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NPUAP Pressure Injury Staging System Laura Edsberg, PhD August 25, 2016

NPUAP Mission The National Pressure Ulcer Advisory Panel (NPUAP) serves as the authoritative voice for improved patient outcomes in pressure injury prevention and treatment through public policy, education and research.

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International Guideline NPUAP – in collaboration with the European Pressure Ulcer Advisory Panel (EPUAP) and the Pan Pacific Pressure Injury Alliance (PPPIA) – has worked to develop a NEW pressure ulcer prevention and treatment Clinical Practice Guideline and a companion Quick Reference Guide. Purchase your copy today at www.npuap.org

npuap.org ©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

NPUAP Monograph Released in November 2012, the 254-page, 24 chapter monograph, Pressure Ulcers: Prevalence, Incidence and Implications for the Future was authored by 27 experts from NPUAP and invited authorities and edited by NPUAP Alumna Dr. Barbara Pieper. The monograph focuses on pressure ulcer rates from all clinical settings and populations; rates in special populations; a review of pressure ulcer prevention programs; and a discussion of the state of pressure ulcers in America over the last decade. Purchase the monograph today at www.npuap.org •

E-version

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Individual Chapters

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©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

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Save the date

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8/16/2016

25 – 29 September

www.wuwhs2016.com

THANK YOU to the following companies that have provided support for this webinar!

American Medical Technologies ArjoHuntleigh Augustana Care ConvaTec EHOB, Inc. First Quality Healthcare Hill-Rom

The NPUAP webinar commercial supporters did not have any input regarding the content of this presentation.

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THANK YOU to the following companies that have provided support for this webinar!

Joerns Healthcare Leaf Healthcare Medline Industries Mölnlycke Health Care Sage Products Span America Tamarack Habilitation Technologies Wellsense

The NPUAP webinar commercial supporters did not have any input regarding the content of this presentation.

Faculty Disclosure

Dr. Edsberg has none to declare

©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

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Planning Committee Disclosures • Sharon Baranoski, MSN, RN, CWCN, APN-CCNS, FAAN • Joyce Black, PhD, RN, CWCN, FAAN • Jeffrey Levine, MD • Mary Litchford, PhD, RD, LDN • Sally O’Neill, PhD • Mary Sieggreen, MSN, CNS, NP, CVN The planning committee members have listed no financial interest/arrangements that would be considered a conflict of interest. ©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

Objectives 1. Learners will be able to more effectively identify and stage pressure injuries. 2. Attendees will be able to describe changes to the staging system

©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

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NPUAP Formed Task Force January 2015 Co-Chairs • Laura Edsberg, PhD • Joyce Black, PhD, RN, CWCN, FAAN Margaret Goldberg, MSN, RN, CWOCN Laurie McNichol, MSN, RN, GNP, CWOCN, CWON-AP Lynn Moore, RD, LD Mary Sieggreen, MSN, CNS, NP, CVN

Purpose of Task Force • Review the current staging system and relevant literature.

• Revise the staging definitions and artwork to clarify and refine the system.

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New Understanding of Etiology Global Guidelines • Pressure • Shear • Microclimate o Temperature, humidity, airflow

• Tissue Tolerance • Nutrition, Age, Mobility

The Process Literature review • Reference librarian • Over 3000 references identified • 242 addressed topic directly

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The Process Review questions NPUAP receives about staging

Draft Definitions • Draft proposed definitions o NPUAP Board of Directors and Panel

• Elicit Opinions/ Comments

• Edit/Revise definitions o Repeat

• Create new artwork

o Organizations, Stakeholders, General Public

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Staging System Consensus Conference

• April 2016 • Moderator – Mikel Gray, PhD, APRN, FNP-BC, PNP-BC, CUNP, CCCN, FAANP, FAAN

Proposed Definitions • Proposed changes were based on science and expert opinion • Regulatory compliance, documentation, and legal issues were considered • NPUAP history of consensus conferences to draft staging definitions 1989 and 2007 • Facilitate discussion of the parts of the definitions that needed clarification or revision, based on stakeholder and public comments

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Ideal Definition • Concise and clear

• Teaching points vs. definition – Glossary

Pre-Conference • Roman to Arabic Numerals • Injury • Updated and improved artwork • Drafted revised definitions for each stage

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Prior to Staging a Wound • Clean the wound • Determine etiology – Presence of pressure and/or shear

Ulcer to Injury Pressure injuries present as both intact and open wounds

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Ulcer • A break in skin or mucous membrane with loss of surface tissue, disintegration and necrosis of epithelial tissue, and often pus

Merriam Webster

Injury Definition Injury = Bodily damage caused by transfers of energy and also the absence of energy • Drowning, asphyxia, hypothermia

Low energy exposure injuries • Carpal tunnel • Pressure injury J Langley and R Brenner, Injury Prevention, 2004.

