Pressure Injury Prevention: Hospital Acquired Pressure Injury (HAPI) General Principles
Skin and Wound Care. Produced by the Emory Nursing Wound Ostomy Continence Nursing Education Center.
Transcript
In the last class we talked about the pathology, clinical presentation and progression of wounds caused by pressure or a combination of pressure and shear.
Speaker A:We also talked about the fact that almost all pressure injuries are avoidable and that currently development of a hospital acquired pressure injury is considered to be a never event and an important patient safety issue.
Speaker A:We know as nurses that pressure injuries can be extremely painful.
Speaker A:We know that they're accompanied by a high risk of infection, even osteomyelitis, and that sometimes they result in death.
Speaker A:So our goal as wound care nurses is to prevent.
Speaker A:Prevent agency acquired hospital acquired pressure injuries and preventive care is the focus of this presentation.
Speaker A:So you can see here that we're going to talk about pressure injury prevention in general and then we're going to move ahead to use of support surfaces as part of a pressure injury prevention protocol.
Speaker A:Now, as a wound care nurse, you have major responsibilities for for establishing an effective agency wide program for pressure injury prevention.
Speaker A:And that's where we're going to start.
Speaker A:But then we're going to move ahead because the other responsibility you have is to assure that every at risk patient is managed with an appropriate prevention protocol.
Speaker A:So we're going to talk first about how you go about setting up an agency wide pressure injury program and then we're going to talk about how you make sure that your pressure injury prevention bundle is appropriate for every individual patient.
Speaker A:So let's start with your agency wide program.
Speaker A:This is one of the first things you'll probably target in your role as a wound care nurse if you're working in an acute care setting.
Speaker A:Remember we talked yesterday about our goals.
Speaker A:So you want to set a goal of 0% avoidable hospital acquired pressure injuries.
Speaker A:Some agencies set a goal of 0% hapies.
Speaker A:We think that that's unrealistic because we know that some patients are so high risk and have so many co morbidities that are contributing to tissue breakdown that happies may not be preventable.
Speaker A:And we don't want to make staff feel bad about an injury that occurs despite all preventive care.
Speaker A:So we recommend establishing a goal of 0% avoidable hospital acquired pressure injuries.
Speaker A:We defined avoidable pressure injuries in our previous class as a hospital acquired pressure injury that's associated with gaps and either delivery or documentation of preventive care.
Speaker A:What's an unavoidable pressure injury?
Speaker A:We define this also, but I want to review that again.
Speaker A:So a pressure injury is considered to be unavoidable when there was prompt identification of the patient as being at risk.
Speaker A:There was an equally prompt initiation of an Evidence based prevention protocol, and that protocol was consistently delivered.
Speaker A:There was ongoing monitoring of skin status to determine the effectiveness of the prevention protocol and if there was any deterioration in skin status, there were modifications made in the prevention protocol.
Speaker A:If all of those elements of care were delivered and an injury develops anyway, it is considered to be unavoidable.
Speaker A:We talked a little bit in a previous class about the importance of root cause analysis.
Speaker A:So root cause analysis is a very valuable tool in the determination as to whether a pressure injury was avoidable or unavoidable.
Speaker A:So root cause analysis requires the staff to go back and look very critically at the care delivered to any patient who develops a hospital acquired pressure injury.
Speaker A:Your area of focus is the 72 hours preceding initial identification of the hospital acquired pressure injury.
Speaker A:When you look at that 72 hour window of care, you're looking very critically to determine were all elements of preventive care delivered?
Speaker A:Were there any gaps?
Speaker A:Are there any things that you can identify that you could use to improve care for other patients?
Speaker A:Very helpful to use a structured tool for root cause analysis.
Speaker A:So I'll share a little anecdote from my agency.
Speaker A:Until we started using a very structured tool.
Speaker A:When we would bring all of our skin and wound champions together and we would discuss hospital acquired pressure injuries that had occurred in their units, they would basically present the patient information and say, oh, this patient was 66, came in with coronary artery disease, went to surgery for coronary artery bypass, had these complications, blah, blah, blah, and then it basically came down to she was very sick.
Speaker A:And so they took that to essentially mean that because she was very sick, the pressure injury was unavoidable.
Speaker A:But what a root cause analysis tool does, an objective root cause analysis tool forces you to look objectively at each element of prevention.
Speaker A:Was the patient consistently turned on day one prior to pressure injury development, day two prior, day three prior, were there gaps in turning and positioning?
Speaker A:Were heels offloaded?
Speaker A:Was the patient on an appropriate surface?
Speaker A:Was moisture managed?
Speaker A:Was the skin inspected?
Speaker A:All of those things.
Speaker A:And it allows you to either objectively say all elements of preventive care were consistently delivered and documented, or it allows you to say we did well in this area.
Speaker A:But there was a gap here.
Speaker A:So you definitely want to look at a structured tool.
Speaker A:You should be aware that the National Pressure Injury Advisory Panel has a tool on their website and you can use or modify that tool.
Speaker A:And the value of that type of tool is, number one, you know, it's evidence based, it comes from a recognized agency dedicated to pressure injury prevention.
Speaker A:But you very well may need to modify it to work in your setting.
Speaker A:Now let's talk about factors that are frequently associated with unavoidable pressure injuries.
Speaker A:There have been consensus conferences to look at unavoidable pressure injuries.
Speaker A:There have been a number of studies looking retrospectively at factors that were associated with pressure injuries eventually determined to be unavoidable.
Speaker A:And they're bulleted here.
Speaker A:So you may very well want to incorporate this in your root cause analysis tool.
Speaker A:National Pressure Injury Advisory Panel has incorporated some of these.
