL,USA, [email protected] Rick E. Hall, BA, RN, CWCN, Helping Hands Wound Care, Wichita, KS, USA, [email protected] Karen Lou Kennedy-Evans, RN, CS, FNP, KL Kennedy, LLC, Tucson, AZ, USA, [email protected] Diane Langemo, PhD, RN, FAAN, Langemo & Assoc, Grand Forks, ND, USA, [email protected] Joy Schank, RN, MSN, ANP, CWOCN, Schank Companies, Himrod, NY, USA, [email protected] Thomas P. Stewart, PhD, Gaymar Industries, Inc., Orchard Park, NY & S.U.N.Y. at Buffalo, USA,[email protected] Nancy A. Stotts, RN, CNS, EdD, FAAN, University of California, San Francisco, San Francisco, CA, USA,[email protected] David R. Thomas, MD, FACP, AGSF, GSAF, CMD, St. Louis University, St. Louis, MO, USA, [email protected] Dot Weir, RN, CWON, CWS, Osceola Regional Medical Center, Kissimmee, FL, USA, [email protected] Expert Panel Members SCALE Final Consensus Statement, October 1, 2009Page 2 SCALE Final Consensus Statement, October 1, 2009Page 3Table of