Preventing hopsital acquired pressure injuries by Megan Maupin

Introduction

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Issue

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What is the problem?

Hospital acquired pressure injuries (HAPIs) are known to slow patients recovery and prolong their hospital stays. According to IHI, nearly 60,000 hospitalized patients in the US are estimated to die each year from complications due to hospital-acquired pressure injuries (2019). "Complications, including
sepsis, osteomyelitis, and poor healing requiring surgical
intervention, contribute to increased lengths of hospital stays" (Bry, Beuscher, & Sandrik, 2012, p. 274). There is a total annual estimated cost of 11 billion dollars to treat pressure injuries within the US (IHI, 2019).

Who is affected?

All individuals admitted for inpatient care are at risk for HAPIs. Surgical and critically ill patients seem to be deemed at a higher risk for developing HAPIs due to immobility (Rondinelli, et al., 2018). All sedentary patients are vulnerable, while the elderly and severely compromised patients whose skin is fragile are also especially at risk (IHI, 2019).

How?

Pressure injuries occur when a patient stays in the same position for too long without shifting their weight to relieve pressure on their bony prominences. It can also occur when the skin is exposed to moisture for to long, or friction/shearing from the bed sheets (IHI, 2019).

When?

During an inpatient hospital stay, anyone can acquire pressure injuries at any time.

Where?

Pressure injuries occur on bony prominence's on the body such as the heels, hips, shoulders, and tail bones. They can also occur in mucus membranes such as the nares when oxygen tubing is in place for too long or in the oral cavity if the patient is on a ventilator (IHI, 2019).

Why?

The patient is bed bound or chair bound while also having many factors contributing such as episodes of incontinence, poor nutrition, medical devices hooked up, etc.

Recommendations to sustain nurse participation

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1. Continual education for nurses and patients

Educating nurses about the importance of using the HAPI bundles, documenting Braden scores for patients each shift, and completing a comprehensive skin assessment every shift are steps that may be taken towards preventing HAPIs. Reminders can be given during huddle between shift changes each day. The HAPI bundles that are in place are known as quality improvement interventions acquired through evidence based practice which lead to better patient outcomes. The bundle includes 4 eyes skin inspection on every admission and transfer, mepilex place on the sacrum of all patients, waffle cushion and heel offloading boots used, stars report placed for pre-existing or new HAPIs, and implementation/documentation of any interventions deemed necessary. Teach the patients and families why these interventions are being implemented and the importance of them.

(Padula, W. V., Mishra, M. K., Makic, M. B. F., Wald, H. L., Campbell, J. D., Nair, K. V., & Valuck, R. J., 2015).

2. Maintaining continuity of care and team work

Prevention of HAPIs occurs with the continuity of care around the clock. Nurses must work together with patients, families and other members of the care team to help maintain skin integrity. This includes repositioning patients frequently and utilizing the devices on the unit to help with pressure redistribution, reducing sheering and friction, and making appropriate consults for PT/OT/other disciplines as needed. This must occur during every shift to maintain the continuity of care. Working together effectively within a team promotes optimal patient healing.

3. Reminder systems

On most units throughout the Sentara system, there are lights outside of the patients rooms that light up, reminding the nurses to round. It would also be beneficial if there was something in the EMR system that reminded nurses when to turn and reposition patients in order to help in the prevention of skin breakdown. There should be an alert fired for the RN, just like the alert that fires for the completion of a sepsis screening. According to recent research, the use of visual reminders or ques has been proven to be effective in the reduction of HAPIs in the acute care setting (Shieh et al., 2018) This may help prevent the lack of participation on the RNs end, if there is any.

By optimizing these recommendations, nurses will continue to positively contribute to the reduction of HAPIs for patients who are admitted to the hospital. They can educate themselves while also educating the patients on the best practices based on research.

Analysis: Importance of the nurse's role

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Nurse's are among the health care providers who are immediately working along the patients side throughout the day. They are the first ones to notice a change in the patients status, or notice the development of a pressure injury the quickest. It is important that nurses are continuing to do their part with the implementation of evidence-based HAPIs reduction techniques. These techniques include:

Turning the patient every two hours to shift weight off pressure points
Making sure they are receiving adequate nutrition
Placing prophylactic foam pads over sacrum and heels

Through the use of these evidence-based practice guidelines, nurses are continuing to provide safe care to patients.

Conclusion

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Clinical Practice Guideline

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Designed by the National Pressure Ulcer Advisory Panel (NPUAP), this document provides evidence-based recommendation for prevention and treatment of HAPIs.

Analysis: Nurse's current roles

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Nurse's are an essential component when it comes to preventing HAPIs in hospitalized patients. Nurse's provide the education needed, while maintaining prevention programs that are classified as best practice through evidence-based research to help maintain skin integrity. Leadership, training, collaboration and relentless focus of making skin care priority are key elements to preventing HAPIs.There are five key components nurses use to preventing pressure injuries including:

Conduct a pressure injury assessment for all patients upon admission
Reassess risk for all patients/inspect the skin of the most at-risk patients daily
Manage moisture
Optimize nutrition/hydration
Minimize pressure

(IHI, 2019).

