Skin & Wound Care: General Concepts, Overview, and Hospital Acquired Pressure Injuries (HAPI)
Skin and Wound Care. Produced by the Emory Nursing Wound Ostomy Continence Nursing Education Center.
Transcript
Welcome back.
Speaker A:In this class we're just going to do an overview of the wound care course.
Speaker A:I wanted you to know some key concepts and kind of how things will be set up.
Speaker A:There's nothing that's directly testable from this section.
Speaker A:So instead of trying to make a ton of notes, I just really want you to kind of listen along and get the big picture here.
Speaker A:Everything that's testable will be covered in another class.
Speaker A:So here's our objectives.
Speaker A:I want you to understand the essential elements of a comprehensive wound management plan.
Speaker A:We'll keep coming back to that throughout the course.
Speaker A:Obviously we're going to talk about the importance of and guidelines for accurate wound classification.
Speaker A:That is again a key concept that we'll keep addressing throughout the course.
Speaker A:We're going to discuss the impact of hospital acquired pressure injuries and guidelines for monitoring happy rates in the acute care setting, which will be very important to those of you in the acute care setting.
Speaker A:But again, not testable.
Speaker A:Finally, I want you to be very clear about the current definition of unavoidable pressure injury and the role of root cause analysis in determining whether a specific pressure injury was avoidable or was not.
Speaker A:And I want you to be able to discuss the wound care nurses responsibilities in setting up a program that assures appropriate pressure injury prevention.
Speaker A:So again, you're going to see this over and over, you're going to watch the video, you're going to complete the self study learning exercises and if you need additional reading It'll be chapter 16 in your core curriculum.
Speaker A:So let's start with the essential elements of a comprehensive wound management plan.
Speaker A:And we call this ESP E.
Speaker A:Just to make it easier to remember.
Speaker A:We hope so.
Speaker A:We actually see wound management as kind of this four legged stool like you see on top.
Speaker A:And the first is your first goal always is to figure out what caused that wound and what needs to be done to interrupt the cycle of injury.
Speaker A:So throughout the course there's tremendous focus on how do you accurately determine etiologic factors?
Speaker A:How do you differentiate a pressure injury from a moisture wound?
Speaker A:How do you differentiate an arterial wound from a venous wound?
Speaker A:We'll keep coming back to that.
Speaker A:So goal number one, figure out the etiologic factors and do everything you can to either correct or to reduce the impact of those etiologic factors.
Speaker A:Secondly, remember that wound healing is a systemic phenomenon.
Speaker A:It's not what we put on the wound that heals the wound, it's what the body does.
Speaker A:So we always have to look at wound healing from a systemic perspective and we have to address any factors that would interfere with wound healing.
Speaker A:So is this patient a poorly controlled diabetic?
Speaker A:We have to address that.
Speaker A:Is this patient malnourished?
Speaker A:We have to address that.
Speaker A:Is this patient owns steroids?
Speaker A:We have to be aware of that and maybe make some modifications in our management plan.
Speaker A:The third element, the third support for the stool, is principle based topical therapy.
Speaker A:So what we do with the wound from a topical therapy perspective is never going to be enough to heal the wound.
Speaker A:But it is important in terms of either promoting repair or interfering with repair.
Speaker A:So we'll spend a good bit of time talking about wound management and the principles of topical therapy.
Speaker A:And finally, once you put that together, you figured out the causative factors, the etiologic factors, and you've done everything you can to address them.
Speaker A:You've looked at the patient from a systemic perspective and done everything possible to put that person in a position to heal.
Speaker A:You have assessed the wound and you've put together a topical therapy program to optimize repair at the wound surface.
Speaker A:Then the fourth element is ongoing evaluation.
Speaker A:How's the wound responding?
Speaker A:Are you getting the results you expected to get?
Speaker A:If not, you have to back up, reassess, and modify your management plan.
Speaker A:So what do we say goal number one was?
Speaker A:Is to determine and correct etiologic factors, and this gets into wound classification.
Speaker A:Now, throughout the course, we're going to look at big categories of etiologic factors, and then we're going to break each big category down into specific causes.
Speaker A:So these four categories pretty much encompass the different etiologic factors.
Speaker A:Many of the wounds you see will be caused either by surgery or by trauma.
Speaker A:So you'll see a lot of surgical incisions that have dehisced, that have failed to heal for a variety of reasons.
