Pressure injuries and IAD Realistic endpoints

Jan Rice Director

Jan Rice WoundCareServices woundconsultant8@gmail.com

1/06/2015 1 Blenheim May 2015

New guidelines

Available from www.awma.com.au

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www.accreditation.org.au All these standards are related to pressure prevention and wounds

• 2.4 Clinical care

• 2.5 Specialised nursing care needs

• 2.8 Pain management

• 2.9 Palliative care

• 2.10 Nutrition and hydration

• 2.11 Skin Care

• 2.15 Oral and dental care

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Implications of these within accreditation standards??

• Accreditation can be a motivation to review practices

• Reviewing practices often opens our eyes to the obvious

• Stand back and look at what you are doing to prevent pressure injuries

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Definition

• “a localised injury to the skin and/or underlying tissue usually over a bone prominence, as a result of pressure , shear and /or friction, or a combination of these factors ”

- Pan Pacific Clinical Practice Guidelines for the Prevention and

Management of Pressure Injury, Oct 2011

Pressure sores, pressure areas, bedsores, decubitus ulcers = Pressure Injury

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Alternative Definition

• Pressure ulcers are defined as ‘localized areas of tissue necrosis that tend to develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period’(NPUAP,2008)

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So can you influence....

• Soft tissue?

• Bony prominences?

• Hard surface?

• Time?

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Immobility

• Major cause of sustained localised pressure that leads to occlusion of blood vessels and pressure ulcers

• Immobility may result from neurological, physical or cognitive dysfunction or

• Neuropathy, by reducing the awareness or sensitivity to pain or pressure, can be a significant factor leading to skin ischaemia

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How much pressure does it take to close a capillary?

• For cellular damage to occur, pressure must exceed capillary closing pressure which is cited as 12-32 mmHg(Leigh & Bennett,1994)

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Parameters affecting capillary closing pressure

• Capillary closing pressure will vary between patients, depending on vessel structure, presence of good tissue overlying bony prominences, blood pressure and general health. (Burman 1994)

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Pressure injury

95 % of all pressure injuries are preventable (Hibbs 1985)

• Pressure ulcers in Australia: patterns of litigation and risk management issues

• http://www.awma.com.au/journal/library/1104_02.pdf

• Also review this website----http://www.welshwoundnetwork.org/

• www.safetyandquality.gov.au

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Pressure injury

Potential for litigation

• Evidence indicates that patient litigation is increasing

• This seems to be the driving force behind reforms of practice

• Many cases settled out of court

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Pressure injury

• Pressure injuries drain personal emotions and finances, strain healthcare system resources and fuel feelings of guilt and blame (Krasner 1997)

• Consider the prevention strategies as an investment—costs are eventually always cost effective

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So what relationship do you have with the person who holds the purse

strings?

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“I thought I would die from it”

• The video is available for purchase. Orders can be placed by emailing Col Kilmier at col.kilmier@wh.org.au

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“I thought I would die from it” • The interim results were very good and demonstrated a real change in staff

behaviour. They described the toolkit as excellent, powerful, moving, confronting and thought-provoking. A high proportion of staff said they were more vigilant about skin assessment and were focussing on bedside handover and increased sensitivity to patients’ reports of pain. We watched and listened to the section of the DVD containing the stories told by the two patients; they were moving and distressing in the extreme. One of the patients said “I thought I would die from it”, because she was in such pain. The DVD’s greatest value was to trigger behavioural change as a result of the powerful and poignant stories presented. Involving patients in storytelling in a non- blaming way had enormous impact across the organisation in relation to pressure ulcers and raised multidisciplinary awareness of preventative strategies. The DVD also led to improved care after discharge from hospital. Patients discharged after acquiring severe pressure ulcers had an alert placed on their medical records and were issued with an “at risk” card identifying specific strategies required, for example, ensuring appropriate seating is provided - ie comfortable chairs and cushions, when triaged in the Emergency Department.

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Strategy...

• Invite the people who hold the purse strings to a presentation on pressure injuries

• Ask them how they would feel if someone they loved sustained a pressure injury while in care?

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Can you influence these intrinsic factors that are stated to affect tissue

tolerance?

• Nutrition

• Age

• Oxygen delivery

• Temperature

• Cognitive status

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Extrinsic factors affecting tissue

tolerance:

• Moisture

• Friction

• Shear

So what of these can you influence?

