While hospital acquired conditions (HACs) have steadily declined, hospital acquired pressure injuries (HAPIs) are rising in the U.S. Angelia Rose, FNP-C, family nurse practitioner of wound care at Hunt Regional Medical Center, isn’t surprised given the challenges her own organization has had in reducing pressure injuries.
“While hospitals have become proficient at reducing HACs, they aren’t always focused on identifying and treating the underlying causes of HAPIs, which have increased even more since the onset of COVID-19.” Still, Rose says the medical center has successfully reduced pressure injuries in the last three years by following pressure injury prevention (PIP) protocols aligned with the new 2019 international guidelines. They include three primary recommendations: prophylactic use of foam dressings, implementing reminder strategies such as wearable patient sensors to increase adherence to repositioning protocols, and preventive skin care. Here, Rose shares challenges along the way and the key steps to a complete turnaround.
Q: What issues did your team have with pressure injuries? Were those issues frequently discussed among hospital leadership?
Rose: When I started three years ago, I saw specific types of pressure injuries. For example, we found that some patients who came in with hip fractures were developing deep tissue injuries on their sacrum or heels in addition to regular pressure injuries that did not appear to be related to their admitting diagnosis. The pressure injuries developed because they were not being repositioned enough. This led to stage-two and stage-three pressure injuries. I met with clinical coordinators, inpatient directors, the director of nursing, and all nurse leadership to discuss solutions. Hospital leaders were also brought in. We determined a need for better protocols aimed at wound care and skin care support, focused education, patient rounding, and new products to reduce pressure injuries.
Q: How were those pressure injury issues addressed in your facility?
Rose: We put in place several protocols for all patients at risk for pressure injuries, starting with wound and skin care education for staff twice a year, as well as nurse rounding every two hours. We also implemented a different skin assessment tool on admission, where in addition to head-to-toe assessment, nurses now do an actual skin integrity assessment, documenting the patient’s BMI, skin appearance, and wound size. A surface support algorithm suggests an appropriate mattress for patients at risk for a pressure injury. We use waffle and air mattresses, along with wedges for positioning the patients more effectively. Finally, we started using prophylactic dressings to prevent pressure injuries, switching to Smith+Nephew ALLEVYN◊ LIFE Foam Dressings. We place the dressings on a patient’s heel, sacrum, and other bony prominences at risk for skin breakdown. We also use the LEAF◊ Patient Monitoring System, which consists of wearable, wireless sternal sensors and visual turn cues that help us ensure we are appropriately repositioning patients.
Q: We’ve talked about the awareness in your hospital; how do you think that compares to other U.S. hospitals?
Rose: Across healthcare, hospital administration, staff, and patients may not realize that HAPIs are drastically rising compared to other HACs. Many are not aware that pressure injuries are a big deal. They know there are protocols in place and that they must reposition patients, but they are usually more focused on the admitting diagnosis and on reducing individual conditions, such as catheter associated UTIs, rather than addressing HACs as a whole. Consequently, HAPIs may fall lower on their radar. At the same time, physicians and nurses require more training on how to assess and diagnose pressure injuries appropriately. Further, with the pandemic, HAPIs are increasing because we are putting patients with COVID-19 in new positions that are unfamiliar to staff.
Q: What are the key principles that hospitals should follow to make pressure injury prevention a top priority?
Rose: Nurse education is critical. Staff need to understand that the skin is the largest organ and that when pressure injuries are not controlled and healed, they can lead to pain and discomfort, other complications, hospital readmissions, and financial burdens. Staff must know how to assess and reposition patients, treat and prevent pressure injuries with offloading, and educate patients and family members. Hospitals should also implement the three key recommendations from the international clinical practice guidelines.
Q: What led your team to use the LEAF System and ALLEVYN LIFE Foam Dressings? And how did those products help with your hospital's pressure injury issues?
Rose: We were looking for new products and did a trial of ALLEVYN LIFE Foam Dressings in 2017. After six weeks, we were impressed and made the switch. We like that the dressings themselves are offloading with good pressure redistribution. Also, they stay on well, minimize pain on removal, and can absorb drainage yet are gentle on skin. The nurses like that they can be removed and put back on without sticking to skin or to itself. The next year, we did a trial of the LEAF System. Within two weeks, the administration was again impressed and wanted to move forward and put the system in all inpatient units. These products have made a serious difference. In one year, we dropped from nine reportable pressure injuries to just one, which we attributed to the patient’s refusal to use the sensor.
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Asset Number: PPME47-23060-1020
“Within two weeks, the administration was again impressed and wanted to move forward and put the system in all inpatient units. These products have made a serious difference.”