Speaker A:First of all, patient family non adherence.
Speaker A:So what if you go to turn the patient, but on multiple occasions the patient refuses to be turned, they say it's too painful or whatever.
Speaker A:Very important to document that, or otherwise it looks like you just didn't do it.
Speaker A:But here's the other thing.
Speaker A:It's critically important to state that the patient refused repositioning despite education, because of course, if I'm in pain, I don't want to be repositioned.
Speaker A:I want you to leave me alone if I've just gotten comfortable.
Speaker A:So it's important for you to explain to me, Dorothy, this is why we want to reposition you.
Speaker A:We know it's uncomfortable.
Speaker A:We're going to do everything we can to make it as easy as possible.
Speaker A:But it's critically important for us to do this to protect your skin, to keep you from developing any wounds.
Speaker A:Also important to improve lung function, to improve circulatory status, etc.
Speaker A:If I still say I don't care, leave me alone, then you want to document that a huge area is the area of vascular compromise.
Speaker A:So if this patient is hemodynamically unstable, if they're in shock.
Speaker A:So a lot of tools look at what's your mean arterial pressure if the patient's on vasopressors, how many vasopressors?
Speaker A:All of those things have been shown in multiple retrospective studies to contribute to unavoidable pressure injury development.
Speaker A:So you want to capture that.
Speaker A:What about prolonged immobility off the unit?
Speaker A:Prolonged immobility over which you had no control.
Speaker A:So what about that patient who goes to surgery and they're in surgery for 10 hours and then they go to PACU for two to four hours and it may be very difficult to reposition them.
Speaker A:And pacu, it's typically impossible to reposition when the patient's in the operating room.
Speaker A:So you want to capture that on your root cause analysis tool as well.
Speaker A:So what if I'm reviewing care for a patient and day three, prior to development of the hospital acquired pressure injury, this patient was in the operating room for a 10 hour vascular procedure, and then they were in PACU for four hours before they came back to the unit.
Speaker A:And I was able to reinitiate turning.
Speaker A:That's a huge period of time.
Speaker A:What if during that operative procedure, the patient also experienced multiple hypotensive episodes?
Speaker A:That's also important to capture.
Speaker A:And then the last bullet point is something that I can only share the current state of confusion regarding this topic, and that is skin failure.
Speaker A:So, as a wound care nurse, you're going to hear a lot about the concept of speaking skin failure.
Speaker A:You're going to hear about Kennedy terminal ulcers.
Speaker A:What does that mean?
Speaker A:Well, there's been a lot of discussion in the wound care world about the fact that the skin is an organ system.
Speaker A:And just like you can develop heart failure, you can develop renal failure, you can develop liver failure, that you can probably develop skin failure.
Speaker A:But as of this time, that concept is still being investigated.
Speaker A:We do not have clear criteria for what would constitute skin failure.
Speaker A:So you can't just write on the chart that the patient has skin failure and that's what caused the breakdown.
Speaker A:We're going to talk about that a little bit more.
Speaker A:How many of you have heard the term Kennedy terminal ulcer?
Speaker A:So that's a term that is sometimes used alternatively to skin failure.
Speaker A:So some people will use skin failure, other people will use Kennedy terminal ulcer.
Speaker A:Now, that whole phrase and concept was initially brought to the literature and brought to clinical discussions by a nurse practitioner who noted that in the 24 to 48 hours prior to death, a number of patients developed, usually sacrococcygeal wounds that were very rapidly progressive despite appropriate preventive care.
Speaker A:So she began to document this.
Speaker A:She began to do photo documentation and to capture the characteristics of patients who she believed developed Kennedy terminal ulcers.
Speaker A:So you can see that the premise here is that at the end of life, what's happening, you're getting shut down of the cutaneous circulation.
Speaker A:So we know that mottling that begins distally and proceeds proximally, that's commonly seen during end of life.
Speaker A:We know extremities become cold.
Speaker A:So we have a lot of evidence that at end of life there is progressive shutdown of the cutaneous circulation.
Speaker A:And she theorized that this shutdown of the cutaneous circulation was the major pathology underlying rapid development of sacrococcygeal breakdown that occurred regardless of preventive care.
Speaker A:But notice bullet point three.
Speaker A:As of yet, this is not a totally proven concept, though most clinicians acknowledge that there is a Lot of validity here.
Speaker A:It's not yet accepted as an official designation.
Speaker A:It's not yet incorporated into any of the wound classification systems or any of the staging systems.
Speaker A:Here's the other thing.
Speaker A:Almost all Kennedy terminal ulcers occur over bony prominences.
Speaker A:The vast majority occur over the sacrococcygeal area.
Speaker A:So even though failure of the cutaneous circulation probably plays a major role, we cannot rule out pressure as a contributing factor.
Speaker A:So currently, the thinking is that skin failure, that this concept of a terminal ulcer, that those are contributing factors to unavoidable pressure injuries.
Speaker A:But there still is a pressure component in these wounds.
Speaker A:So somebody asked me a few weeks ago, she said, you know, we're looking at, in our setting, we're looking at possibly eliminating all of our very critically patients from our NDNQI survey, because, you know, they're so high risk, they're probably going to develop pressure injuries anyway, and they're making our numbers look really bad.
Speaker A:I'm like, yes, but you cannot eliminate those people from your survey because those are the very people we're trying to protect.
Speaker A:It's critical for us to document the percentage of those patients who develop breakdown.
Speaker A:And then our role is to determine was that pressure injury avoidable or unavoidable.
Speaker A:So here's what I want you to take away.
Speaker A:There are many things that may contribute to unavoidable pressure injuries.
