PREVENTING PRESSURE ULCERS by Eileen Wilkins for The Wound Centre February 2011

Today I have another wonderful contribution from a lover of all things in wound care, my friend and colleague, Eileen Wilkins. You may know her name already as co-author of my e-book ‘Sharp Clinical Solutions for the prevention and treatment of skin tears’ (which you can download for FREE by clicking here)

This time Eileen’s passion for preventing pressure injury is brilliantly expressed in her paper from the heart…

You can either read the full article below or download the PDF here.

PREVENTING PRESSURE ULCERS 2010

Eileen Wilkins

ABSTRACT

Pressure ulcers, considered a preventable adverse event, continue to be a problem around the world, despite a plethora of instructive literature on prevention. In nearly every wound care journal I read, or at any conference I attend, pressure ulcers are still discussed as a major concern, by clinicians.

Yet preventing pressure ulcers is basic nursing care and it has been since I started my nursing career in 1970, so what are we doing wrong? The risk of pressure ulcer development hasn’t changed over the years so when will we get this right?

Could it be that nursing is now harder and heavier than it ever has been; an occupational health and safety concern when it comes to repositioning patients? Increased longevity, a positive factor in many ways, means that there are many more bedridden frail aged for whom pressure ulcers can be a common, serious and deadly condition. This along with the huge amount of paperwork and computer data entry nurses have to fit into their day means staff are struggling to meet the basic care needs of the patients.

It is clear that we are missing something so we need to get back to basics and rethink risk assessment and protocols for intervention to relegate pressure ulcers to history books.

INTRODUCTION

Pressure ulcers (PU) are a significant burden to all health care systems. Once a deep Stage 4 PU exposing muscle and bone develops, the cost associated with treatment of just one such PU has been estimated at $61,230.00 [1] and legal action as much as $632,500. [2] Patients may be admitted to, or

discharged from, any healthcare facility, with one or more PU [3,4,5,6]. Pressure ulcers result in an increased length of stay [7] increase morbidity and mortality [8] and are very painful, causing suffering for the poor patient.

There have been so many advancements in the prevention of PU so I question why they still occur, especially in this day and age. Should we be seeing any PU at all?

Most hospitals and facilities would have a protocol in place to prevent PU from occurring, along with a risk assessment tool to predict which patients are ‘at risk’ of developing a PU.

The aim of the risk assessment tool is to distinguish risk factors considered associated with the cause and to identify patients ‘at risk’ of a PU [9] then intervene immediately with appropriate equipment to reduce the incidence of these nasty ulcers.

Many numerical assessment tools have been used to assess the patient to determine whether they are ‘at risk;’ the Norton 1962, Waterlow 1962, Braden 1984 just to mention a few, but are they truly evidence-based? [9]

In 1992, Brenda Ramstadius, a clinical nurse consultant in wound care in Australia noticed that nurses were not using the available PU risk assessment tool (Norton) in her hospital, to identify “at risk” patients. Nurses said they found it time consuming evaluating the numerous variables. Ramstadius then designed an assessment tool that reflected pressure ulcer aetiology, which has more clinical relevance and was able to determine “not at risk” status earlier in the assessment process.

In 1996 this brought about a collaborative clinical research study between University academics and nurse clinicians in Australia, comparing the “Ramstadius Tool with the “Waterlow scale” in four nursing homes. [10] The Waterlow scale was chosen as the comparison tool as nurses said they thought it the most suitable for all patients.

In 1999 Annette Hoskins, a senior lecturer at Wollongong University, Australia, decided to conduct further study to assess the validity and reliability of the Ramstadius Pressure Ulcer Risk Assessment Tool, as well as to explore if mobility is the primary factor for PU formation.

This is when I first became excited by the idea that PU could be prevented. I came across an article in the Nursing Times that was asking for hospitals to participate in research comparing tools that predict who was ‘at risk’ of PU. I applied and my hospital Port Macquarie Private, in Port Macquarie, New South Wales, was accepted along with three other hospitals in Australia; Townsville Hospital in Queensland, Queen Elizabeth Hospital in South Australia and Dubbo Base Hospital in New South Wales..

The purpose of the descriptive study was to validate by comparison the recently developed “Ramstadius” PU risk assessment tool with an already existing tool, the “Waterlow” scale and explore the most significant factors in PU formation.

