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Implementation of Pressure Ulcer Prevention Protocol Interventions (PUPPI) to Address Hospital-Acquired Pressure Ulcers

Amy Bradley, Trevor Mattarella, MiSuk Robinson, & Kaylee Sullivan

Ferris State University

INTRODUCTION
Problem statement: Does implementation of Pressure Ulcer Prevention Protocol Interventions (PUPPI) help reduce or prevent hospital-acquired pressure ulcers?

PURPOSE

According to Baumgarten et al. in light of the growing recognition of pressure ulcers as an important contributor to patient outcome and the cost of health care, there is an urgent need for effective implementation of PUPPI (2009).

We will provide analysis of four articles on implementing effective PUPPI to provide data to support evidence-based nursing practice change. We will also review associated complications and staging of pressure ulcers so you are aware of any issues the patient may be having that would need to be addressed.

BACKGROUND
Pressure Ulcers (PUs) in Hospitalized Patients: A pressure ulcer is an injury to the skin that occurs when a patient lies or sits too long in the same position. Pressure keeps blood from getting to the tissue, causing cells to die and the skin to break down. As the tissue dies, an open sore forms. Patients who are unable to get out of bed or spend most of the day in a wheelchair are at high risk of getting a pressure ulcer. People who cannot move certain parts of their bodies are also at risk and individuals with certain health conditions. ("Preventing and caring," 2010)

RISK FACTORS

Confinement to bed or wheelchair Paralysis Sedation Coma Long term ventilation use Poor nutrition and hydration Underweight or overweight Urinary and bowel incontinence Decreased mental status Medical conditions affecting circulation such as diabetes and congestive heart failure Elderly patients

PATIENT SAFETY

According to Grown Up, the most common places for PUs to occur are over bony prominences, such as elbows, heels, hips, ankles, shoulders, back, and the back of the head. The sacrum/coccyx area at the base of the spine has consistently been documented as the most common site of pressure ulcers. The heels come in a close second. The average person adjusts his or her position, while awake and when sitting or lying down, at least every 20 seconds. This is in response to the discomfort from capillary closure caused by pressure on that part of the body (Dunlap, 2012). In reviewing this information, it tells us a lot about why hospitalized patients are at risk for PUs. Many of them have diseases and illnesses that decrease their ability to move around and even reposition themselves. Some illnesses such as diabetes can also affect response to sensation. They may not be able to feel the discomfort from capillary closure, which does not send a signal to their brain to reposition themselves. Always think about patient safety and what it takes to reduce pressure ulcers. Reposition, reposition, reposition. Follow your facilities protocols.

ASSOCIATED COMPLICATIONS
("Medical Dictionary", 2012)

CELLULITIS

Diffuse and especially subcutaneous inflammation of connective tissue. Cellulitis usually manifests itself as redness, warmth, and swelling. As a nurse I have seen cellulitis mostly in the lower legs. (Klein)

SEPSIS

A systemic response. Typically caused by a serious, usually localized infection. Typically the infection is of bacterial origin and is usually marked by abnormal body temperature, increased white blood cell count, tachycardia (increased heart rate), and tachypnea (rapid breathing).

(Lickiss, 2010)

OSTEOMYELITIS

An infection. Painful inflammatory disease of the bone. Often bacterial in origin. May result in death of bone tissue.
Dorsal ulcer associated with deep infection resulting from osteomyelitis ("Diabetic foot ulcer" )

NECROTIZING FASCIITIS

A severe soft tissue infection. Typically Group A streptococci or a mixture of aerobic and anaerobic bacteria. Marked by edema and necrosis (death) of subcutaneous tissues with involvement of the fascia. Often involves undermining (removing underlying support) of adjacent tissue. Painful red swollen skin over affected areas. Usually occurs as a complication of surgery, injury, or infection by extension from the initially affected site. ("Necrotizing fasciitis picture," 2010)

GANGRENE

Local death of soft tissues due to loss of blood supply. It is a complication resulting from infectious or inflammatory processes, injury, or degenerative changes associated with chronic diseases, such as diabetes. Initially, the area becomes cold, numb, and pale before later changing in color to brown, then black. This dead tissue will gradually separate from the healthy tissue and fall off. It is very painful.