Speaker A:End of life status, cutaneous circulation shut down, either because of terminal status or because of vasopressors, are probably major contributing factors.
Speaker A:But pressure is also a contributing factor.
Speaker A:So currently, we have no objective way to distinguish between an unavoidable pressure injury and skin failure.
Speaker A:Currently, the thinking is that skin failure may be a cause of an unavoidable pressure injury.
Speaker A:So what's your responsibility?
Speaker A:Your responsibility is to monitor the incidence of hospital acquired pressure injuries in your setting, to look critically at every hospital acquired pressure injury, and to determine was it avoidable, was it unavoidable to document factors thought to be contributing to any unavoidable pressure injury, and then to stay current, because our guidance is going to continue to change as our body of evidence expands.
Speaker A:So have I confused you enough?
Speaker A:Probably.
Speaker A:We'll just move along.
Speaker A:So let's talk about establishing a comprehensive program for pressure injury prevention.
Speaker A:What does it look like?
Speaker A:So, first of all, we talked a lot in previous classes about establishing a program to monitor happy rates.
Speaker A:Most agencies either do quarterly surveys or monthly surveys.
Speaker A:If you're a magnet, you're required to do that.
Speaker A:A lot of agencies also have a program for ongoing data collection so that all new hapies are reported to the wound care team and they track them month to month so they can look at how their performance is improving, hopefully, or if there are any issues.
Speaker A:Now, when you put together your program, we do have some data from multiple agencies who have been involved in aggressive programs to minimize development of happies.
Speaker A:And what have we found?
Speaker A:First thing we found is that administrative support is critical all the way from the top to the bottom.
Speaker A:So it has to be a priority at the top.
Speaker A:If it's a priority at the top, then there's support for replacement of support surfaces to assure that we're providing our patients with the best protection.
Speaker A:There's support for ongoing staff education, there's support for quarterly surveys.
Speaker A:There's attention to the results of the surveys and you see preventive care showing up as a priority and initiatives from the top down.
Speaker A:If it's a priority at top level management, it's going to be a priority for mid level management, for unit directors or head nurses, and then that message is going to be transmitted to the staff.
Speaker A:So administrative support is critical.
Speaker A:Also very helpful to have a multidisciplinary team because pressure injury prevention is definitely everybody's responsibility.
Speaker A:Physical therapy helps.
Speaker A:Physicians can play a role by talking to patients and encouraging them to participate in therapy programs, to participate in repositioning.
Speaker A:You definitely want the caregivers involved.
Speaker A:So it's not enough to just have the staff nurses educated.
Speaker A:You have to educate your bedside care providers like your CNAs, your nurse techs, or in the home, the home caregivers.
Speaker A:You want dietary nutrition involved because that's a critical element of management.
Speaker A:And it's frequently helpful to have your safety officers involved, your quality improvement team involved.
Speaker A:They are the ones with clout in most agencies.
Speaker A:So if your safety officer says this is a priority, everyone listens.
Speaker A:If your people who are responsible for risk say, we have to improve our preventive program and we have to do whatever that takes.
Speaker A:People listen.
Speaker A:So look at your agency, look at who's responsible for what.
Speaker A:Put together a strong team to address pressure injury prevention from an agency wide perspective.
Speaker A:What's our role as the wound care nurse, as the WFC nurse, or as a team?
Speaker A:Our primary role is to make sure that all policies, procedures and protocols are current and evidence based to educate the staff regarding the importance of pressure injury prevention and the specific specifics of pressure injury prevention, to make sure that there are appropriate prevention products in place and then to validate when the.
Speaker A:When a staff nurse says, I think this Patient has DTI over the sacrum, or I think this patient has a stage one pressure injury to go to the bedside and validate that that's indeed what that patient has, or to correct the classification if it's not a pressure injury.
Speaker A:What about staff nurses?
Speaker A:They are the soldiers in your pressure injury prevention program.
Speaker A:They're the most important people, the bedside care providers.
Speaker A:So you want your staff nurses involved, you want your nurse techs involved, because pressure injury prevention comes down to every caregiver, every shift, turning that patient, floating the heels, managing moisture, encouraging nutritional intake and monitoring skin status.
Speaker A:So you want them to know how important they are, how important their interventions are, and you want to celebrate their successes.
Speaker A:So the essential tools and products, we've talked about this to some extent.
Speaker A:You want to look at all of your policies and procedures that address skin and risk assessment on admission and at routine intervals thereafter.
Speaker A:You want to make sure they're current and clear.
Speaker A:You want to make sure you have an evidence based risk assessment tool.
Speaker A:This is the tool you're going to use to identify patients at risk for pressure injury development.
Speaker A:Now, at this point, across the world, the most widely used risk assessment tool is the Braden Scale.
Speaker A:It has the strongest evidence base, it has the best validity, it's appropriate for children 8 and above and throughout the adult population.
Speaker A:So this is probably a tool you're very familiar with.
Speaker A:But what if you're in a pediatric setting?
Speaker A:What about children under age 8?
Speaker A:What about neonates?
Speaker A:What about infants?
Speaker A:So we have tools that are designed just for those patient populations.
Speaker A:And the most widely used is the Braden Q, which was developed specifically for the pediatric population.
Speaker A:And a recently released updated tool, the Braden qd.
Speaker A:So as you can see, this is intended for neonates and infants.
Speaker A:The difference is in the Braden Q, they added hemodynamic status in the Braden qd.
Speaker A:I think it's an excellent updated tool because the Braden QD includes perfusion status, adds medical devices, which are the most common reason for pressure injury development in neonates, and deletes activity and moisture.