Each hospital was asked to assess 100 patients to see if they were ‘at risk’ of a PU comparing the “Ramstadius Tool” with the “Waterlow” scale. At that time the hospital was not interested in making any changes so they offered no assistance. I did the assessments in my own time mostly at the end of my shifts. I can remember wondering why I had bothered to take the project on, BUT it has actually been one of best projects that I have ever done as it is embedded in my head that if a patient cannot move then it is my job as a nurse to do something about it.

After a few assessments comparing the two tools, it became very clear that the ‘Waterlow’ scale was over predicting as there were too many variables to take into account and it was very time consuming to use. But what I found was that the “Ramstadius” tool was simple and easy to use. It had more clinical relevance and was able to determine “not at risk” status earlier in the assessment process.

Even though that research by Annette Hoskins was never published it changed my life as a nurse. It taught me about ‘best practice;’ improving patient outcomes and since participating in the study I have made a commitment to fight to prevent PU from ever occurring again in my hospital.

WATERLOW RISK ASSESSMENT SCALE

The Waterlow tool was designed for both medical and surgical patients. Risk factors for build/weight for height, continence, skin types, visual risk areas and appetite are categorised and scored from 0-3, sex and age from 1-5. Mobility is categorised into fully mobile, restless/fidgety; apathetic; restricted; inert/traction and chair bound each of which is scored from 1 -5 Special risk medication, can be scored 1 – 8 with more than one risk factor being scored in each subsection. A Score > 10 = the patient is at risk, > 15 = high risk and > 20 = very high risk.

Ramstadius Pressure Ulcer Risk Assessment

This is a non-numerical tool and begins with the assessment of mobility as yes/no. If the patients can reposition themselves independently, such as rolling over in bed and/or are fully mobile, the assessment is complete with the patient classified as not being at-risk of PU. If patients cannot reposition themselves without assistance they are at risk of a PU and guidance is provided for suitable preventative equipment, such as an alternating pressure air mattress (APAM). The Ramstadius tool has the advantage of requiring one factor only to be assessed – mobility and until other risk factors have been tested for positive predictive value, Sharp and McLaws [9] suggest the Ramstadius approach is evidence-based and may be very cost-effective.

If a patient walks into hospital for elective surgery they are not at risk at that moment but as soon as they are anaesthetized they are immediately at risk, because of their immobility, and the intervention should focus on a support surface that will prevent the development of a PU.

Patients that cannot roll from side to side or lift their limbs and pelvis off the bed unassisted are at risk, [11] irrespective of age, of developing a PU. [9]

This risk applies to patients who are bed- or chair-bound, on operating theatre tables, on trolleys in the emergency department, radiology, or whilst being transported in an ambulance, or in a ward or community setting.

Patients who have a disease or disorder which interferes with their ability to reposition or leads to failure of sensation (feeling) or of appreciation of pressure, places them at risk of PU, as they may not reposition in a timely or effective manner. For example: patients with fractured hips peripheral, neuropathy, (diabetes), Parkinson’s disease, Multiple sclerosis, Cerebro-vascular accident (CVA), loss of sensation (spinal injury/spinal anaesthesia) may be at risk if immobile or if their mobility is decreased.

To address these issues and assist members of The Wound Care Association of New South Wales (WCANSW) Inc. a small passionate group got together to write the first State Pressure Ulcer Prevention Guidelines released in 2000; [12]. These Guidelines, revised in 2007 [13] are based on the ‘Ramstadius tool’ along with clinical judgement so that it is easy and simple for clinicians to follow. The WCANSW Inc. Guidelines also advise that the prevention of pressure injury is best achieved by prioritizing management in the following order:

1. Identifying and documenting patients ‘at risk’ of pressure injury immediately on admission to all wards, units, facilities and services.

2. Selecting pressure relieving equipment.

3. Implementing regular repositioning regimes, consistent with the efficacy of the equipment.

4. Assessing ‘risk’ status following any change in the clinical condition of the patient.

The main message is that any patient that cannot change their position, or chooses not to, either knowingly or not, irrespective of age, is ‘at risk’ of developing a PU.

They need to be placed on an APAM immediately unless contraindicated i.e. unstable spinal fractures. When this is the case the medical officer in charge must be consulted.