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Pressure Ulcer Injury • Ulcer does not accurately describe the physical presentation of Stage 1 or Deep Tissue Pressure Injuries – Can have an injury without an ulcer – Can not have an ulcer without an injury

Pressure Injury Comments • Overwhelming support for the term injury • Medical device related pressure injuries – Proposed adding to the definition

• Define microclimate – Glossary vs. Definition

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New Artwork Healthy Skin Lightly Pigmented

Darkly Pigmented

Include medical device-related pressure injuries as a cause in the definition of a pressure injury.

Yes = 83% No = 17%

17%

83%

Yes No

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Yes if medical device or No = medical or other device. 7%

Yes = 7% No = 93% 93%

Yes No

In the first sentence: “A pressure injury is localized damage to the skin and/or underlying soft tissue” 5%

Yes = 95% No = 5% 95%

Yes No

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Old Pressure Ulcer Definition

New Pressure Injury Definition

A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.

A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.

Pressure Injury Teaching Points • Prior to staging as a pressure injury – Clean the wound – Determine etiology • Presence of pressure and/or shear

• Define microclimate – Determine whether microclimate is adverse

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FAQ: Injury and Potential Litigation • Discussed in detail by NPUAP prior to the conference • Plaintiff and defense attorneys were consulted – Professionals need to develop the science; attorneys look at the facts in the case to determine if it was unavoidable.

• The word "injury" occurs in other clinical diagnostic labels that may or may not be litigated – Acute kidney injury, spinal cord injury, traumatic brain injury

Stage 1 Pressure Injury Lightly Pigmented

Darkly Pigmented

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Comment Themes • DTPI reference at the end of the definition – Pros and Cons

• Erythema vs. Redness

Stage 1 Pressure Injury: Erythema Blanchable

Non-Blanchable

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Remove the statement - Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Yes No

After discussion Differential diagnosis

14% Yes No

44% 56% Yes = 44% No = 56%

Yes = 14% No = 86%

86%

Stage 1 Pressure Injury Without Edema

With Edema

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Old Stage I Pressure Ulcer Definition: Non-blanchable erythema

Stage 1 Pressure Injury: Non-blanchable erythema of intact skin

Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons.

Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

Stage 1 Teaching Points • First visible change in the skin – Heralding sign – Blanch response

• Stage 1 is Not – Scar tissue – Deep tissue pressure injury

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Stage 2 Pressure Injury

Stage 2 Comment Themes and New Literature • Partial thickness loss of skin with exposed viable dermis • Addition of MASD, IAD, ITD and MARSI as being different from a Stage 2 – Dorothy Doughty, MN, RN, CWOCN,CFCN, FAAN

• Add more conditions that are not Stage 2 – Examples: mucosal pressure injuries, surgical wounds, friction injuries

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Remove viable from the definition of Stage 2 (Exposed viable dermis)

Second Vote

Yes No

Yes

40%

No

46% 54%

60% Yes = 60% No = 40%

Yes = 54% No = 46%

The wound bed is viable pink or red, moist, and may also present as an intact or ruptured serum-filled blister. 3%

Yes = 97% No = 3% 97%

Yes No

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Retain skin conditions that may be incorrectly identified as a Stage 2 pressure injury. 8%

Yes = 92% No = 8% 92%

Yes No

Old Stage II Pressure Ulcer Definition • Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanguineous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation. • *Bruising indicates deep tissue injury.

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Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).

Stage 2 Teaching Points • Heals by reepithelialization, not granulation • Define MASD, MARSI, IAD, ITD

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Stage 3 Pressure Injury

Themes of Comments • Epibole • Presence of granulation tissue • Tissue types and descriptors • Bridge of nose vs. trochanter

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Retain the term “epibole” in the definition of Stage 3

Yes = 80% No = 20%

20%

80%

Yes No

Stage 3 Pressure Injury with Epibole

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Include the sentence describing anatomical locations: "The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous (adipose) tissue and Stage 3 pressure injuries do not occur in these areas”.