Speaker A:Because when you think about it, all of your neonates are bed bound, none of them are chair bound, none of them are ambulatory.
Speaker A:So that's an irrelevant subscale for that population.
Speaker A:And all of them are incontinent.
Speaker A:So deletion of activity and moisture, the addition of perfusion status and use of medical devices makes a lot of sense.
Speaker A:So if you're in the pediatric setting, you want to look at the Braden qd.
Speaker A:Okay, now let's look at the pressure injury Prevention bundle.
Speaker A:First of all, it should be nurse driven.
Speaker A:What do I mean by that?
Speaker A:In the past, a lot of agencies set up programs that would have you do risk assessment on admission and at routine intervals there.
Speaker A:And then there would be guidance that if the patient scored less than 18, say, on the Braden scale, that the staff nurse should initiate a wound nurse consult, then it was expected that the wound nurse would come and would set up the prevention program.
Speaker A:We have moved way past that.
Speaker A:Staff nurses don't need for us to come and set up a prevention program, and it's a waste of their time and it's a waste of our time to do repetitive things that the staff is responsible for and the staff nurse knows how to do.
Speaker A:So your pressure injury prevention should be staff nurse activated.
Speaker A:And here are the things that must be available to the staff to carry out pressure injury prevention.
Speaker A:We have to have appropriate support surfaces.
Speaker A:So that's your mattresses and your overlays and chair cushions, and they have to be within warranty.
Speaker A:We're going to come back to that and talk about that in detail.
Speaker A:You have to have something to protect the heels.
Speaker A:So you really should have well designed heel offloading boots.
Speaker A:It's not enough for most patients to just have pillows because they'll kick their way off pillows, kick the pillows on the floor, and then their heels are right back on the bed.
Speaker A:So you should have heel offloading boots available to your staff who are doing pressure injury prevention.
Speaker A:You are going to need products that support turning and positioning.
Speaker A:So you're going to need wedges.
Speaker A:You probably need bariatric wedges.
Speaker A:If you have a lot of bariatric patients, heavy patients, you're going to need specific turning systems that are designed to make it much easier to turn a heavy patient.
Speaker A:You probably are going to need overhead lift systems that work with lift sheets.
Speaker A:You're going to need skin protection products.
Speaker A:So that includes your silicone adhesive foam dressings to pad bony prominences.
Speaker A:It includes your moisture management products like moisture barriers and highly absorptive containment products.
Speaker A:Underpads and briefs, if you're using briefs, another key responsibility for you.
Speaker A:So you want to look at your policies and procedures, you want to look at your products, and then you want to make sure that staff is educated appropriately and that you keep staff current.
Speaker A:So you should be very current in pressure injury prevention, and then you should be constantly passing that on.
Speaker A:Now, staff education is usually a joint venture between the wound team.
Speaker A:Anybody you have on staff who's charged with staff education, like the clinical specialist or unit educators, and your vendor representatives, they can be incredibly helpful in providing education related to appropriate product use.
Speaker A:So what are the things staff really needs to know?
Speaker A:Well, first of all, as a staff nurse, I need to be very aware of the significance of hospital acquired pressure injuries.
Speaker A:I need to be aware that they significantly increase morbidity and mortality rates and that they're very painful.
Speaker A:I want to be aware that they convey a very negative message to family members who have typically heard that bedsores mean the patient is not getting appropriate care.
Speaker A:We'll come back later and talk about how important it is to educate the family about everything we're doing to prevent pressure injury development and things they can do to help.
Speaker A:So we want staff to be very tuned in to the importance of pressure injury prevention because you know how busy everyone is, you know how easy it is for preventive care to get lost in the shuffle of critical care delivered every day.
Speaker A:So we have to incorporate it.
Speaker A:It has to be built into our care routines and we have to constantly remind people how important this is, how critically important it is to keep those heels off the bed.
Speaker A:So we frequently say, you do not want to get your patient through a very critical life threatening event only to have them develop osteomyelitis from an avoidable heel pressure injury.
Speaker A:So keep it in everyone's focus and their consciousness on their radar.
Speaker A:You want to teach staff how to do accurate skin assessment, how to do accurate risk assessment?
Speaker A:We'll talk about that.
Speaker A:You want them to be very familiar with the pressure injury prevention bundle, and usually you can bring that down to a pretty short list that you can just repeat over and over and over again.
Speaker A:So they should be on the right surface, they should be on a cushion.
Speaker A:When they're up in the chair, they should be routinely repositioned, heels should be offloaded, moisture should be managed, nutrition should be encouraged, and skin should be assessed.
Speaker A:So it's a pretty short list that you can constantly reiterate until it just becomes part of their consciousness in terms of what needs to be done critically.
Speaker A:Important to emphasize that we've got to do ongoing skin assessments.
Speaker A:So we have a pressure injury prevention bundle in place.
Speaker A:We should be monitoring the effectiveness on an ongoing basis.
Speaker A:Is it working?
Speaker A:Is there any evidence of skin deterioration?
Speaker A:If so, what should I do?
Speaker A:Should I turn them more frequently?
Speaker A:Should I bump them up to a higher level support surface?
Speaker A:Definitely.
Speaker A:I need to let everyone know.
Speaker A:And here we're back to the importance of patient and family education.
Speaker A:So I know that a lot of you have heard family members say things that indicate that they have heard that bed sores mean bad nursing, inadequate nursing care is somebody's fault.
Speaker A:But imagine if when that patient was admitted to your unit, when that patient was admitted to critical care, if in addition to explaining what you're doing to manage cardiac issues, what you're doing to manage their renal failure, if you also said your mom's very high risk to develop what you probably know of as a bed sore, what we call a pressure injury, here are the things we're doing to prevent that.