In 2004 at the Port Macquarie Base Hospital, where I work, we were also seeing too many PU. The “Ramstadius Tool” was implemented to see if it would make a difference. The hospital has been fantastic making sure that APAMs are always available for the patients deemed ‘at risk’ of PU development.

The hospital mattresses were all very basic, a standard single piece of foam covered with a hard plastic which then felt like a hard board or rock. Patients lying on the mattresses for long periods nearly always sustained a PU. Management agreed to replace all the sub standard mattresses. This action has greatly reduced the incidence of PU and thankfully with ongoing education we intend to continue working to improve patient outcomes.

Understanding the pathophysiology of PU development [14] will make the clinician aware of the damage to tissue if a patient has been lying on the floor at home for hours then brought into hospital. The frequent repositioning required to prevent a PU [14] is simply impractical and near impossible to do. Unless carried out every few minutes throughout the 24 hours Sharp and McLaws hypothesise that repositioning can cause ischaemia-reperfusion injury resulting in more damage to tissue and contribute to PU. [14] Clinicians know patients need pressure relief to prevent tissue injury as well as avoiding pulmonary complications. By placing the ‘at risk’ patient on an APAM the pressure is off the clinician as well as the patient.

CONCLUSION

Pressure ulcers are a problem for all health care workers. We know that immobility resulting in unrelieved pressure is the cause of PU development and judicious screening to identify those at risk of developing a PU is the cornerstone of PU prevention.]

So knowing that immobility and unrelieved pressure can cause PU it is clear that policies need to change immediately to reflect this. Patients need to be assessed as soon as they arrive at a hospital or facility and if the patient is found to be ‘at risk’ appropriate equipment supplied immediately. We may still see the odd PU but until we change our practice things will continue to remain the same.

Research is a fundamental part of our nursing practice and is necessary to improve best practice. Wound clinicians may be happy to read and implement guidelines relevant to their practice, but the cold hard facts are that other clinicians not as interested in wound care will not spend time reading long screeds of information they feel is not relevant to their practice.

With nursing workloads increasing assessment tools should be kept easy and simple for compliance to occur. Assessing risk and supplying APAM must be mandatory so that everyone knows their part

Finally as registered nurses we are personally accountable for our practice and actions. We are taught to promote health and healing, and prevent harm and complications so for our patients’ sake we have to keep fighting for best practice to improve patient outcomes; no pressure ulcers!

I would like to acknowledge the assistance of Kate Sharp, Wound Care / Infection Control Consultant. Founder & CEO The Wound Centre, Sydney Australia www.thewoundcentre.com She has happily given of her time to proofread this paper and offer advice.

REFERENCES
1. Young C. What cost a pressure ulcer? Primary Intention 1997; 5(4): 24-25.
2. Dean A. Patient’s hospital care ‘inferior.’ 1994 Sydney Morning Herald;  Thursday August 25th
3. Cullum N. & Clark M. Intrinsic factors associated with pressure sores in elderly people. Journal of Advance Nursing 1992; 17: 427-431
4. Taler G. What do prevalence studies of pressure ulcers in nursing homes really tell us? Journal of the American Geriatrics Society 2002; 50: 773-774
5. Bliss M. & Simini B. When are the seeds of postoperative pressure sores sown? Often during surgery. British Medical Journal 1999; 319(7214): 863-4.
6. Van Marum RJ, Ooms ME, Ribbe MW. & Van Eijk JT. The Dutch pressure sore assessment score or the Norton scale for identifying at-risk nursing home patients? Age and Ageing 2000; 29: 63-68
7. Graves N, Birrell F. & Whitby M. Effect of pressure ulcers on length of hospital stay. Infection Control and Hospital Epidemiology 2005; 26: 293-297
8. Redelings MD, Lee NE and Sorvillo F. Pressure Ulcers: More Lethal Than We Thought? Advances in Skin & Wound Care: September 2005  Volume 18 Issue 7 pp 367-372
9. Sharp CA and McLaws M-L. Estimating the risk of pressure ulcer development: is it truly evidence-based? International Wound Journal December 2006 Volume 3 Issue 4 Page 344 – 353
10. Hoskins A, Ramstadius B, Risk assessment for pressure sores: A Comparison of two tools Primary Intention (Journal of the Australian Wound Management Association) December 1998. 6 (4)  pg 161.
11. Mino, Y, Morimoto S, Okaishi K, Sakurai S, Onishi M, Okuro M, Matsuo A. & Ogihara T. Risk factors for pressure ulcers in bedridden elderly subjects: Importance of turning over in bed and serum albumin level. Geriatrics Gerontology International 2001; 1(1-2): 38–44
12. Ramstadius B, Sharp CA, Carter R & Cavanagh J. Wound Care Association of NSW Inc. 2000 Pressure Ulcer Prevention Guidelines An Expert Consensus Statement www.wcansw.com.au
13. Ramstadius B, Sharp CA, Blanchfield D, Wilkins E, 2007 Pressure Ulcer Prevention Guidelines  (Revised Edition) An Expert Consensus Statement WCANSW.
14   Sharp CA & McLaws M-L. A discourse on pressure ulcer physiology: the implications of repositioning and staging. World Wide Wounds http://www.worldwidewounds.com/2005/october/ Sharp/Discourse-On-Pressure-Ulcer-Physiology.html