Speaker A:You're going to see a number of traumatic wounds, lacerations, abrasions, burns, skin tears, tape, trauma.
Speaker A:Obviously, when you have a dehisced incision, it's too late to go back and redo the surgery, so you can't fix that.
Speaker A:But when you have a wound caused by trauma, you definitely do want to identify the source of trauma and you want to make sure that you take measures to prevent additional wounds.
Speaker A:A huge category is wounds caused by mechanical factors, things like friction, moisture, shear, pressure.
Speaker A:These are very common causes of trunk wounds.
Speaker A:And we see a lot of these wounds in patients who are hospitalized or patients who are bed bound or chair bound.
Speaker A:So we'll spend time talking about each of those factors and the things you need to Address those factors.
Speaker A:A third huge category is vascular conditions.
Speaker A:This is the causative factor for many, many of your leg wounds.
Speaker A:Most of them will be caused either by arterial insufficiency, venous insufficiency, lymphedema, possibly neuropathy.
Speaker A:But there are other causes of leg wounds that we will address as well.
Speaker A:And finally, that big other category.
Speaker A:So some wounds are caused by bacterial infections, some are caused by fungal infections, some by viral infection.
Speaker A:Some of them are autoimmune in origin, some of them are malignant.
Speaker A:So all of these different causative factors are going to be addressed along with implications for management.
Speaker A:Now, there's major clues to etiologic factors that you'll keep hearing throughout the course.
Speaker A:So I'm going to go in and address them now so that they're kind of hopefully there as background for you.
Speaker A:Always.
Speaker A:We start by getting the patient's history and identifying any comorbid conditions, because that gives us a lot of clues as to what might be going on here.
Speaker A:So if I have a patient who is post stroke, and they're essentially, they have a lot of residual weakness in both right extremities, so right upper extremity, right lower extremity, they're also obese, so they have a very hard time turning themselves.
Speaker A:They're frequently incontinent of stool or urine, so they're exposed to a lot of moisture.
Speaker A:If they're also a poorly controlled diabetic and a cigarette smoker, then already know, gosh, that patient's very high risk for pressure injury.
Speaker A:Also potentially at risk for conditions associated with incontinence and possibly for leg wounds caused by poor perfusion.
Speaker A:Another critical indicator is the wound history.
Speaker A:So we always ask the patient, how long have you had this wound?
Speaker A:Do you know how it started, what's been done, and what has helped?
Speaker A:What hasn't helped?
Speaker A:That frequently provides you with very helpful clues.
Speaker A:So if you have a patient with a venous wound, they might say, well, you know, I just scratched my leg.
Speaker A:And then it turned into this open wound, and it just.
Speaker A:Just got worse and worse.
Speaker A:And really, the only thing that seemed to help was when they wrapped it up with that thing that stopped the swelling.
Speaker A:Okay?
Speaker A:All of those are very important clues as to venous insufficiency as the etiologic factor.
Speaker A:Another thing you'll hear us talk about a lot is pain pattern.
Speaker A:This is particularly important when you talk about lower extremity wounds.
Speaker A:The pain pattern can be very helpful in terms of differential assessment, because what you see in terms of pain with an arterial wound will be very different than what you see with a venous wound.
Speaker A:And we'll go over that in detail.
Speaker A:Location.
Speaker A:If it's a lower extremity wound, I'm thinking, well, it could very well be because of artillery insufficiency, venous insufficiency neuropathy.
Speaker A:But if it's over the heel, it can also be due to pressure.
Speaker A:If it's a trunk wound, it's very commonly caused by some combination of pressure, shear, friction and moisture.
Speaker A:And in differentiating between pressure related wounds and moisture or friction related wounds, contours and depth are very, very informative.
Speaker A:Pressure injuries are going to reflect the underlying bony prominence.
Speaker A:So they're usually well demarcated, they're typically deeper.
Speaker A:They either reflect the bone or reflect the medical device.
Speaker A:In contrast, if you have a wound caused by incontinence, it's typically much more diffuse with very irregular borders.
Speaker A:All of these factors will be discussed.
Speaker A:The type of the tissue in the wound bed can be helpful.
Speaker A:If you have a very poorly perfused wound, it's much more likely to be necrotic.
Speaker A:If you have a well perfused wound, it's much more likely to be healthy tissue in the wound bed.