Speaker A:We have her on this special bed so it evenly distributes the pressure underneath her.
Speaker A:We'll be turning her on a routine basis and it's very helpful if you can encourage her because turning is hard for her.
Speaker A:So if you can encourage her every time, that will be helpful.
Speaker A:We're going to put her in these special heel boots so that her heels are off the bed.
Speaker A:You see, we have this moisture barrier that we're going to use on her bottom to try to keep her from getting into any issues related to urine exposure or stool exposure.
Speaker A:And we're going to be watching her skin very carefully now.
Speaker A:We're going to do everything we can to prevent this, but I cannot guarantee you that she will not develop any issues.
Speaker A:She's very high risk because of her blood pressure, because of what's going on with her heart, because of what's going on with her kidneys, what's going on with her liver, et cetera, et cetera.
Speaker A:If we did that, then right away the family would be very aware that we identified this as an important priority and that we have measures in place.
Speaker A:And then if I saw any deterioration in skin status, if I notified the family, this is what happened, this is what we're doing.
Speaker A:I just wanted to let you know, I think this is probably related to what's going on with her blood pressure.
Speaker A:We're doing everything we can, but we just wanted to keep you informed.
Speaker A:That's what surgeons do.
Speaker A:That's what the medical team does.
Speaker A:They say, this is what we're doing to deal with shock.
Speaker A:This is what we're doing to deal with renal failure.
Speaker A:This is what we're doing to deal with heart failure.
Speaker A:But sometimes things get worse.
Speaker A:Despite preventive measures, it's important for the family to know that we're carrying out those preventive measures.
Speaker A:So I'll share a little story from our setting.
Speaker A:We had a patient who had been in surgery for a very long time.
Speaker A:He had had like, I think an eight hour transplant, very complicated transplant procedure.
Speaker A:And postoperatively the nurses Identified a deep tissue injury on the occiput and they immediately initiated a wound care consult.
Speaker A:When I walked into the room, the family was talking about how they were going to own our hospital and what they were going to name the wound because they were going to sue.
Speaker A:So I assessed the wound.
Speaker A:I spent time talking to them about the fact that his surgery had been approved prolonged procedure.
Speaker A:During that procedure, he had a tube in to protect his airway and to breathe.
Speaker A:For him that turning was not an option when they were doing the transplant.
Speaker A:And so there was this period of time when he could not be moved and that in addition, during the surgery he had had several episodes where his blood pressure dropped.
Speaker A:They were doing everything, they were monitoring, they were giving him fluids, they were giving him medications.
Speaker A:But what I explained to them is it's not that anybody failed to do anything.
Speaker A:This sometimes happens during surgery when it's a very long procedure and when there are issues with blood pressure management.
Speaker A:Our goal now is to keep this from progressing and this is what we're going to do.
Speaker A:So this is what we're going to do in terms of positioning, this is what we're going to do in terms of management and we'll be monitoring.
Speaker A:So we did provide very consistent follow up and the wound did consistently improve.
Speaker A:But they also stopped talking about renaming the hospital.
Speaker A:So education makes a difference.
Speaker A:One thing you have to think about when you're putting together your comprehensive program for pressure injury prevention is your non bedded patient care areas.
Speaker A:So typically we focus heavily on the nursing units.
Speaker A:We talk about risk assessment, we talk about the mattress on the bed, we talk about the cushion in the chair, we talk about offloading heels, turning the patient, et cetera.
Speaker A:But what happens in the emergency department?
Speaker A:What happens in pacu?
Speaker A:What can be done in the operating room?
Speaker A:What about interventional radiology?
Speaker A:What happens when they're gone to dialysis?
Speaker A:So if we're going to provide comprehensive, consistent preventive care, we have to address those areas.
Speaker A:Here are some things that other agencies have done.
Speaker A:If you know that there's a prolonged time in the emergency department while patients await a bed, they're awaiting admission.
Speaker A:Some emergency departments have created two areas, have created the triage and initial intervention area.
Speaker A:And then they've created a pre admit area.
Speaker A:And in the pre admit area, the nurses go ahead and do risk assessment and initiate routine preventive care.
Speaker A:And you also want to look at things like what's on your stretcher, what do the stretcher pads look like?
Speaker A:Are they thin or do they meet the guidelines for a Pressure redistribution surface.
Speaker A:So that's something that should be done throughout your agency.
Speaker A:Your stretchers throughout the agency should have pressure redistribution pads, because, as you know, sometimes patients end up being on those stretchers for prolonged periods of time.
Speaker A:So look at what's happening in the emergency department.
Speaker A:What about pacu?
Speaker A:Do the nurses identify repositioning as a prompt priority and an important priority?
Speaker A:Because early studies suggest that patients who have had prolonged operative procedures, if we change their position as soon as possible when they get to the pacu, we can help reduce the incidence of intraoperative pressure injuries.
Speaker A:So talk to your PACU nurses.
Speaker A:What's being done in the operating room?
Speaker A:Now, the association of Operative Operating Room Nurses, aorn, has done a lot with prevention of intraoperative pressure injuries.
Speaker A:So most of your OR nurses are highly tuned in to careful padding, use of pressure redistribution surfaces, heal offloading, documentation of skin status prior to the surgery, documentation of skin status after the surgery.
Speaker A:But you just want to check with them.
Speaker A:You know, is there anything you can do to help them?
Speaker A:Is there any education that's needed?
Speaker A:Do they need support for upgrading any of their equipment?
Speaker A:Interventional radiology, a lot of it comes down to the stretcher pad and making the staff aware that if the patient's there for a prolonged period of time, if they can reposition the patient, at least slight turns at intervals is very beneficial.