Are your mattresses protecting patients against pressure ulcers?

Are your mattresses protecting patients against pressure ulcers?

IF THEY ARE THIS WOULD NEVER HAPPEN!!

This patient was being nursed on an air mattress overlay so why did he develop these huge pressure ulcers on the left hip and foot? They are shockers aren’t they!

I was asked to see him because of the pressure ulcers and told that he was on an ‘air mattress’. He was—but just look at it! A deflated overlay ripple style mattress…but nobody was aware that it was deflated! The motor was face down under the bed and not plugged in….

Who is checking the mattresses when making the beds; not that this mattress will ever prevent pressure ulcers?

On top of the mattress there was a thick, green plastic macintosh, a pillow, a kylie (thick incontinence draw sheet, with quilted padding) and several ‘blueys.’

All these extra layers add to the pressure placed on the tissues sandwiched between the mattress and the bony skeleton, causing tissue ischaemia which results in pressure ulcers.

You only need a sheet between the mattress and the patient; don’t use anything more.

So what should you look for in an alternating pressure air mattress?

• Ask to try before you buy / lease / rent;
• Choose fully automatic; don’t use anything that needs to be ‘set’ by nurses;
• A loud audible alarm in case it is unplugged;
• Cells that deflate to atmospheric pressure at the very least; preferably zero pressure;
• A visible CPR pull at the foot of the bed; not one that is hidden under the mattress at the head of the bed…imagine looking for that in an emergency!!
• Alternating pressure (unless contra-indicated e.g. unstable fracture) every few minutes;
• Wipe-clean cover, impermeable to water and bacteria;
• Side-formers so patients cannot roll off the mattress & land on the floor and/ or get stuck between the edge of the mattress and bed rails. Side-formers will also prevent the edge of the mattress from collapsing when nurses are trying to get the patient in and out of bed. Nurses have been known to really hurt their backs trying to hang on to patients who slip, unexpectedly, off the edge of the bed.

And hey… the mattresses are not expensive… compare the cost of wound dressings for a pressure ulcer and nursing time to care for pressure ulcers once they develop, then talk to the companies about the daily cost to eventually own the mattress.. a rent and buy plan..YOU WILL BE AMAZED!!

Managing the chronic wound environment with Hydration Response Technology; Excerpt from a case study

Mr S. an elderly, obese, gentleman was admitted for assessment and management of bilateral lateral malleolar leg ulcers. The patient’s legs were grossly oedematous with virtually circumferential, severe, bilateral, sloughy, malodorous, maceration of the peri-wound skin. (Figures 1-3)

Fig. 1 Left leg Day 0		Fig. 2 Close-up of Left lateral malleolus

The production of exudates was unrelenting so that dressings and bed linen required at least daily changes and sometimes night changes as well. Dressing change took more than an hour each time to complete, often requiring the assistance of a second nurse.

If a (chronic) wound is to make progress then the barriers to healing need to be identified and addressed. The persistent inflammation that is found in chronic wounds is a consequence of elevated levels of pro-inflammatory cytokines, proteases and neutrophils². This is often accompanied by elevated production of exudate. The high levels of exudate combined with the pro-inflammatory mediators result in a detrimental effect on healing, including wound enlargement and damage to the peri-wound skin such as maceration and excoriation³. It has been suggested that the wound bed preparation (WBP) model may assist in overcoming these barriers to healing when targeted therapeutic measures are initiated¹.

