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Considering the evidence for pressure injuries. Andrew Jull Associate Professor, UoA Nurse Advisor, Quality, ADHB. What goes in a change package. Bundle acronyms often insufficient for identifying interventions SSKIN (Scottish change package) Surface selection Skin inspection Keep moving - PowerPoint PPT Presentation
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Considering the evidence for pressure injuries
Andrew JullAssociate Professor, UoA
Nurse Advisor, Quality, ADHB
What goes in a change package
Bundle acronyms often insufficient for identifying interventions
SSKIN (Scottish change package) Surface selection Skin inspection Keep moving Incontinence Nutrition
What surfaces and when?
Guidelines
High level summaries Information quality
assessed Recommendations graded
by quality of evidence A, B, C, D, CBR Practice points (consensus)
Surface selection when at risk
At Risk of PI
Use a high specification reactive (constant low pressure) support foam mattress on beds and trolleys for patients at risk of pressure injuries.
Graded A
At high risk of PI
Active (alternating pressure) support mattresses could be used as an alternative in patients at high risk of pressure injuries.
Graded A
Evidence sourced from Cochrane review
Using imperfect information
Trials of both devices compared to standard hospital mattresses
Trials recruited patients at high risk of PI to both devices
Interpretation and consensus needed Use less expensive device with lower risk More expensive device with higher risk
Evidence gap High spec foam vs AP mattress
RCT of alternating pressure overlay vs high spec foam mattress (and Q4 turning) Not included in GL Unfair comparison? Repositioning in one
group but not in the other. Or does it model clinical practice?
Surface selection if has PI
Manage patients with existing pressure injuries on a high specification reactive (constant low pressure) or active alternating pressure) support surface on beds and trolleys and when seated.
Grade A
Evidence drawn from same source as when patient at risk or higher (not patients with PI)If patient has PI are they not at high risk and thus above recommendation soemwhat inconsistent with previous recommendation?
Limitations of guideline
Data source systematic reviews or previous guidelines Currency of evidence
Missed RCTs of recent evidence Heel off-loading devices
Curious re-interpretations Honey
Heel off-loading devices (HOLD)
Any device used to prevent heel pressure injuries should be selected and fitted appropriately to ensure pressure is adequately offloaded.
Graded CBR (consensus-based recommendation)
Missed reasonable quality RCT that showed 19% reduction in all PIs when HOLD used in addition to pressure-redistributing surfaces
Donnelly J et al. J Wound Care 2011;20:309-18.
Honey as wound dressing
Systematic review found one trial comparing honey to saline dressings
Review finding The effect of honey on pressure ulcers
cannot be determined from the single trial
Guideline recommendation Consider using topical medical grade honey
to promote healing in pressure injuriesGrade D
Jull A, et al. Cochrane Database Sys Rev 2008.
Systematic reviews
Cochrane database the best source of SRs Access free via
www.nzgg.org.nz
Other SRs published
Require own quality check
Quick quality assessment
Does it have an objective Does it use exhaustive searches Does it quality assess studies Does it use processes to reduce bias
More than one person checking processes Does it assess publication bias
Positive studies more likely to be published
Sheepskins
“Medical grade” sheepskin Four RCTs
Incidence halved in sheepskin group No cost-effectiveness information
If evidence accepted, questionable whether feasible in acute care setting May be more feasible in residential care
setting?
AP Mattress vs AP overlay
Large high quality RCT & cost-effectiveness study No difference in incidence of Grade≥2 PI Small difference in number requesting
change in device (19% vs 23%)
Mattresses more cost-effective due to longer time to development of PI 10.6 days longer to develop PI
Individual studies Type of study important
Privilege RCT over other designs
Require own quality check Tools available
CEBM-type CAT (http://www.cebm.net/?o=1216)
GATE (http://www.fmhs.auckland.ac.nz/soph/depts/epi/epiq/ebp.aspx)
Risk assessment using Waterlow scale and skin inspection. Document.
Start turning regimen & document frequency
At riskAt very
high riskAt high
risk
Pressure ulcer present?
Grade pressure ulcer, document in clinical record &
report on Risk Pro
Turn 2 hourly at a minimum. Document.
Is patient independently
mobile?
Reassess Waterlow score daily and following changes in clinical
condition or after significant clinical procedures. Document. Educate patient/family/whanau about necessity of prevention
strategies e.g. turning
If on a standard hospital mattress, consider high
specification foam mattress in consultation with Charge
Nurse (or delegate) or Clinical Nurse Advisor (after hours).
Document rationale.
Has malnutrition screening tool (CR 6647)
been completed?
Complete malnutrition screening tool (CR 6647) and initiate appropriate action from
nutrition management guidelines with screening tool.
Document.
If pressure damage continues to deteriorate
despite high specification foam mattress and minimum of 2 hourly turning, consider alternating pressure mattress in consultation with Charge
Nurse (or delegate) or Clinical Nurse Advisor (after hours).
Document rationale.
Yes
No
Yes
No
No
Yes
Is the patient incontinent?
Initiate continence management as per Urinary
Function Changes RBP
Yes
No
Follow nutrition management guidelines as per screening tool (CR 6647). Document.