Speaker A:Same thing in dialysis.
Speaker A:Also, go back to when you're doing your root cause analysis.
Speaker A:You want to be very attentive to any time off the unit during the 72 hours preceding recognition of that pressure injury.
Speaker A:So if the patient was off the unit for six hours in interventional radiology, you want to capture that.
Speaker A:And, you know, wound care nurses are doing a variety of inventive things.
Speaker A:So I read one article where if the patient was at risk for pressure injury, they put a pink armband on and that was a signal.
Speaker A:That was a message to the IR staff, to radiology staff, to everyone throughout the agency.
Speaker A:This patient's high risk for pressure injury development.
Speaker A:If there's any way you can position them at any point in time, that would be helpful.
Speaker A:So I wanted to talk just a little bit more about intraoperative pressure injuries.
Speaker A:This has been an area of increased focus in terms of research.
Speaker A:Susie Scott is one of the researchers in this area.
Speaker A:She is a wound care nurse and she's done a lot and trying to identify specific risk factors for intraoperative pressure injuries.
Speaker A:And she's put together a tool known as the Scott triggers tool that is widely used.
Speaker A:The Other tool that is being used is the Monroe Scale.
Speaker A:It's a little bit more complex, it has more factors, and research is ongoing to determine, well, is one of these much better than the other?
Speaker A:Is one recommended as opposed to the other?
Speaker A:But here are the risk factors that have been identified so far and that show up in both tools.
Speaker A:First of all, lengthy operative procedures, because that tells you how long the patient's going to be essentially immobile.
Speaker A:So if it's four hours or more, that's pretty much a predictor that they're more likely to develop an intraoperative pressure injury.
Speaker A:So look at length of the surgery procedure, low albumin or low bmi.
Speaker A:So low BMI is very understandable.
Speaker A:Those are your very cachectic patients who have practically no padding.
Speaker A:And that ties into what we discussed in previous classes about tissue tolerance.
Speaker A:So they're going to have very low tissue tolerance.
Speaker A:They're going to develop pressure damage more rapidly.
Speaker A:Age.
Speaker A:Age is a risk factor in many studies.
Speaker A:So as age increases, so over 70, higher risk, over 80, even higher risk episodes of hypotension.
Speaker A:Because of course, when you're in the OR suite, you're essentially immobile.
Speaker A:And then if you have hypotensive episodes, what is happening to the cutaneous circulation?
Speaker A:You know what happens.
Speaker A:You tend to shunt blood away from the skin and to the vital organs, leaving the skin even more vulnerable.
Speaker A:And then if they are overall sicker.
Speaker A:So your patients who have multiple comorbid conditions, some of the tools you use ASA score as an indicator of overall health status and risk.
Speaker A:What can be done in the operating room to minimize the risk of pressure injury development?
Speaker A:Things we've already talked about.
Speaker A:What kind of pressure redistribution surface do you have on the OR table?
Speaker A:Are we offloading the heels?
Speaker A:A few years ago, 50% of intraoperative pressure injuries were heel injuries.
Speaker A:And those are almost always preventable because we can get the heels off the underlying surface.
Speaker A:Protective dressings have been found to be effective.
Speaker A:So sacral dressings, heel dressings, and then we mentioned early repositioning postoperatively.
Speaker A:So if I've been supine in the operating room, when I get to pacu, if you can turn me to my right side, turn me to my left side, offload the sacrococcygeal area, then I stand a much better chance of recovering without an open wound.
Speaker A:So we've talked about putting together an agency wide program for pressure injury prevention.
Speaker A:Now we're going to talk about providing preventive care to the individual patient.
Speaker A:This obviously is the Bundle that you want to incorporate into your big agency program.
Speaker A:So I'm your patient, you're admitting me.
Speaker A:Your responsibility for protection of my skin begins when I come to your emergency department, to your unit.
Speaker A:Critically important that at the time of admission you do two skin related assessments.
Speaker A:First of all, you want to assess the skin itself to determine any areas of breakdown present on admission.
Speaker A:And secondly, you want to do risk assessment to determine which patients are likely to develop pressure injuries, which patients require supervised consistent pressure injury prevention program.
Speaker A:So the two key elements, head to toe skin assessment and accurate risk assessment, we're going to talk about each of those.
Speaker A:So your first goal is look at my skin, determine do I have any breakdown present on admission?
Speaker A:That's visual inspection of bony prominences.
Speaker A:So you literally have to turn me.
Speaker A:That might require two people to turn me so that you can look at the back of my head, you can look at the shoulders blades, the scapula, you can look at sacral coccygeal area, you can look at heels, look at elbows.
Speaker A:So all of your bony prominences should be inspected at the time of admission.
Speaker A:What if I come in and I have a dressing on the sacrococcygeal area?
Speaker A:You've got to take it off.
Speaker A:You've got to know what's underneath there, right?
Speaker A:Even if I say, oh, that's just for protection, you still have to take it off so you know what's underneath there.
Speaker A:A lot of agencies to underscore the importance of this skin assessment on admission have incorporated or established policies known as it takes two or four eyes.
Speaker A:And what does that mean if my agency requires this?
Speaker A:It means that I have to get a second clinician to come and look at the patient with me and to verify either that there is no breakdown at the time of admission or that there is breakdown over the sacrum or over the right heel or wherever.
Speaker A:Agencies that are doing this are doing it to understand the importance of that skin assessment on admission.
Speaker A:So just like we require a second RN to witness when we discard narcotics or when we hang blood or whatever, because those are critical interventions, the agency is saying to the staff, skin assessment on admission is critical, critically important for us to get this right.