Speaker A:The volume of exudate, type of exudate and the periwound characteristics all provide clues.
Speaker A:All of these things we will discuss over and over again.
Speaker A:Now, there's also some terminology issues that come into play here.
Speaker A:So I wanted you to know that the current term for a wound due to pressure or pressure in combination with shear is pressure injury.
Speaker A:So this terminology has gone through a lot in terms of evolution.
Speaker A:You go way back and these were called bedsores and then they were called decubitus ulcers or decubiti.
Speaker A:Very inaccurate terminology because decubitus means lying down.
Speaker A:And many pressure injuries occur when someone is sitting up.
Speaker A:Then we went to pressure ulcer and the current term pressure injury, and that term has been approved by the National Pressure Injury Advisory Panel.
Speaker A:They are considered the definitive source in terms of terminology related to anything caused by pressure.
Speaker A:So take out all those other terms.
Speaker A:Decubitus, bedsore, pressure ulcer, replace it with pressure injury.
Speaker A:Now, what's the primary pathology of a pressure injury?
Speaker A:It's ischemia.
Speaker A:What happens is you get tissue that's over a bony prominence or under a medical device, it gets compressed.
Speaker A:So that tissue gets compressed either between the medical device and the body surface or between the bone and the resting surface.
Speaker A:So if you have, say a sacral wound in a Bed bound patient, you get ischemic damage to the tissue between the sacral bone internally and the bed surface or the chair surface externally.
Speaker A:If you have a medical device related pressure injury, it's going to be related to pressure and possibly ischemia caused by the medical device which compresses the soft tissue between the device and the underlying body surface.
Speaker A:You keep coming back to tissue compression.
Speaker A:When you get tissue compression, you get vessel compression.
Speaker A:When you get vessel compression, you get ischemic damage.
Speaker A:And most pressure injuries will reflect either tissue loss or tissue death.
Speaker A:Again, this will be discussed in more detail.
Speaker A:I'm trying to give you big picture.
Speaker A:Why did I select or why did we select pressure injury to focus on in a little more depth?
Speaker A:Because it's such a huge issue in any inpatient setting, pressure injuries are considered to be patient safety issues.
Speaker A:They're considered to be never events, things that should not happen if the patient's getting appropriate care.
Speaker A:We'll come back to that whole concept.
Speaker A:Well, we know that pressure is a common etiologic factor for trunk wounds and for heel wounds.
Speaker A:But we also know that many trunk wounds are just superficial skin loss and they're caused by friction or friction and moisture in combination and not by pressure at all.
Speaker A:How do you label those wounds?
Speaker A:And this is important because in the past we tended to label anything on the trunk as a bedsore, a decubitus ulcer, a pressure ulcer or a pressure injury.
Speaker A:Really important to differentiate between wounds caused by pressure wounds caused by friction alone and wounds caused by some combination of friction and moisture.
Speaker A:Because remember, your first goal is to identify those causative factors and intervene to correct them.
Speaker A:So if you don't identify them correctly, no way you're going to intervene correctly.
Speaker A:So here's your current terminology.
Speaker A:Pressure injury.
Speaker A:We just said for anything caused by a combination of pressure and shear friction.
Speaker A:For wounds caused by friction only superficial skin loss from rubbing incontinence associated dermatitis or IAD is the current terminology for wounds caused by friction plus moisture in areas exposed to urine and or stool.
Speaker A:So urine or stool or a combination is the source of moisture and then rubbing against the underlying linens or a bed pad or incontinence brief is the source of friction.
Speaker A:You see the third bullet point, intertridis dermatitis itd.
Speaker A:That's the correct terminology for fissures wounds caused by friction and moisture in areas with trapped perspiration.
Speaker A:So if you have linear breaks or kissing lesions associated with a body fold and trapped moisture.
Speaker A:So where do you see itd very commonly seen underneath the pannas, underneath breast, sometimes in the groin fold, frequently in the gluteal cleft.
Speaker A:And again, we'll come back to this.
Speaker A:Now, classification and accuracy in classification sounds pretty easy when we're talking about it, but once you go to the bedside, when you're addressing this issue in clinical practice, you find it's anything but easy.
Speaker A:I face this every day that I'm at the hospital.
Speaker A:What should I call this?
Speaker A:Is this truly a pressure injury?
Speaker A:Is this moisture and friction?
Speaker A:Can I reliably, consistently differentiate between ITD and pressure injury?