Yes No

Anatomy Issues

24% 76%

Yes = 76% No = 24%

Yes No

25% 75% Yes = 75% No = 25%

Old Stage III Pressure Ulcer: Full thickness skin loss

Stage 3 Pressure Injury: Full-thickness skin loss

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

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Stage 3 Teaching Points • Anatomy differences in body areas can result in very different depths of injury, • Extent of damage and visible tissue layer • Slough is an inflammatory exudate comprised of proteinaceous tissue, fibrin, neutrophils and bacteria, rather than nonviable tissue. • Often produced in response to biofilm • Epibole (rolled wound edges) are often present. • If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury

Stage 4 Pressure Injury

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Stage 4 Themes of Comments • Inclusion/description of osteomyelitis • Reference to unstageable pressure injuries

Remove the term osteomyelitis from the definition of a Stage 4.

Yes = 41% No = 59%

41% 59%

Yes No

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Discussion • Helps non-experts remember osteomyelitis is a possibility • Complication not part of definition • Need to raise awareness so keep in • Cut so that we don’t throw antibiotics at it without diagnosis • Leave out – other complications, cellulitis, infected joint space not mentioned

Remove the term osteomyelitis from the definition of a Stage 4. • Second Vote 20%

Yes = 80% No = 20%

80%

Yes No

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Remove the statement “If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury” from Stage 4.

Yes = 20% No = 80%

20% 80%

Yes No

Old Stage IV Pressure Ulcer: Full thickness skin loss

Stage 4 Pressure Injury: Fullthickness skin and tissue loss

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable.

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

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Stage 3 Pressure Injury: Full-thickness skin loss

Stage 4 Pressure Injury: Fullthickness skin and tissue loss

Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

Stage 4 Teaching Points • Clinicians should assess for osteomyelitis

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Unstageable Dark Eschar

Themes • Wound bed obscured

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Themes Clarify that this stage is unstageable due to • Inability to visualize wound base (obscured) • Clinician unable to determine the injury stage

Descriptors • Serves as “the body’s natural (biological) cover”

Unstageable Focus on Slough

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Change “depth” to “extent” in Unstageable. 4%

Yes = 96% No = 4% 96%

Yes No

Include the phrase eschar on the heels serves as “the body’s natural (biological) cover” in Unstageable definition.

First vote:

Second vote: Not just heel – teaching point

Third vote:

Yes = 48% No = 52%

Yes = 44% No = 56%

Yes = 61% No = 39%

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Change the statement Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.

Yes = 81% No = 19%

19%

81%

Yes No

Old Unstageable Pressure Ulcer: Full thickness skin or tissue loss – depth unknown

Unstageable Full-Thickness Pressure Injury: Obscured Fullthickness skin and tissue loss

Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.

Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be softened or removed.

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Unstageable Teaching Points • Describe the role of eschar as the body’s natural (biological) cover. • Removing stable eschar in the poorly perfused area results in an open wound that may expose the limb to infection and tax the ability to heal. • Treat the stable eschar as dry gangrene; do not moisten or soften it. • Most important intervention is pressure redistribution rather than eschar removal. • As eschar loosens from the wound bed, trim the edges to avoid inadvertent removal.

Deep Tissue Pressure Injury (DTPI)

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• Many changes made to proposed definition based on comments received • Differential diagnoses and the definition – Traumatic – Ischemic – Dermatologic

The word “Suspected” should precede the name “Deep Tissue Pressure Injury”. First vote:

Second vote:

Third vote:

Yes = 59% No = 41%

Yes = 49% No = 51%

Yes = 25% No = 75%

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FAQ Suspected • Original DTPI definition was written over 10 years ago • Little was known about DTPI at that time

• Today we are able to diagnose with more accuracy. • Can add the word “suspected” to the documentation about any definition or condition. – Suspected pressure injury or a suspected Stage 2 pressure injury.

Add the phrase in italics to the definition: Wounds may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss.

Yes = 86% No = 14%

14%

86%

Yes No

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Place the definition of DTPI between Stage 1 and Stage 2. Second vote: Yes No

• Evolution • Linearity • 24% If it resolves where do we put it? • 76% DTI is intact or not, but that places it between 1 and 2

16% Yes No

84% Yes = 16% No = 84%

Yes = 24% No = 76%

Add: “Do not use this stage for ischemic, traumatic, or dermatologic conditions”.

23%

Yes = 77% No = 23%

77%

Yes No

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Add: “Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions”.