Speaker A:It has care implications, it has legal implications, it has regulatory implications.
Speaker A:We're going to require two clinicians.
Speaker A:So think about that.
Speaker A:Now, when I talk to my staff and we talk about documenting any breakdown that's present on admission, I emphasize that the most critical element of documentation is the location.
Speaker A:If you can at least indicate in the record that there was breakdown on the sacrum.
Speaker A:Even if you call it the wrong thing, even if you stage it incorrectly, there's clear evidence that that breakdown was present on admission.
Speaker A:It will protect the agency and it alerts you to get the wound care team involved.
Speaker A:So location is the most critical element.
Speaker A:Now, ideally, you would also accurately classify the breakdown as being a pressure injury stage two, or that this is incontinence associated dermatitis, or this is entering dermatitis.
Speaker A:But most critical is location.
Speaker A:You're going to have to determine in your agency how you divide the responsibility for documentation of any breakdown present on admission.
Speaker A:In some agencies, the staff nurses responsible for documenting location, determining probable etiology, does this look like moisture related breakdown?
Speaker A:Does this look like a pressure injury?
Speaker A:What?
Speaker A:And for staging any pressure injuries in other agencies, the staff nurse is responsible for documenting the presence of breakdown, the location of breakdown, and notifying the wound care team.
Speaker A:And then the wound care team assumes responsibility for classifying the injury.
Speaker A:Pressure, moisture, friction, whatever, and for staging any pressure injuries.
Speaker A:There's no right or wrong.
Speaker A:You have to determine what's going to work best in your agency.
Speaker A:The critical thing is if it's present on admission, you want to recognize it and you want to document it and you want to make sure that appropriate management is implemented, which usually involves wound care consult.
Speaker A:Now, let's talk about the admission risk assessment.
Speaker A:So, yes, you want to look at skin status.
Speaker A:You also want to determine is this patient at risk for skin breakdown?
Speaker A:And that's the value of structured risk assessment tools.
Speaker A:So that's what we've already talked about.
Speaker A:The Braden Scale, the Braden Q, the Braden qd.
Speaker A:You want to know how your risk assessment tool is structured and you want to know what the cutoff is for risk.
Speaker A:With the Braden Scale, which is the most widely used, the cutoff is 18 or below.
Speaker A:So if your patient scores 18 or below on the Braden Scale, they are considered at risk for pressure injury development.
Speaker A:It's an inverse scale.
Speaker A:So the lower the number, the higher the risk.
Speaker A:If you score 10 on the Braden Scale, you're very high risk.
Speaker A:For pressure injury development, there's increasing emphasis on looking at the subscale score.
Speaker A:And when you're using the Braden Scale, any subscale on which they score less than three, some agencies say three or less, definitely one or two.
Speaker A:That indicates an individual risk factor.
Speaker A:So If I score 2 on the mobility subscale score, you know that I'm immobile, I'm going to require a repositioning program.
Speaker A:I should definitely be on a pressure Redistribution surface.
Speaker A:If I score one on the moisture subscale score, then you know that I have some combination of incontinence and diaphoresis.
Speaker A:And you have to incorporate moisture management in my prevention program.
Speaker A:Now, we've talked about using a structured risk assessment tool.
Speaker A:A lot of agencies augment that structured tool with other criteria.
Speaker A:So they may say if your patient scores less than 18 on the Braden, or if your patient is over age 70, or if they have any indicators of compromised perfusion, such as, and they would list those, implement the pressure injury prevention protocol.
Speaker A:So you can always add things in.
Speaker A:You can augment those structured tools.
Speaker A:And that's exactly what Barbara Braden says in every lecture I've heard from her.
Speaker A:She's like, use this tool to help you.
Speaker A:Don't let it limit you.
Speaker A:So if they come out 19 on the Braden scale, but your gut says it's patients that risk because of their nutritional status, because they have multiple comorbid conditions, whatever, put them on prevention.
Speaker A:Now, probably all of you are very familiar with this Braden risk assessment Scale.
Speaker A:You want to be extremely aware.
Speaker A:You've got to increase your staff nurses understanding of this tool.
Speaker A:Sensory perception is one element of the tool that is frequently misunderstood.
Speaker A:So here what you're trying to capture is any sensory compromise that would limit the individual's ability to recognize and appropriately respond to ischemic discomfort.
Speaker A:So it could be altered level of consciousness or sedation, but it could also be some kind of neurologic condition.
Speaker A:So any of your quadriplegic patients would score a one, Right?
Speaker A:They're very compromised.
Speaker A:They have limited ability to recognize pain over most of the body.
Speaker A:Your paraplegics would score two because they have limited recognition of pain over half of the body.
Speaker A:What about your older patient who may have been diabetic for 10, 20, 30 years?
Speaker A:What's the likelihood that they have neuropathy that would interfere with their recognition of heel discomfort?
Speaker A:Plus there's some age related reduction in the ability to recognize heel discomfort.
Speaker A:So if I have an older patient or a patient with long standing diabetes, probably the best they're going to get from me is a three.
Speaker A:Then you've got mobility, which is pretty straightforward, and activity, which is also pretty straightforward.
Speaker A:So if our patient is say bed bound or chair bound and unable to independently reposition themselves, they definitely need to be on a prevention protocol with repositioning.
Speaker A:What about moisture?
Speaker A:So we're looking not just at incontinence, we're also looking at diaphoresis.
Speaker A:And diaphoresis is probably a bigger issue for many of our patients because we know that wet skin is vulnerable skin.
