Visual Guide for Accurately Designating the Anatomic Location of Buttocks Lesions

J Wound Ostomy Continence Nurs. 2016;43(2):148-149. Published by Lippincott Williams & Wilkins

VIEW FROM HERE Visual Guide for Accurately Designating the Anatomic Location of Buttocks Lesions

Christine T. Berke

isual aids are useful for identifying selected phenom- wounds on the buttocks (the larger general surface area Vena in healthcare; they are particularly helpful in de- from the lower back to the posterior thighs) as pressure scribing the location of various wounds. I sought to ulcers. I also observed multiple types of lesions on the but- develop a visual aid for accurately assigning location of tocks, including pressure ulcers, moisture-associated skin wounds and lesions in the buttocks area. The need for this damage (MASD), psoriasis, and friction injuries. I became was determined based on clinical experience and literature concerned that some wounds being diagnosed as pressure review. My goal was to create a guide that would assist the ulcers were caused by factors other than pressure and clinician to accurately identify the anatomic location for shear, and that anatomic locations were being incorrectly skin lesions and/or wounds, to determine the wound etiol- identifi ed, partially based on limitations in the ICD coding ogy and appropriate management, and to track outcomes. system then in use. After realizing that colleagues and I I fi rst became aware of the need for the type of visual aid were not describing and diagnosing many wounds simi- described in this article when I noted that the coding sys- larly, I decided to look for a visual aid to narrow the com- tem did not include all possible anatomic locations re- munication gap. quired for pressure ulcer diagnosis and documentation, forcing nurses to sometimes use inaccurate terminology ■ Image Search when describing the location of pressure injuries in the buttocks area. Within the context of this project, I opera- I initially spoke with WOC nurse colleagues within my tionally defi ned the buttocks as the portion of the poste- facility to determine if they were aware of a visual aid to rior lower torso from just superior to the posterior iliac correctly identify the anatomic location of wounds lo- crests proximally to the gluteal creases distally. When se- cated on the buttocks and differentiate between bony lecting codes for location of pressure ulcers involving the prominences and soft tissue areas. They were not aware of posterior lower torso, clinicians are limited to the lower any such visual aids. They provided support for the idea of back (including coccyx and sacrum), hip, and buttocks creating a visual aid and agreed with my concerns about (defi ned within the ICD-10 [ International Classifi cation of incorrect diagnoses of buttocks lesions often encountered Disease, 10th Revision ] diagnosis manual as encompassing in clinical practice. a large soft tissue area, which is a common site for friction I then completed a Google Image search; I found gen- injuries but a less common site for pressure ulcers, which eral anatomical illustrations but nothing specifi c to my ob- usually occur over bony prominences)1 as well as laterality jectives. Most of the images identifi ed via the Google search for the practitioner to choose from, but codes still lack engine had been developed for describing surgical proce- specifi city and anatomical correctness. Despite 2014 and dures or basic anatomical education for various healthcare subsequent updates to the ICD-10 , there are still no spe- and/or science students. I also searched Netter Images4 but cifi c anatomical coding designations for the coccyx, is- did not fi nd a detailed surface anatomy of the buttocks. chial tuberosities, the posterior iliac crests, or the Finally, I searched scholarly articles, using the CINAHL and trochanters, all of which are common sites for pressure MEDLINE databases. This search was based on the key ulcer development.2 This coding and identifi cation prob- lem became critically important when the Centers for Ⅲ Christine T. Berke, MSN APRN-NP, CWOCN-AP, AGPCNP-BC, Medicaid & Medicare Services began to deny payment for Nebraska Medicine, Omaha. pressure ulcers (PU) that occur while a patient is hospital- The author declares no confl icts of interest. 3 ized or being treated in a long-term care facility. Correspondence: Christine T. Berke, MSN, APRN-NP, CWOCN-AP, I became an advanced practice WOC nurse (APRN) in AGPCNP-BC, Nebraska Medicine, 9884438 Nebraska Medicine, 2008. I noticed that practitioners (nurses, physicians, Omaha, NE 68198 ([email protected] ). APRNs, physician assistants) frequently labeled many DOI: 10.1097/WON.0000000000000208