Hydration Response Technology

A recent publication by Evans4 shows how sorbion sachet S utilises the concept of Hydration Response Technology (HRT) and specifically its value in managing infection in a recalcitrant pressure ulcer. Hydration Response Technology was created specifically to meet the challenge of wounds which produce moderate to high levels of exudates.

Clinical performance and related evidence

Hydration Response Technology using sorbion sachet S enables effective wound bed preparation and can lead to a significant reduction of overall treatment costs^4,5,6,7. Efficient management of exudates extends beyond mere absorption and includes,:^{4, 5, 8, 9}

* extended dressing wear time5,6,7 * excellent fluid retention properties5,6,7 * dressing form stability ensuring wound edge protection, * Matrix metalloproteinases (MMP) modulation avoiding extracellular matrix (ECM) degradation, * bacterial sequestration (immobilisation), lowering the bacterial burden, * maintenance of hydro-balance avoiding too wet or too dry interface even under compression * debridement of moist devitalised tissue on the wound surface and improvement in quality of life5,6

Table 1

Read the full article and see more photographs of the progress of this gentleman’s leg ulceration in Sharp C.A. Managing the wound environment with Hydration Response Technology. Wounds UK 2010 Vol 6, No 2 and on the website http://www.sorbion.com/en/clinical-data/

References

1. Schultz GS, Barillo DJ, Mozingo DW, et al. Wound bed preparation and a brief history of TIME. Wound Repair and Regeneration 2004; 1(1):19-32.

2. Wolcott RD, Rhoads DD, Dowd SE. Biofilms and chronic wound inflammation. Journal of Wound Care 2008; 17(8):333-341.

3. Nelson A. Is Exudate a Clinical Problem. In: (Eds.) Cherry, G., Harding, K. Proceedings, Joint Meeting, European Wound Management Association and European Tissue Repair Society. Management of Wound Exudate. London:. Churchill Communications Europe 1997.

4. Evans J. Hydration response technology and managing infection. Journal of Community Nursing 2010; 24(1):15-16.

5. Romanelli M, Dini V, Bertone M. A pilot study evaluating the wound and skin care performances of the Hydration Response Technology dressing: a new concept of debridement. Journal of Wound Technology 2009; 5:1-3.

6. Chadwick P. The use of sorbion sachet S in the treatment of a highly exuding diabetic foot wound. The Diabetic Foot Journal 2008; 11(4):183-186.

7. Cutting KF, Acton C, Beldon P, et al. Clinical evaluation of a new high absorbency dressing. EWMA conference, Lisbon 2008; 14-16 May.

8. Cutting KF. Managing wound exudate using a super-absorbent polymer dressing: a 53-patient clinical evaluation. Journal of Wound Care 2009; 18(5):200-205.

9. Armitage M, Macaskill C. Simplifying the management of complex chronic leg ulcers. Poster presentation – Wounds-UK 2009; Harrogate.

Preventing Pressure Ulcers

6 Great PDF Documents You Can Download Immediately

I have received a wonderful contribution from Sheila Robertson & Barbara Page in Scotland. How generous of them to share this magnificent set of six PDF documents with question and answer sheets, the anatomy of the skin, skin care, emollients and much more…..
Teaching Notes Promoting Healthy Skin
Dermatology Fife Scotland
Answers to emollient questionnaire
Training Support Pack
Skin Integrity Framework for study reflection
Skin integrity case history answers

You may wish to start with the document ‘Promoting Healthy Skin,’ or ‘Promoting Healthy Skin in Older People’ then follow on with the ‘question and answer’ sheets. I found myself going from one to the other and you may too!

You will find the best way to use all the documents as you read them. Unfortunately I am unable to supply the CD mentioned but if you contact Barbara or Sheila directly (their contact details are in the documents) they may be able to help.

This is quite an amazing contribution that I am certain will be truly appreciated by those of you in countries that may have no access to anything like this…FOR FREE!!.

This is what The Wound Centre website www.thewoundcentre.com is all about….sharing information across the world….thank you Sheila and Barbara!!!!

If you would like to share your wound care tips, case studies, education packs, conferences, websites etc. please email me at info@thewoundcentre.com and tell me what you want to share with members in ~ 40 countries.