(Fierer, 2005)

Staging Pressure Ulcers


(Dunlap, 2012)

STAGE I

The skin is intact with non-blanchable redness over a bony prominence.

The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. Darkly pigmented skin may also not have visible blanching, as color may differ from the surrounding area.
The area may be painful, itchy, firm, soft and/or warmer or cooler as compared to adjacent tissue. Stage 1 indicates at high risk persons. The hardness or firmness is called induration and is one of the most common signs of a stage 1 pressure ulcer. Never massage a stage 1 pressure ulcer. It will increase the damage and can cause it to progress to an open (stage 2 or deeper) pressure ulcer .

(Stage 1 pressure sore)

STAGE II

Partial thickness skin loss involving the epidermis, dermis, or both. Ulcer is shallow, open, dry, and shiny. Wound bed is reddishpink. No sloughing or bruising. This stage should not be used to describe skin tears or tape burns.
(Stage II decubitus ulcer on ischeal tuberosity)

STAGE III

Full thickness skin loss occurs in this stage, involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through underlying fascia. Subcutaneous fat may be visible, but bone, tendon and/or muscle are not exposed. Sloughing may be present, but does not obscure the depth of tissue loss. The ulcer presents clinically as a deep crater with or without changes to the adjacent tissue. ("Deep stump wound," 2005)

STAGE IV

Full thickness loss of all layers of the skin. Bone, tendon, or muscle exposed. Slough or eschar may be present on wound bed. May extend into fascia, tendon, or joint capsule.
2009

UNSTAGEABLE

Some pressure ulcers, that are covered by slough (yellow, tan, gray, green, or brown) and / or eschar (black, brown, or tan) in the wound bed, are unstageable. Until enough slough and/or eschar is removed to expose the base of the wound, the stage cannot be determined. However, stable, dry and adherent eschar serves as the bodys natural, biological cover and should not be removed.

(Pressure ulcer photos)

PUPPI

Any intervention or combination of interventions from nationally accepted guidelines:

AHRQ (Agency for Healthcare Research and


Quality)

NPUAP (National Pressure Ulcer Advisory Panel) ICSI (Institute for Clinical Systems Improvement) WCON (Wound, Continence and Ostomy Nurses)

RELEVANCE
Why is this topic relevant to Nursing Practice? The national incidence of PU and the high costs associated with hospital acquired PUs indicate the relevance of this research to nursing practice. According to Dibsie (2008) an estimated 2.5 million patients are treated for preventable pressure ulcers (PU) in the United States at a cost of $11 billion dollars annually. Griffin et al. (2007) estimates that 60,000 acute care patients die from pressure ulcer complications. Hospital-acquired PUs can lead to extended hospitalization, sepsis, decreased mobility, and poor patient outcomes (Dibsie, 2008).

PU INCIDENCE RATE
Defined as: rate of new PU in hospitalized patients/total number of hospitalized patients over a specific time period. Proportion of patients at risk for developing PU. Used for tracking hospital-acquired PU (new onset). Preferred measure of PU frequency when implementing PUPPI. Best measure of effectiveness of PUPPI.

(Catania et al., 2007)

PU PREVALENCE RATE
Defined as: number of patients that have existing PUs and develop hospital-acquired PUs/total number of hospitalized patients over a given time period

Indicates quality of care/treatment. Indicates burden of PU. May be inaccurate due to risk factors and comorbidities.
(Catania et al., 2007)

SKIN SAFETY PROTOCOL


Risk assessment:

Completed for many different reasons such as to improve quality of care and decrease costs, but assessments are ultimately designed to assess who is at risk for pressure ulcers. A tool that most hospitals utilize is call the braden scale.

Prevention:

Support surface such as speciality mattresses and cushions


Repositioning Exercise Treatment of incontinence Targeting impaired mobility Targeting impaired nutritional status

Targeting impaired skin health

(Reddy, Gill & Rochon, 2006)

Research Articles
Summary of Research Findings

Article 1:
Preventing Pressure Ulcers in Hospitals: A Systematic Review of Nurse-Focused Quality Improvement Interventions (Soban, Hempel, Munjas, Miles, & Rubenstein, 2011)

Purpose and problem

The purpose of the article Preventing Pressure Ulcers in Hospitals: A Systematic Review of Nurse-Focused Quality Improvement Interventions (Soban et al., 2011) was to review the literature for evidence that PU protocols can be successfully integrated in hospitals through quality improvement (QI) interventions (Soban et al., 2011).