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Services, and to ask that it be used to expand the codes for designation of wound location. I believe that its incorporation into their documents enables more accurate identifi cation and classifi cation of multiple injuries of the buttocks such as pressure ulcers, friction injuries, and MASD. I have discussed this issue with many clinicians and found that many providers code based on their personal beliefs or preferences since specifi c locations are not avail- able in the current coding system. Because of this limita- tion, it is not possible to accurately identify how many pressure ulcers occur on the sacrum versus the coccyx, ver- FIGURE 1. Surface anatomy of the buttocks. sus the posterior iliac crests, versus the ischia, versus the gluteal areas. Accurate identifi cation of wound location also infl uences the assessment of wound etiology. For example, terms “surface anatomy,” “skin,” “buttocks,” and “gluteal suspicion of a pressure ulcer is heightened when it occurs area.” This search did not retrieve useful visual aids. over a bony prominence, while MASD is considered more likely when skin damage follows the path taken by urine or ■ Creation of an Original Image stool in the incontinent person. Therefore, the ability to accurately identify anatomical location would be helpful to When these searches failed to produce a useful visual aid, all clinicians in making appropriate diagnoses and imple- I revisited an article I published in the Journal that de- menting appropriate management plans. Accurate determi- scribed a case series of patients with friction injuries. 5 nation of location and etiology also may reduce the risk of While formulating that clinical case series, I developed a withheld reimbursement due to inaccurate labeling of a visual aid that is the focus of this View From Here feature moisture or friction wound as a pressure ulcer. column. I began by locating photos of several patients’ buttocks areas; all identifying markers and dates were re- ■ Summary moved. Using verbal descriptors from Gray’s Anatomy,6 I drew markings to indicate the different areas of the but- Accurate description of wound location is an important tocks based on the location of bony prominences, and I element of wound assessment, and a contributing factor added soft tissue and skin crease locations to complete the to correct determination of wound etiology. Wounds lo- initial aid ( Figure 1 ). My daughter, who is a graphic de- cated in the buttocks area may be caused by pressure, signer, provided substantial assistance in the development moisture, friction, or other etiologic factors, and correct of this image. I sent the initial draft to a member of our determination of wound location is of particular impor- Department of Anatomy at the University of Nebraska tance in determining etiology of these wounds. Accurate College of Medicine, who kindly responded with sugges- description of location has been compromised by the lack tions that were used to improve the visual aid, including of a visual aid that provides clear defi nition of all key ana- terminology changes for anatomic accuracy and consist- tomic locations, including bony prominences, soft tissue ency. The fi gure was then shown to 2 prominent plastic areas, and body folds. This article introduces a visual aid surgeons in the community who are wound experts; they designed to promote accurate description of the location agreed with the anatomical markings and labels and of- of buttock wounds. fered some aesthetic suggestions, which were used to fur- ther improve the visual aid. Lastly, the image was shown ■ References to my WOC colleagues and internationally known wound 1. ICD-9-CM for Physicians—Volumes 1 & 2. 2014 Expert. 6th ed. experts on pressure ulcer. Their comments were favorable Eden Prairie, MN: OptumInsight Inc. with only a few minor additional aesthetic changes; no 2. ICD-10-CM Complete Draft Code Set . Draft 2014. Clinical signifi cant changes were made to the anatomical designa- modifi cation. Eden Prairie, MN: OptumInsight Inc; 219 – 220 . tions or labeling. The fi nal aesthetic edits were made and 3. Centers for Medicare & Medicaid Services . Never events. http:// a PDF fi le was created and submitted to our skin wound downloads.cms.gov/cmsgov/archived-downloads/SMDL/ downloads/SMD073108.pdf. Published 2008 . Accessed July 31, advisory team, who agreed to place the image in our elec- 2015. tronic record to be used by all staff for documentation of 4. Netters Atlas of the Human Body, Barron’s Educational Series , Inc. wounds on the buttocks surface area. Icon Learning System LLC . New York: Hauppauge; 2006 : 2-3 . 5. Berke CT . Pathology and clinical presentation of friction injuries: case series and literature review. J Wound Ostomy Continence Nurs. ■ Next Steps 2015; 42 ( 1 ): 47 – 61 . 6. Standing S , ed. Gray’s Anatomy: the Anatomical Basis of Clinical I plan to take this visual aid to the American Medical Practice . 40th ed. Philadelphia, PA: Churchill Livingstone Association and the Centers for Medicare & Medicaid Elsevier, printed in Spain; 2008: 1341– 1343 .

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