Speaker A:Between pressure injury and friction injury?
Speaker A:The answer is many times yes and sometimes no.
Speaker A:So here are the challenges.
Speaker A:We know that the very same patients who are at risk for pressure injury because they're relatively immobile, they may also be at risk for wounds due to friction or moisture, because not only are they immobile, they're also diaphoretic.
Speaker A:They're immobile and incontinent.
Speaker A:The fact that they're immobile means that we reposition them so they're exposed to friction when we move them up and when they slide back down.
Speaker A:So sometimes it is difficult to accurately determine the etiology of wounds that are located over the buttocks or within the gluteal cleft.
Speaker A:Here are some things to help.
Speaker A:I'm going to tell you the things that help, and I'm going to tell you it's still sometimes really hard.
Speaker A:So patient history is helpful.
Speaker A:If I know that this patient is immobile, has been immobile, that they've been exposed to prolonged or intense pressure, then I'm pretty sure it's pressure.
Speaker A:But if they're moving around on their own, however, their skin is fragile, so any moving around causes friction.
Speaker A:And if I know they're also diaphoretic, then I know it's not pressure.
Speaker A:But it may very well be friction injury.
Speaker A:I have to think about the location and the contour of the wounds.
Speaker A:Those are very important clues.
Speaker A:So if it's over a bony prominence, if it's sacral coccygeal, I'm thinking it's probably pressure.
Speaker A:But if it involves the perineum, the buttocks and the inner thighs, and the patient's incontinence, I'm thinking it's probably iad.
Speaker A:If it's at the base of a fold or on opposing surfaces of a fold, in a patient who's diaphoretic, I'm thinking it's probably itd.
Speaker A:Sometimes it's a combination.
Speaker A:And then you're like, well, what should I Call it.
Speaker A:So the current guidance is if there's a history of immobility or the wound is over a bony prominence and you suspect that pressure is at least one of the causative factors, you should classify it as a pressure injury.
Speaker A:Now, we've already talked about why it matters, so this just should reinforce that accurate classification is important because it assures appropriate management.
Speaker A:Remember, goal number one is to identify and correct ideologic factors.
Speaker A:There's another reason.
Speaker A:In inpatient settings, we do what we call benchmarking.
Speaker A:So we track the rates of hospital acquired pressure injuries in our setting and we compare our rates to those of comparable agencies.
Speaker A:Obviously it matters that I classify wounds correctly, because if I'm classifying everything in the trunk as a pressure injury, even though 50% of them are actually caused by non pressure factors like moisture and friction, my rates of hospital acquired pressure injuries are going to look very high and my agency is going to look like they're not doing a good job with pressure injury prevention.
Speaker A:So does it matter if I get it right?
Speaker A:Yes, it helps assure appropriate management and it helps assure appropriate and accurate benchmarking.
Speaker A:So now let's talk a little bit about hospital acquired pressure injuries and current expectations.
Speaker A:So one expectation is that all agencies will track and monitor their rates of hospital acquired pressure injuries and we'll compare their rates to the rates in comparable facilities so that they know if they're on track, if they're doing better than others, or if they're doing worse than others.
Speaker A:If we're doing worse than others, we definitely need to ramp up our prevention program.
Speaker A:Right.
Speaker A:So prevalence data.
Speaker A:We talk a lot about doing prevalence studies, we talk some about doing incident studies, and we talk a little bit now about terminology.
Speaker A:So what does prevalence tell you?
Speaker A:It tells you how many patients have pressure injuries at a specific point in time.
Speaker A:So if you survey 300 patients and 30 of them have pressure injuries at the time of survey, that gives you a 10% prevalence rate.
Speaker A:And that's the data that we use to benchmark against other agencies.
Speaker A:So we've already said prevalence is the percentage of patients with pressure injuries at one point in time at the time of your survey.
Speaker A:What's the difference in prevalence and incidence?
Speaker A:Incidence tells you the percentage of patients who develop pressure injuries following admission.
Speaker A:Most of us do not do true incident studies because they're very hard to do.
Speaker A:To do a truly accurate incident study, you would have to track a cohort of patients from the time of admission all the way through to discharge, transfer or death.
Speaker A:And you would have to determine what percentage of that cohort developed a pressure injury during the hospital stay?
Speaker A:We don't typically do that because it's very time intensive.