Literature Review

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Effectiveness of pressure injury prevention in critically ill patients

In a systematic review by Tayyib and Coyer, they discovered that despite the availability of published
prevention strategies that are already in effect, there is little evidence about which strategies can be safely integrated
into routine standard care and have an impact on HAPIs prevention in ICU patients (2016). The objective of this review was to identify the effectiveness of single strategies to reduce incidence compared to no strategies, other strategies or unusual practice. The review included 25 studies, while the meta-analysis revealed a significant effect that the use of silicon foam dressing have in reducing HAPIs incidences in critically ill patients. Other inventions such as the effectiveness of skin risk assessments, nutrition and incontinence did not show much of a different in ICU patients.

Evaluating characteristics of patients who experience HAPIs

In a descriptive study conducted by Bry, et al., a chart review and patient assessment data was collected to identify the characteristics of patients who experience HAPIs as well as their intrinsic and extrinsic risk factors (2012). Eighty-two patients with at least one HAPI incidence that was classified by a wound care nurse were explored. Eighty percent of subjects had six or more risk factors associated with an increased risk for pressure injury development. Their average age was 67.3 years old and males accounted for 58.9% of the subjects. Most patients remained in the hospital for an extended period of time prior to the development of HAPIs. These patients were classifed as high risk for skin breakdown according to the scores that were calculated using the Braden Scale. Intrinsic risk factors included DM, anemia, malnourished, sepsis, and vascular disease to name a few. Extrinsic factors included immobility, incontinence, obesity, and a past history of developing pressure injuries. This research concluded that current risk assessments do not account for patients with multiple organ failure or the effects of multiple co-morbid conditions.

HAPIs impact on the healthcare system and patient outcomes

A retrospective chart analysis was conducted by Brem, et al., to assess the cost related to the treatment of stage IV pressure injuries and their associated complications (2010). This was done by following hospital records and treatments outcomes of 19 patients for 29 months. Of those 19 patients, 11 had hospital acquired pressure injuries and 8 had community acquired pressure injuries. The average cost for hospital treatment associated with the stage IV hospital acquired pressure injuries resulted in $129,248 during one admission, while the hospital treatment for the community acquired pressure injuries resulted in $124,327 over an average of four admissions. "Halting the progression of early stage pressure ulcers has the potential to eradicate enormous pain and suffering, save thousands of lives, and reduce healthcare expenditures by millions
of dollars" (Brem, et al., 2010, p.1).

Reduction in HAPIs using a pink paper reminder system

This study conducted by Shieh, et al., looked at the effectiveness of placing pink paper at the head of patients bed who were at an extremely high risk for skin breakdown to remind the nurse to implement the correct intervention in order to reduce HAPIs (2018). The criteria for the pink paper placement included a Braden score of 12 or greater OR a Braden score of 18 plus any 2 of the following: Age >65, Albumin level <3.0 g/dL, skin at risk: skin that partially blanches, irritant dermatitis, and pressure injuries that are already present. There was a 67% reduction in HAPIs over a 4 year span following the implementation of the pink paper reminder system.

Two Curricular concepts

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1. Skin assessments
During fundamentals nursing, we learned how to complete a skin assessment and how to stage pressure injuries from stage 1 to unstageable. According to the National Pressure Ulcer Advisory Panel (NPUAP), pressures injuries are classified as such:

Stage 1 - Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin.
Stage 2 - Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister.
Stage 3 - Full-thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and epibole are often present. Slough and/or eschar may be visible. The depth of tissue damage varies.
Stage 4- Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer
Deep tissue injury - 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
Unstageable - 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

(2017).

2. Patient advocacy and safety

Many patients who are admitted to the hospital are in a vulnerable state. With that being said, it is the nurses job to advocate for these patients and make sure they are getting the treatment needed to bring them back to a good state of health. During this time, nurses shall also try to prevent other adverse effects that may occur due to hospitalization. The ANA code of ethics provision 3 states that "the nurses promotes, advocated for, and strives to protect the health, safety, and rights of the patient"

(ANA, n.d.).

Leadership role

These two curricular concepts that I have learned during my time at SCOHS have helped in the preparation needed to take on a leadership role as I transition into a RN and began working within the field. Skin is known as the largest external organ on the body and the first line of defense against invading micro organisms. Skin assessments are extremely important and should be done every shift or more frequently depending on the patients illness and health status. Advocating for patients and their safety will always be of highest concern for nurses. We are our patients voice when they are unable to communicate. These concepts will allow me to take leadership and provide competent and safe nursing care to my future patients.

Analysis: Challenges or barriers for nurse's involvement

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Patient refusal - the patient may refuse to be repositioned every two hours, or refuse to wear the protective items we have on the units that relieve pressure on bony prominences that are most susceptible to skin breakdown. This places a great challenge on the nurses to make sure these patients do not develop HAPIs during their hospital stay.
Lack of collaboration - wound care experts, staff nurses and other healthcare providers must work together in order to provide optimal outcomes for the patients. Teamwork allows for a more accurate treatment plan and greater outcomes for patients. If the nurses are not keeping up on their end, the result may end with the development of HAPIs.
Keeping track of quality measures - this provides the information needed to analyze the success of the interventions being used to help with the prevention on HAPIs. When not documented properly or not documented at all, this may lead to the lack of information needed to properly assess how well these intervention are working to meet the quality outcome standards.

(Padula, W. V., et al., 2015).

References

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