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Moisture

• Moisture contributes to tissue degradation by removing the natural protective oils from the skin, making it more friable

• Maceration leads to softening of the connective tissues

• Faecal incontinence is more detrimental than urine

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Skin—without it you die

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Skin—the brick wall of defense

Image --With thanks to Convatec

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Skin care

• Cleanse, pat dry no rubbing

• Apply moisturiser immediately cleansing and once or twice again in a 24hr period

• www.woundsinternational.com/pdf/content_10608.pdf

• Best practice statement for Emollient therapy- www.bdn.org.uk

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Maintaining skin barrier

• The skin assists in fluid homeostasis

• The outer most layer of the epidermis, the stratum corneum provides this protection through an impermeable barrier made up of fatty acids, cholesterol, and ceramides cemented between tight-knit protein-rich cornified cells

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Types of emollient formulations

• Oil-in-Water Emulsions ( Creams)

• Water-in-oil Emulsions ( Ointments)

• Water-free preparations (Fatty Ointments)

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What lipids do the things we put on our skin contain?

• Animal Fats

• Vegetable Oils

o Fixed

o Essential/Volatile

• Mineral Oils

• Synthetic Oils

• Waxes

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What else do emollients contain? • Preservatives

• Antioxidants

• Buffers and pH adjusting agents

• Emulsifying/Viscosity Inducing Agents

• Fragrances

• Humectants

• Colouring

• Sunscreens

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Maintaining skin barrier cont.

• One goal of topical treatments is to restore and maintain the essential functions of the skin barrier

Some suggestions: • Ego 1800 033 706 • Hamilton (08) 82232957 • Dermaveen 1800 818 220 • NutriSynergy 1300 366 833 • Sukin organics 1300 858 898 • Dermeze, Epaderm and other very simple skin hydration

products that contain no preservatives, and non-allergenic agents

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Skin cleansing

Evidence shows that perineal skin cleansing should involve a product whose pH range reflects the acid mantle of healthy skin (pH between 5.4 and 5.9).

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Skin cleansing

• Most people do not require a full body wash daily

• Only pH balanced soaps or cleansers should be used

• Avoid excessive use of exfoliating scrubs, washcloths and brushes

• Some fragrances and antibacterial agents can be irritating

• Avoid washing with very hot water

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Many no-rinse skin cleansers are "pH balanced" in order to ensure that their pH is closer to that of healthy skin. Cleansers emulsify dirt and microorganisms on the skin surface so that they can be easily removed. During cleansing, there is a complex interaction between the cleanser, the moisture skin barrier, and skin pH. No-rinse skin cleansers combine detergents and surfactant ingredients to loosen and remove dirt or irritants; many also contain emollients and/or humectants to restore or preserve optimal barrier function.

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Comfort Shield Barrier Cloths • Pre-moistened, disposable cloths deliver all-

in-one perineal cleansing, moisturizing and deodorizing all while treating and protecting skin with 3% dimethicone.

• One study showed that consistency in using the cloths reduced sacral buttock pressure injuries by 89% ( Clover K, et al. Ost/Wound Managament Dec 2002; 48 (12)

60-7.

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Let’s discuss this case

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IAD--definition

• Incontinence Associated Dermatitis (IAD): inflammation of the skin associated with exposure to leaked urine or stool

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Betadine Surgical Scrub Solution

• BETADINE® Surgical Scrub contains 7.5% povidone-iodine and is a microbicidal sudsing cleanser that promptly kills a broad spectrum of pathogens. It is used for hand hygiene, surgical hand-scrubbing, and topical degerming of patient's skin prior to surgery. (Because Betadine® Surgical Scrub contains detergents this product must be rinsed off.)

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Actions of Betadine

• Lethal to gram-positive and gram-negative bacteria, fungi, protozoa, spores and viruses

• BETADINE antiseptic solution is active against antibiotic-resistant microorganisms

• No resistance to BETADINE antiseptic solution has been observed

• BETADINE antiseptic solution has an immediate onset and prolonged duration of action

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Treating fungal skin infections

• Clotrimazole

The primary mechanism of action of clotrimazole is against the division and growing of fungi. Clotrimazole alters the permeability of the fungal cell wall and inhibits the activity of enzymes within the cell. It specifically inhibits the biosynthesis of ergosterol and other sterols required for cell membrane production. Studies show minimal concentrations of clotrimazole cause leakage of intracellular phosporous compounds into the ambient medium, along with the breakdown of cellular nucleic acids and an accelerated K+ efflux. This leads eventually to the cell’s death. It does not appreciably spread through the user's body, but remains at the point of application

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Conveen Critic barrier cream

• Contains Karaya Powder which has absorbent properties to allow the barrier cream to be used on exuding and moist skin.