Review of literature
from January 1990 to present (Soban et al., 2011).

The authors conducted a literature search from six electronic databases for publications

Theoretical theory

A theoretical model is not clearly identified in this article.

Research design

Meta-analysis of research that reported a measure of PU incidence using the

Stata 9.2 program (Stata Statistical Software). Research was categorized by


countries, hospital setting (single facility, multi-hospital research, single nursing unit, multiple nursing units). Majority of the studies utilized uncontrolled before-after design (Soban et al., 2011).

Study findings

From the literature review 39 studies met the inclusion criteria (Soban et al., 2011). The most common intervention was the development and implementation of PUPPI. The research supported a positive effect on nursing process and patient health outcomes when implementing PUPPI (Soban et al., 2011)

Article 2

PUPPI: The Pressure Ulcer Prevention Protocol Interventions (Catania, Huang, James, Madison, Moran, & Ohl, 2007)

Purpose and Problem

The purpose of this research article is to encourage PUPPI implementation based


on the evidence supported by the literature review and clinical data obtained by the researchers.

Review of literature

The literature review consists of 24 articles published from 1989-2007 (Catania et al., 2007). The authors presented a summary of four research that focused on cost of PU treatment and effectiveness of PU prevention programs (Catania et al., 2007).

Theoretical model

A theoretical model or conceptual framework is not identified in this research


study.

Research design

The authors did not explain the research design. This was not an experimental design since all patients admitted to the hospital were included in the study. Each unit was assigned a designated day of the week to assess patients for PU risk: Braden Scale score, albumin/pre-albumin levels, and skin assessment (Catania et al., 2007).

Study findings

The prevalence rates for all PUs and for hospital-acquired PUs decreased.

Article 3
Implementing Evidence-Based Practice to Prevent Skin Breakdown (Dibsie, 2008)

Review of literature

One of the main interventions to prevent pressure ulcers involved a new


standardization of all wound care products and specialty pressure reduction devices. Nurses have had a major impact on patient outcomes and the reduction of pressure ulcers due to their close involvement in bedside care.

Theoretical model

A specific theoretical model is not identified in the article.

Research design

The nursing staff were required to participate in quarterly data collection regarding pressure ulcer prevalence and ongoing implementation of the skin care protocols (Dibsie, 2008).

Study findings

This proven reduction in hospital-acquired pressure ulcers has saved the patients from extended hospitalization and has reduced overall treatment costs for the hospital. The study proved the effectiveness of the protocol and improved patient outcomes.

Purpose and problem

According to Baumgarten et al., "A significant decline in pressure ulcers was observed---from 32.7% before the intervention to 8.9% after the intervention." (2009, p.184).

Article 4

Methodological Issues in Studies of the Effectiveness of Pressure Ulcer Prevention Interventions (Baumgarten, Shardell, & Rich, 2009)

Purpose and Problem


research methods that have yielded positive results regarding pressure ulcer

The purpose of this article is to provide the reader with an understanding of different
prevention.

Review of literature
who are consumers of the published literature on the effectiveness of pressure ulcer intervention within their own health care settings (Baumgarten, et. al., 2009, p. 181).

The target audience for this analysis consists of clinicians and healthcare administrators

The research study was performed through the Advances in Skin & Wound Care
Journal, a reputable source of literature regarding the prevention of pressure ulcers through nursing intervention. These studies were conducted through research of pressure ulcers through a variety of healthcare professionals with experience in management of pressure ulcers.

The article did not present a specific theoretical or conceptual framework.

Theoretical Model

Research design

The main research design used for this article analysis was randomized control trials (RCT). According to Baumgarten, "In an RCT trial, patients who agreed to take part in the study are randomized, that is, they are assigned at random, to the intervention group or to the comparison group. Both groups are followed for a specific period of time to determine if they develop a new pressure ulcer. (2009, p. 181).

Study findings

According to Baumgarten et al., "A significant decline in pressure ulcers was observed--from 32.7% before the intervention to 8.9% after the intervention." (2009, p.184).