Speaker A:Instead, what most agencies are tracking is hospital acquired pressure injuries.
Speaker A:What is that and how does it differ from incidence?
Speaker A:To determine the number and percentage of patients who have a hospital acquired pressure injection entry, you start by doing a prevalence study.
Speaker A:So that means you survey everyone in your agency at a specific point in time on a particular day.
Speaker A:Okay, I'm going to use a different denominator.
Speaker A:I'm going to use 500.
Speaker A:So let's say you survey all 500 patients in your hospital and let's say that 50 of those patients are found to have a pressure injury at the time of survey.
Speaker A:So that gives you a 10% prevalence rate.
Speaker A:You notice I'm using easy numbers, right?
Speaker A:Okay, now how do you differentiate between prevalence and hospital acquired pressure injuries?
Speaker A:So I take those 50 patients who were found to have an injury at the time of survey.
Speaker A:I go back in each one's record and I determine, okay, was this injury documented at the time of admission?
Speaker A:If it was documented at the time of admission, it is not a hospital acquired pressure injury.
Speaker A:So let's say that out of those 50 patients who were found to have a pressure injury at the time of survey, 25 of them had that documented at the time of admission.
Speaker A:That leaves 25 patients out of 500 who have a pressure injury at the time of survey.
Speaker A:There's no indication, there's no evidence that that breakdown that pressure injury was present at the time of admission.
Speaker A:That would give you a 5% rate for hospital acquired pressure injuries.
Speaker A:So in other words, if a patient has a pressure injury at the time of survey and it was not documented on admission, it is considered, considered to be hospital acquired.
Speaker A:What's the difference between happy and incidents?
Speaker A:If it's a happy, it could represent one of two things.
Speaker A:It could truly be a hospital acquired pressure injury or it could be a failure of assessment and documentation on admission.
Speaker A:Incidence.
Speaker A:True incidence means we looked at this patient on admission, they did not have a wound.
Speaker A:We followed them all the way through.
Speaker A:This percentage developed a wound.
Speaker A:But in your world today, you're going to deal with prevalence and with hospital acquired pressure injuries.
Speaker A:And the data that is reportable at this point in time is happy rates.
Speaker A:Okay, so what is your happy prevalence?
Speaker A:Okay, at any given point in time now what are the requirements?
Speaker A:What are the trends?
Speaker A:If you're a magnet agency, if you're trying to achieve magnet status, you're required to conduct quarterly prevalence Incident studies.
Speaker A:So it tells you overall prevalence and then it tells you happy incidents.
Speaker A:Okay.
Speaker A:Hospital acquired pressure injuries.
Speaker A:But remember, it just means that that injury is present today at the time of survey and not documented on admission.
Speaker A:Does not differentiate between documentation issues and actual pressure injury development.
Speaker A:However, look at it this way.
Speaker A:If this patient has a pressure injury at the time of survey and it wasn't documented on admission, there's definitely an issue.
Speaker A:Whether it's a documentation issue or a care issue, it's definitely something that has to be addressed by your agency.
Speaker A:And if you have high happy rates, it certainly means that your agency is more subject to regulatory action, more subject to litigation.
Speaker A:So back to requirements and trends.
Speaker A:If you're magnet, you're required to do quarterly studies.
Speaker A:So most agencies, agencies treat that as baseline.
Speaker A:Many agencies are now conducting monthly surveys or they're monitoring happies on an ongoing basis.
Speaker A:So what does that ongoing monitoring mean?
Speaker A:It means that the staff reports all suspected pressure injuries to the wound department.
Speaker A:Okay, I did my morning assessment of this patient.
Speaker A:He has an area on the sacrum that wasn't there yesterday.
Speaker A:I think it's a pressure injury.
Speaker A:I think it's a stage two.
Speaker A:Can somebody from the wound team come verify?
Speaker A:So then somebody from the wound team goes to verify.
Speaker A:Yes, this is a pressure injury and it is a stage two.
Speaker A:So if you did that, you could compare the number of pressure injuries, hospital acquired pressure injuries, month to month.
Speaker A:So you can kind of see how you're doing.
Speaker A:Is your rate going down?
Speaker A:Is your rate going up?
Speaker A:Are you doing this kind of number?
Speaker A:What are the factors that might be impacting on that?
Speaker A:So what if your rate's coming down and then you have a sudden influx of new graduates and your rate goes up?