• Use the Conveen Easiclens to remove and clean without further trauma

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Protecting skin against the effects of moisture

• Appropriate continence management

• Appropriate barrier creams

• Regular repositioning and good bedding

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Shear

• Mechanical stress parallel to a plane of interest

• This is caused by the interplay of gravity & friction

• It is a distorting force

• This separation of the dermis and epidermis is responsible for 40% of pressure ulcers (McNaughton 2000)

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Protecting skin against shear • Reduce the angle of the bed head when sitting

in bed

• Use good quality sheepskin products

• Flex the knees if able –(split beds)

• Gel boots/Spenco boots

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Friction • Friction is the force related to two surfaces

moving across one another

• Studies have shown that a moist surface causes the friction coefficient to rise, if great enough, will actually lead to adherence of the patient’s skin to the damp surface—so microclimate now needs to be considered

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So know we have some basic information on pressure injuries and

IAD- we really should look at prevention

Use a risk assessment tool

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How often should we assess?

Local policies

Guidelines

Common sense

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Targeting specific areas?

Ideally we look at the entire body but clearly higher risk areas should be

viewed at every intervention

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Common pressure injury location

• More than 95% of all pressure ulcers develop over five classic locations:

1. Sacral/coccygeal area

2. Greater trochanter

3. Ischial tuberosity

4. Heels

5. Lateral malleolus

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Highest pressure points in specific positions

• Supine position=occiput, sacrum and heels

• Sitting position= ischial tuberosities

• Sidelying position= trochanters

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Pathway to necrosis Pressure occludes capillaries

Tissue deprived of oxygen (hypoxia)

Nutrients and metabolic waste begin to accumulate in tissues

Damaged capillaries become more permeable oedema

Perfusion through oedematous tissue hypoxia worsens

Cellular death occurs

More metabolic wastes are released into surrounding tissues

Increased tissue inflammation

Increased cellular death

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Intensity & duration of pressure

• An inverse relationship exists between duration and intensity of pressure causing ischaemia.

• Low intensity pressures over a long period of time can create damage just as high intensity pressure can over a very short period of time. (Husain 1953)

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Pressure injuries

• Tissues can tolerate higher cyclic pressures versus constant pressure (Kosaik 1953)

• Pressure differs in various body positions

• Pressure on the buttocks in the lying position can be as high as 70mmHg

• Pressure on the buttocks in the sitting position can be as high as 300mmHg over the ischial tuberosities

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Vertical pressure • This is the pressure passing down from the

point of contact to underlying bone, and compressing all tissues in between

• It is also the pressure of the bone on the muscle and subcutaneous tissue from within (McClemont’s cone of pressure)

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Tissue Interface Pressure

This is the pressure ‘applied to the epidermis

by the surface that is supporting it’(Burman & O’Dea 1994)

Interface Pressure= Patient weight

Surface area supported

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Limb contractures place more pressure over smaller surface area

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Tendon release with surgery

• Botox is being trialled

with some MS patients

www.wheelessonline.com/image2/bmal11.jpg

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Risk assessment and prevention

“Diagnostic acumen is not measured by the ability to recognise a pressure ulcer once it has developed but the recognition of early signs of potential skin breakdown and prevention of any further breakdown” (Edberg 1973)

• So consider what will YOU be looking for?

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Once the pressure wound has healed…

• The area is always susceptible to further injury—remember this tissue is scar

• Wean the patient up to longer periods of sitting out if sacral or hip wounds

• The first sign of any illness will increase their risk, so perform risk assessment regularly

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What is wrong with this chair?

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Seating support surfaces

The goal in seating a patient is to help maintain a position that is as close to ideal as possible. Ideal is the position the body should be in to be anatomically aligned for muscle balance, to achieve proper alignment of the bones and joints according to their design and to take advantage of the most load –tolerant areas of the body.

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Devices for the heels Gelbo’s

Repose Prevalon

Foam wedges

Heel lift

Spenco

MPO Medical

sheepskin

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Can we prevent these??-what are our end points?

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Answer

• It is my personal opinion that not all pressure related injuries can be avoided...however...

• We should not have stage 3 or stage 4 injuries

• IAD sometimes cannot be prevented but a resident/patient should never have a second episode

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What could be the problems here?

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What were they trying to achieve ?

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What is wrong with this image?

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Is there a problem here?

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Prevention strategies

• Perform risk assessment regularly—particularly when health or environment condition alters

• Feed and hydrate patients/residents well

• Monitor elderly skin very closely for any subtle changes in colour

• Ensure bedding and seating equipment are fully functioning and supporting with no risk of creating excess sweat

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More resources

• www.ewma.org

• www.awma.com.au

• www.npuap.org

• www.worldwidewounds.com

• www.nice.org.uk

• www.woundsinternational.com

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