RESEARCH REVIEW CONCLUSION

Continued nursing research is needed to build the evidence for effective implementation of PUPPI to prevent or reduce the incidence of hospital-acquired PUs. One area that seems to be consistently lacking in the current literature review is the identification of a theoretical or conceptual framework for research. Not one of the four research articles we reviewed clearly identified a theoretical or conceptual mode. Researchers also need to explain the research design so that readers are able to determine the validity of the research. Only two of the four research papers identified and explained the research design utilized in the study. EBNP is all about incorporating knowledge about nursing theory, nationally accepted standards for patient care, and data from personal or collective research.

Impact on Nursing Practice

Trevor: Misuk:

PERSONAL NURSING EXPERIENCE


In the operating room pressure applied to bony prominences during surgical procedures may cause redness and skin breakdown resulting in hospital-acquired PU during the postoperative recovery phase. Utilization of foam pads, memory foam mattress pads, and addressing body alignment as part of our Universal Time Out before the start of surgery decreases the risk of hospital-acquired PU.

Covenant Healthcare recently started using a system for repositioning patient who are at risk of pressure ulcers. The system is known as the Turning And Repositioning System (TAPS). The TAPS system was designed specifically for patient who are obese, patients who have difficulty repositioning in bed, or who already have breakdown or redness. This reduces overall pressure on the patient and helps to move patients in bed with less friction between the two surfaces.

Kaylee:
In CCU the nurse will complete a head-to-toe skin assessment and a pressure ulcer risk assessment upon admission then daily thereafter. The braden scale is included in this assessment. If there are identified risk factors, such as immobility, the nurse use their judgement to implement interventions and obtain orders from the doctor if needed. Interventions include: repositioning at least every two hours, floating the heels, keep the head of the bed less than 30 degrees when possible, using pillows to reduce pressure over bony prominences, use lift devices to assist with moving and repositioning the patient, assess nutrition and hydration status and educate the patient and the family about the importance of complying with the interventions.

Amy:
At Spectrum Health when a patient is admitted to the ICU they will automatically have a dressing applied to their coccyx called a Mepilex. A Mepilex is a cushioned dressing that absorbs moisture and pressure; preventing pressure ulcers. The Mepilex dressings are not only used on the coccyx but any bony prominence or reddened area. Since the start of this initiative there have been no documented cases of hospital acquired

PATIENT PERCEPTION

Pressure ulcers and their treatment affects patients lives: o emotionally o mentally o physically o socially Patients often do not think that nursing staff acknowledges: o pain o discomfort o distress Factors described that cause distress from PU's: o pain o appearance o smell o fluid leakage (Spilsbury et al, 2007)

NURSING PERCEPTION
A study was completed titled, Registered nurses' attention to and perceptions of pressure ulcer prevention in hospital settings and it concluded:

Although all patients involved were at risk and the nurses described pressure ulcer prevention as basic care, the nurses' attention to prevention was lacking.

Few prevention activities and no structured risk assessments using risk assessment tools were observed.
Few care plans were identified. Registered nurses paid little attention to pressure ulcer prevention among patients at risk.

The planned and unplanned care structures affected the prevention.


The nurses trusted and largely delegated their responsibility to the assistant nurses.

(Sving, Gunningberg, Hogman & Mamhidir, 2012)

IMPLEMENTATION OF PUPPI IN NURSING PRACTICE

The purpose of this information is to review implementation of Pressure Ulcer Prevention Protocol Interventions (PUPPI) that focus on preventing or reducing hospital-acquired pressure ulcers (PUs) to provide better patient outcomes. Treating PUs can be challenging especially in patients with multiple co-morbidities. The hypothesis is that successful implementation of PUPPI prevent or reduce the incidence of hospital-acquired PUs. More nursing research focused on quality improvement process of PUPPI implementation is needed to support EBNP for effective management of PUs in hospitalized patients.

RATIONALE FOR SUPPORT


Hospital-acquired PUs impact patient outcomes and contribute to rising healthcare costs. There are many interventions to help reduce or prevent PUs. In some cases hospital-acquired PUs are unavoidable due to multiple comorbidities. We encourage you to look up your hospital policy and be informed of the nationally accepted guidelines for PUPPI. We hope information from this presentation provide opportunities for evidencebased practice change in your profession for PU management.