Yes = 85% No = 15%

15%

85%

Old Suspected Deep Tissue Injury: Depth Unknown • Purple or maroon localized area of discolored intact skin or bloodfilled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. • Deep tissue injury may be difficult to detect in individuals with dark skin tones. • Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. • Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

Yes No

Deep Tissue Pressure Injury: Persistent nonblanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.

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DTPI Teaching Points • Confirm purple skin (appearing as ecchymoses or bruising) is due to pressure or shear and not medication or trauma • Attempt to identify the timing and setting of the pressure/shear that lead to DTPI for root cause analysis • Document the evolution of the DTPI following discovery • Sloughing of epidermis to reveal deeper tissue damage • If injury become full thickness, the Stage of the resultant injury

Other Definitions

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Old Medical Device Related Pressure Ulcer:

Medical Device Related Pressure Injury:

Medical device related pressure ulcers are pressure ulcers that result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure ulcer generally closely conforms to the pattern or shape of the device.

This describes an etiology. Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system.

87

Frequently Asked Questions – FAQs When a pressure injury forms on the skin beneath a medical device, how is this injury to be identified? • Stage x pressure injury on (named body part) from medical device

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Mucosal Tissues

Mucosal Tissues • Vulnerable to pressure from medical devices – Oxygen tubing, endotracheal tubes, bite blocks, urinary catheters, etc

• Scar tissue of the mucosa is remodeled and most injuries heal without scar formation.

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Add the statement “The staging system for pressure injury of the skin cannot be used to stage mucosal membrane pressure injury.” to the definition of mucosal membrane pressure injury. 2%

Yes = 98% No = 2% Yes No

98%

Old Mucosal Pressure Ulcer

Mucosal Membrane Pressure Injury:

Mucosal Pressure Ulcers are pressure ulcers found on mucous membranes with a history of a medical device in use at the location of the ulcer.

Mucosal membrane pressure injury is found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue these injuries cannot be staged.

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Since April… • “Wound, Ostomy and Continence Nurses™ (WOCN®) Society Board of Directors is in full support of NPUAP’s updated staging definitions and illustrations presented during the consensus meeting” • JWOCN is changing all mention of PrU to PrI • “Academy of Nutrition and Dietetics Board of Directors is in support of NPUAP’s updated staging definitions and illustrations”

The Joint Commission • Preventing Pressure Injuries – Quick Safety Issue 25 July 2016

• Includes the new terms and definitions introduced in April by the NPUAP • Replaces the term "pressure ulcer" with "pressure injury." https://www.jointcommission.org/assets/1/23/Quick_Safe ty_Issue_25_July_20161.PDF

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Coding Systems • Completed initial analysis of changes needed in SNOWMED CT, LOINC (Logical Observation Identifiers Names and Codes) • Will analyze changes needed in UMLS (Unified Medical Language System) and the pressure injury-related VSACs (Value Set Authority Center) • NPUAP is forming a Task Force to look at harmonizing the new NPUAP Definitions with universal coding systems and taxonomies.

Frequently Asked Questions since April

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How will we be paid for pressure injury since it is not in the ICD-10 codes? • The current ICD-10 coding system lists "pressure ulcer" and coders are supplied with synonyms for the condition including bed sore, decubitus ulcer, plaster ulcer, pressure area and pressure sore. • The NPUAP is working with International Wound Organizations on the ICD- 11 to incorporate the term "pressure injury".

Will NDNQI change their reporting systems to pressure injury? • Yes, the National Database of Nursing Quality Indicators is changing their reporting documents and training modules into the new system. The changes should go into effect in 2017.

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How soon will the Federal documents, MDS, OASIS, Acute Rehab IRF –PAI reporting regulations for skin conditions, change to the new staging terms? • The NPUAP has met with CMS and is working towards an implementation plan. • All changes are aimed at improving assessment and documentation precision.

When do we need to make these changes? • There were no changes to the stages of pressure injury; what you know today as a Stage II is still a Stage 2. • Your system can be changed to include pressure injury when you are making other changes. • Many organizations are incorporating the term “injury” into their documentation. • Similar decisions when acute renal failure became acute kidney injury.

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What’s Next? • Manuscript will appear in Nov/Dec issue of JWOCN • Teaching slide set

www.NPUAP.org

Thank you!

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CE Test Information To earn the 1.0 continuing education credit from today’s webinar please visit the link below. This information will also be emailed out to participants ONE HOUR after the conclusion of the webinar.

https://blueq.co1.qualtrics.com/SE/?S ID=SV_4VnQqwwfVI40Pd3

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