Speaker A:Major implications for what kind of education we provide our new graduates during orientation.
Speaker A:Now, here are some things you have to think about when you're conducting prevalence studies.
Speaker A:A lot of you are based in acute care, and if you are, this is going to be a major responsibility for you and your team is to typically coordinate and conduct prevalent studies that provide accurate data for benchmarking.
Speaker A:Now, you can't do all of the survey yourself.
Speaker A:So typically what you're going to do is you're going to form survey teams.
Speaker A:It might be your skin and wound champions, it might be volunteers from each unit.
Speaker A:Whatever your teams, however you put your teams together, it's important to educate them before they go out to do the survey.
Speaker A:One thing you want them to be clear about is what's the difference between a stage one Pressure injury and reactive hyperemia.
Speaker A:We'll talk about this later, but quickly.
Speaker A:Reactive hyperemia is normal.
Speaker A:It's blanchable.
Speaker A:Stage one pressure injury is non blanchable.
Speaker A:It is not normal.
Speaker A:So if it's blanchable redness, it's not a pressure injury.
Speaker A:If it's non blanchable, it is.
Speaker A:Secondly, you want your survey team to be able to differentiate between pressure injuries, skin tears, friction injuries, incontinence, associated dermatitis, but also you want to think, well, what's the best use of the wound team's time?
Speaker A:And in most agencies it's coordinating, educating and validating.
Speaker A:So what does that mean?
Speaker A:It means maybe my survey team surveyed 30 patients and out of that 30 patients, we had three patients that we documented as having hospital acquired pressure injuries.
Speaker A:From our perspective, then somebody from the wound care team would go behind us and they would relook at every one of those injuries to determine is that truly pressure, is it incontinence associated dermatitis?
Speaker A:Was it classified as stage one when really it was reactive hyperemia, it was blancheable.
Speaker A:So basically you validate that is a really important element of a prevalence and incidence study because it assures accuracy in the data you use for benchmarking.
Speaker A:Another big issue related to pressure injuries in the inpatient setting is the concept of avoidable versus unavoidable.
Speaker A:Very important to distinguish if possible, because avoidable pressure injuries are considered to be a medical error, a patient safety issue.
Speaker A:In some states it is reportable.
Speaker A:In some states, there are fines levied for stage three, three, four and unstageable pressure injuries.
Speaker A:Also, if you have an avoidable pressure injury, it increases your risk for litigation.
Speaker A:So if you can distinguish between avoidable and unavoidable pressure injuries, you can help to protect your agency.
Speaker A:And you can also more effectively target quality improvement measures.
Speaker A:For example, we were recently doing root cause analysis on pressure injuries in our ICU patients and we were able to go back and say, okay, this pressure injury was unavoidable.
Speaker A:How do we know that?
Speaker A:Because we carried out all appropriate preventive care.
Speaker A:We had them on the right surface, we were turning them, we had their heels floated, etc.
Speaker A:Etc.
Speaker A:Things we'll talk about later.
Speaker A:However, this pressure injury was avoidable.
Speaker A:It occurred when the patient was sitting up in the chair for a prolonged period of time without a cushion.
Speaker A:Okay, well, you can see how that allows me to target my quality improvement measures.
Speaker A:I'm not going to go around and talk to everybody about turning their bed bound patients.
Speaker A:That's happening.
Speaker A:I'm not Going to talk to them about floating heels that's happening.
Speaker A:I'm going to talk to them about appropriate time frame for sitting up in the chair and the importance of a chair cushion put up.
Speaker A:So here's the current definition of an unavoidable pressure injury.
Speaker A:It's a pressure injury that occurs despite prompt initiation of all preventive measures, ongoing assessment of skin status, prompt modification of the prevention program for any evidence of deterioration in skin status.
Speaker A:Pretty clear that comes from consensus conferences held by the National Pressure Injury Advisory Panel.
Speaker A:Well, here's the question.
Speaker A:How do we differentiate between avoidable and unavoidable?
Speaker A:I've seen people go into the progress notes and say this wound was unavoidable because the patient was very sick.
Speaker A:Well, that doesn't tell me it was unavoidable.
Speaker A:Go back to your definition.
Speaker A:You have to show that all preventive measures were carried out, routine assessment was done, and the prevention program was modified as indicated.
Speaker A:How do you do that?
Speaker A:Through root cause analysis.