REFERENCES
Baumgarten, M., Shardell, M., & Rich, S. (2009). Methodological issues in studies of the effectiveness of pressure ulcer prevention interventions. Advanced Skin Wound Care, (22(4), 180-190. doi: 10.1097/01.ASW.0000305462.3200.7b Catania, K., Huang, C., James, P. Madison, M. Moran, M., & Ohr, M. (2007). PUPPI: The pressure ulcer prevention protocol interventions. American Journal of Nursing, 107(4), 44-52. doi: 10.1097/01.NAJ.0000271182.90068.a1 Dibsie, L.G. (2008). Implementing evidence-based practice to prevent skin breakdown. Critical Care Nursing Quarterly, 31(2), 140-149. Dunlap, M. (2012). Pressure ulcers assessment & documentation. Grown Up.. A Newsletter For Those Who Care For ADOLESCENTS, ADULTS, and AGING ADULTS, 17(3), 1-4. Griffins, B., Cooper, H., Horack, C., Klyber, M., & Schimmelpfenning, D. (2007). Best-practice protocols: Reducing harm from pressure ulcers. Nursing Management. Retrieved from: www.nursingmanagement.com Institute of Clinical Systems Improvement (ICSI). (2007). Skin Safety protocol: Risk assessment and prevention of pressure ulcers (2nd ed.) retrieved from: www.icsi.org Lickiss, P. (2010, September 27). Ems sepsis care part 1. Retrieved from http://510medic.com/2010/09/27/ems-sepsis-care--part-1/ Medical dictionary. (2012, April 18). Retrieved from http://www.nlm.nih.gov/medlineplus/mplusdictionary.html

REFERENCES
Preventing and caring for pressure ulcers. (2010). Retrieved from
http://www.stoppain.org/pressureulcers/common/pdf/BIMC_patient.pdf Reddy, M. R., Gill, S. S. G., & Rochon, P. A. R. (2006). Preventing pressure ulcers: A systematic review.CLINICIAN'S CORNER, 296(8), 974-984. doi: doi:10.1001/jama.296.8.974 Soban, L.M., Hempel, S., Munjas. B.A., Miles, J., & Rubenstein, L.V. (2011). Preventing pressure ulcers in hospitals: a systematic review of nurse-focused quality improvement interventions. Joint Commission Journal on Quality and Patient Safety, 37(6), 245-52 Spilsbury, K. S., Nelson, A. N., Cullum, N. C., Iglesias, C. I., Nixon, J. N., & Mason, S. M. (2007). Pressure ulcers and their treatment and effects on quality of life: hospital inpatient perspectives. J Adv Nurs. ,50(5), 494-504. Sving, E. S., Gunningberg, L. G., Hogman, M. H., & Mamhidir, A. G. M. (2012). Registered nurses' attention to and perceptions of pressure ulcer prevention in hospital settings. J Clin Nurs. , 21(9-10), 1293-303. doi: doi: 10.1111/j.1365-2702.2011.04000.x. The Joint Commission. ( )Pressure ulcers in hospitals: a systematic review of nurse-focused quality improvement interventions. Joint Commission Journal on Quality and Patient Safety, 37(6), 245-52.