Speaker A:It's much less resistant to any kind of frictional forces, it's much less resistant to shear, and it's much less able to appropriately redistribute pressure.
Speaker A:So moisture management is critically important for your diaphoretic and or incontinent patient.
Speaker A:Nutrition.
Speaker A:Now, when this tool was developed, it was developed in the 60s and 70s, I think primarily the 60s, and initially it was developed to identify risk among long term care patients.
Speaker A:So these were older patients.
Speaker A:Our knowledge of nutrition and nutrition assessment was at a much different point.
Speaker A:And so when you look at the subscale descriptors on the Braden scale related to nutrition, it's all about nutritional intake.
Speaker A:Barbara Braden would say, look at nutritional intake, but also look at nutritional status.
Speaker A:So even if you have a patient who's getting appropriate amounts of tube feeding, if they're very cachectic, you would score them very low on the nutrition subscale.
Speaker A:So just remember, factor in your clinical judgment and friction in shear.
Speaker A:So is your patient exposed to friction and shear if they cannot move independently?
Speaker A:If we are repositioning them, the answer is yes.
Speaker A:If they tend to slide down in bed, the answer is yes.
Speaker A:If they're restless and scrubbing around in bed, the answer is yes.
Speaker A:If they're contracted, the answer is yes.
Speaker A:So the vast majority of our patients would score low on the friction and shear subscale.
Speaker A:So putting it all together on risk assessment, we should be using an accepted tool for risk assessment.
Speaker A:We should consider other factors that might increase the risk, and you can think how you might want to modify your agency's protocol.
Speaker A:So things that are commonly incorporated as risk factors in addition to those on the standard risk assessment tool.
Speaker A:If I have a history of pressure injury development, that tells you a lot.
Speaker A:If there are any issues with perfusion, if I have episodes of hypotension, if I'm on vasopressors, if I'm diabetic, if I'm febrile, if I have medical devices in use, and if I have general debilitation, multiple comorbid conditions.
Speaker A:So again, use your tool, add in your clinical judgment, and you'll get much better outcomes.
Speaker A:And then here's the most powerful message that you want to communicate to your staff.
Speaker A:Risk assessment is merely a tool to identify the patients who need prevention.
Speaker A:Your responsibility does not end when you total your score.
Speaker A:You have to implement prevention for any at risk patient.
Speaker A:That's what matters.
Speaker A:In some ICUs, they treat all patients as being at risk.
Speaker A:Which is probably accurate.
Speaker A:They might not even do risk assessment.
Speaker A:They just put everyone on a prevention protocol.
Speaker A:Universal precautions for pressure injury prevention.
Speaker A:That's an acceptable approach as well.
Speaker A:So what can you do to make sure that your nurses are doing a really good job in risk assessment?
Speaker A:Obviously it's critical to get it right, because if I underestimate risk, then there are patients who need prevention, who won't get prevention.
Speaker A:And that's actually what we find in the limited studies that have been done to look at accuracy and risk assessment.
Speaker A:They have found that many times staff nurses underestimate risk.
Speaker A:That maybe the patients immobile at present, they're bed bound and they cannot turn themselves.
Speaker A:But the staff nurse is thinking, but yesterday they were up and around and probably tomorrow they'll be up and around.
Speaker A:So they score them higher or we give patients the benefit of the doubt.
Speaker A:So here are the current guidelines that you want to convey to your staff to assure accuracy and risk assessment.
Speaker A:Okay.
Speaker A:You want them to understand the importance.
Speaker A:Importance of risk assessment and of accuracy and risk assessment.
Speaker A:Remember, many nurses have not received any formal education related to Braden Scale and to pressure injury risk assessment.
Speaker A:My introduction to the Braden Scale.
Speaker A:This form appeared on the chart.
Speaker A:This was back in hard copy days.
Speaker A:And so I say to my colleagues, what is this?
Speaker A:And they're like, oh, yeah, yeah, it's a new form.
Speaker A:It doesn't take long.
Speaker A:Just fill it out.
Speaker A:And I'm like, but what's it for?
Speaker A:And they're like, oh, I don't know, really.
Speaker A:Something about pressure ulcers or something.
Speaker A:Just fill it out.
Speaker A:And I'm like, well, are we going to get classes?
Speaker A:Just fill it out.
Speaker A:I'm like, okay, okay.
Speaker A:Well, that's what a lot of nurses have been taught.
Speaker A:Just fill it out.
Speaker A:You have to complete this to go to the next screen in your patient admission.
Speaker A:So fill it out.
Speaker A:But you want them to realize why they're filling it out, why it matters and things they should do to get it right.
Speaker A:So here are the things they should do to get it right.
Speaker A:They should base their assessment on the patient's current status.
Speaker A:Not last shift, not next shift, this shift.
Speaker A:They should use their clinical judgment if they're wavering between a 2 or a 3.
Speaker A:If in doubt, score low.
Speaker A:So if you're not sure if it's a 2 or 3, go with a 2 and use their judgment.
Speaker A:Don't copy over what somebody did last shift.
Speaker A:So I'm going to summarize this section about putting together an agency wide program for pressure injury prevention.
Speaker A:Your goal is 0% avoidable pressure injuries.
Speaker A:The key elements you want to be doing ongoing surveys so you know exactly how well you're perform performing.
Speaker A:You want to make sure that all of your policies, procedures, protocols and products are current and evidence based.
Speaker A:You want to make sure you're keeping your staff educated so that everyone is on board with pressure injury prevention, that everyone knows how to do an accurate skin assessment and everyone knows how to do an accurate risk assessment.
Speaker A:And in the next class, we will talk about the specifics of a pressure injury prevention bundle.
Speaker A:Thank you.