Speaker A:That is an incredibly important quality improvement tool.
Speaker A:So what you essentially do is you take each hospital acquired pressure injury and you investigate that pressure injury.
Speaker A:You go back in the record 72 hours prior to development of that hospital acquired pressure injury, and you look to see, was all appropriate preventive care provided?
Speaker A:Was the scan routinely assessed?
Speaker A:Was the plan modified if indicated?
Speaker A:You might also want to look at other factors known to contribute to unavoidable pressure injuries, but we'll talk about those later.
Speaker A:Now, the whole goal of root cause analysis is twofold.
Speaker A:One is to differentiate avoidable and unavoidable, and the second is to identify any gaps in care that we can use to improve care and care outcomes.
Speaker A:So let's put some of this stuff together and talk about your role as a wound nurse related to hospital acquired pressure injuries.
Speaker A:You can't do it all, but you play a very important role.
Speaker A:So, number one, you need to make sure that your policies, procedures and protocols are consistent with current evidence and guidelines.
Speaker A:You need to provide ongoing staff education.
Speaker A:You might not do it all yourself, but in conjunction with your clinical specialist and with your staff educators and with vendor educators, you want to keep your staff current.
Speaker A:And pressure injury prevention, you want to either conduct or coordinate root cause analysis for all happies and use that data as a basis for determining whether the injuries were avoidable or unavoidable.
Speaker A:For entries that were avoidable, you want to put together targeted quality improvement programs.
Speaker A:Now, you need to know the best resources to use when you're writing your policies and procedures or updating them.
Speaker A:There are two sets of evidence based guidelines that are kept current and are excellent resources.
Speaker A:One is from the WCN Society and one is from from the European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and the Pan Pacific Pressure Injury Association.
Speaker A:Pressure injuries have an economic impact.
Speaker A:Taking care of these wounds can be very costly, costs a lot more if the wound is deep, full thickness or if it's complicated by necrosis or infection.
Speaker A:So obviously again, we go back to prevention is the goal.
Speaker A:Not only are they costly, they're painful, they're associated with increased morbidity and mortality.
Speaker A:Back to economics.
Speaker A:Hospitals are compensated for the cost of pressure injury care only if that wound was documented as present on admission.
Speaker A:Because the stance of cms, and it's a very reasonable, reasonable stance, is we don't pay for errors.
Speaker A:If you messed up, it's on you.
Speaker A:We're not covering the cost, but this has major implications for us.
Speaker A:In wound care.
Speaker A:It goes back to how critically important it is to document skin status and the presence of any pressure injuries at the time of admission.
Speaker A:Not only to direct care, that's number one thing, but also to protect your agency.
Speaker A:So you want to make sure that a head to toe skin assessment is done at the time of admission and that any breakdown present on admission is documented in the medical record.
Speaker A:Also, either the admitting physician or mid level provider has to document that that pressure injury was present on admission.
Speaker A:They have to verify, validate that that pressure injury was present on admission and they also have to validate the stage of the pressure injury.
Speaker A:So in summary, the essential elements of a comprehensive wound management plan, accurate identification and attention to correction of etiologic factors, looking at the patient from a systemic perspective and doing everything possible to put them in a position to heal by controlling glucose levels, ensuring adequate perfusion and nutritional support, etc.
Speaker A:You want to provide evidence based topical therapies so that the local environment, the wound environment, supports healing.
Speaker A:You have to follow that wound along.
Speaker A:You have to have ongoing assessment and constant modification of your management plan to keep the wound on track.
Speaker A:Second thing we talked about, accurate classification of etiologic factors is challenging, but it's also critical.
Speaker A:So you look at the wound very carefully.
Speaker A:Where is it?
Speaker A:What are the contours?
Speaker A:What's the depth?
Speaker A:What does the wound base look like?
Speaker A:You pay a lot of attention to patient history.
Speaker A:Major, major clues.
Speaker A:If you're in an inpatient setting, you're going to have a lot of responsibility for coordinating and directing your prevalence studies and for creating data that is accurate as a basis for benchmarking, also for using that data to improve the quality of care in your agency.
Speaker A:And finally, you always want to be attuned to legal and economic issues, specifically the importance of documenting skin status and the presence of any wounds that are present on admission.
Speaker A:Okay, thanks.
Speaker A:The next class will start going into specific etiologic factors and management.