PHOTO REFERENCES

PHOTO REFERENCES
Pressure ulcers photos. [Web Photo]. Retrieved from http://images.search.yahoo.com/images/view;_ylt=A0PDoX3d0YRQDD0AOXyJzbkF;_ylu=X3oDMTBlMTQ4cGxyBHNlYwNz cgRzbGsDaW1n?back=http://images.search.yahoo.com/search/images?p=unstageable+pressure+ulcers&n=30&ei=utf8&y=Search&fr=yfp-t-701&tab=organic&ri=23&w=350&h=263&imgurl=www.npuap.org/onlinestore/images/P/247.jpg&rurl=http://www.npuap.org/online-store/product.php?productid=17529&size=11.5 KB&name=Pressure Ulcer Photos&p=unstageable pressure ulcers&oid=057f63da9516a3b006fb059f4d185ff8&fr2=&fr=yfp-t701&tt=Pressure+Ulcer+Photos&b=0&ni=220&no=23&ts=&tab=organic&sigr=11t1utkut&sigb=140c2ruhk&sigi=11bb7epqi&.c rumb=EoqhdpSeGTO Promed-distribution.ch - mepilex border sacrum 23x23cm/5 botes 5 pcs. [Web Photo]. Retrieved from http://images.search.yahoo.com/images/view;_ylt=A0PDoV4CKYhQtR0AdaCJzbkF;_ylu=X3oDMTBlMTQ4cGxyBHNlYwNzc gRzbGsDaW1n?back=http://images.search.yahoo.com/search/images?p=MEPILEX&n=30&ei=utf-8&y=Search&fr=yfp-t701&tab=organic&ri=127&w=300&h=300&imgurl=www.promed-distribution.ch/img/p/347-394large.jpg&rurl=http://www.promed-distribution.ch/product.php?id_product=347&size=20.7 KB&name=Promed-Distribution.ch Mepilex Border Sacrum 23x23cm/5 Botes 5 pcs ..&p=MEPILEX&oid=0ededb6191d9a8335ae411eac3e39f61&fr2=&fr=yfp-t701&tt=Promed-Distribution.ch++%3Cb%3EMepilex+%3C%2Fb%3EBorder+Sacrum+23x23cm%2F5+Bo%C3%AEtes+5+pcs+..&b=121&ni=220&no=127&ts= &tab=organic&sigr=11sjs3f19&sigb=13dn82g2o&sigi=11indtmuk&.crumb=EoqhdpSeGTO

Stage 1 pressure sore. [Web Photo]. Retrieved from


http://images.search.yahoo.com/images/view;_ylt=A0PDoX2CzoRQvS4AkpGJzbkF;_ylu=X3 oDMTBlMTQ4cGxyBH NlYwNzcgRzbGsDaW1n?back=http://images.search.yahoo.com/search/images? Stage ii decubitus ulcer on ischeal tuberosity. [Web Photo]. Retrieved from http://images.search.yahoo.com/images/view;_ylt=A0PDoS90z4RQAX0ARuKJzbkF;_ylu=X3oDMTBlMTQ4cGxyB HNlYwNzcgRzbGsDaW1n?

PHOTO REFERENCES
(2005). Deep stump wound. (2005). [Web Photo]. Retrieved from http://images.search.yahoo.com/images/view;_ylt=A0PDoTBB0IRQsQwA7MCJzbkF;_ylu=X3oDMTBlMTQ4cGxyBH NlYwNzcgRzbGsDaW1n?back=http://images.search.yahoo.com/search/images?p=stage+III+pressure+ulcers&n=30&ei=utf8&y=Search&fr=yfp-t701&tab=organic&ri=1&w=1705&h=1279&imgurl=www.intellicure.com/index/Files/Presentations/PressureUlcerStaging_Pitfall s_files/slide1173_image107.jpg&rurl=http://www.intellicure.com/index/Files/Presentations/PressureUlcerStaging_Pitfalls_files/sl ide1173.htm&size=647.7 KB&name=deep stump wound 3&p=stage III pressure ulcers&oid=8169042822d116966c9ef7b70b660e24&fr2=&fr=yfp-t701&tt=deep+stump+wound+3&b=0&ni=220&no=1&ts=&tab=organic&sigr=1367ceeq6&sigb=13tafg5s3&sigi=13803tiuc&.cru mb=EoqhdpSeGTO

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http://images.search.yahoo.com/images/view;_ylt=A0PDoVwR0YRQThQAo7.JzbkF;_ylu=X3oDMTBlMTQ4cGxyBHNlYwNzc gRzbGsDaW1n?back=http://images.search.yahoo.com/search/images?p=stage+IV+pressure+ulcers&n=30&ei=utf8&y=Search&fr=yfp-t-701&tab=organic&ri=66&w=250&h=230&imgurl=4.bp.blogspot.com/_-Ym-5MJLWww/SZXDD9lRqI/AAAAAAAAAao/PpObNZ8qdNQ/s400/Pressure_Ulcer.jpg&rurl=http://darcysnotes.blogspot.com/&size=14.8 KB&name=Friday, February 13, 2009&p=stage IV pressure ulcers&oid=42fcb8c522538e63d6bc6ff87bf61d58&fr2=&fr=yfp-t701&tt=Friday%2C+February+13%2C+2009&b=61&ni=220&no=66&ts=&tab=organic&sigr=110so527t&sigb=13tfpfqmu&sigi =12q9ds9jj&.crumb=EoqhdpSeGTO