The article I choose is from the American Journal of Critical Care and is titled Hospital-Acquired Pressure Injuries in Critical and Progressive Care: Avoidable Versus Unavailable. The purpose of the study was to determine the proportion of Hospital Acquired Patients Injuries among patients in critical and progressive care units that are unavoidable, and to identify risk factors that differentiate avoidable from unavoidable. The findings found that almost 60% of the HAPIs were determined to avoidable and 41% were determined to be unavoidable. Most HAPIs were deep tissue pressure injuries (61%) followed by stage 2 and unstageable. Medical devices accounted for 36% of HAPIs. Almost 79% of the participants were receiving mechanical ventilation. Participants who were chemically sedated, had a systolic blood pressure below 90mm Hg, and received at least 1 vasopressor were less likely to have an unavoidable HAPI. Bowel management devices, and participants who had previous pressure injury were times more likely to have an unavoidable HAPI. This study is relevant to my practice because I work in an ICU. Regardless of turning the patient every 2 hours patients still can get pressure ulcers. Many times, my patients are on a ventilator and have lots of tubes/lines and are on multiple vasopressors. Advances in medicine have enabled critically ill patients to survive situations that in the past led to death. The article also talked about acute skin failure as being more aligned with these types of injuries caused by medical devices rather than pressure injury caused from not turning the patient. I think this would be a more accurate definition of these types of tissue injuries. This may also help with Medicare and Medicaid when it comes to reimbursement. Unavoidable HAPIs develop despite consistent documentation of evidence-based preventive interventions.
Pittman, J., Beeson, T., Dillon, J., Yang, Z., & Cuddigan, J. (2019). Hospital-Acquired Pressure Injuries in Critical and Progressive Care: Avoidable Versus Unavoidable. American Journal of Critical Care, 28(5), 338–350. doi: 10.4037/ajcc2019264
It is critical that patients be monitored for skin breakdown as often as possible. A full skin assessment should be done at least once per shift for a bedbound/immobile patient. Turning every two hours, while the standard for best practice, truly is not enough. Especially in patients with wires and tubes resting on them creating pressure in uncommon areas. One way that hospitals are trying to assist with less pressure ulcers is the use of the air mattresses. The air mattresses allow for air to be circulated to keep the the coccyx from resting on the hard surface of the bed. You bring up very valid points thought that there is still the potential for breakdown no matter how much we as nurses do to prevent them.
Dvorak, P., Dufrene, R., Dufrene, R., Newmarker, C., & Newmarker, C. (2015, December 21). Engineering the evolution of wound-care air mattresses. Retrieved from https://www.medicaldesignandoutsourcing.com/engineering-evolution-wound-care-air-mattresses/
I agree that just turning the patient every two hours is not enough. Air mattresses are great for assistance in pressure ulcers. I work in a very large hospital and many times when we are need of a specialty air mattress we have to order it from a company called Hillrom. Often we wait days to get one due the lack of supply that the company has. It would be nice if the hospital supplied these beds so we wouldn’t have to wait so long.
In ICU and Critical Care settings, there are a lot of different devices, wires, cords, etc. that are in direct contact with the patient. I don’t think that we think about all of these things affecting the integrity of our patients’ skin, but it is an important factor when caring for patients. Also, proper education is important for staff caring for patients. “unless nursing staff are educated on current practices and have the skills and training to prevent pressure ulcers from occurring then they will continue to develop and cause interruption and concerns to patients and our healthcare system’ (Gill, 2015). There are many different skin assessments available for hospitals to incorporate as part of their patient assessment. With proper education and assessments, I think that the number of pressure ulcers can be greatly reduce. Reducing the number of pressure ulcers benefits both the patient and the hospital.
Reference
Gill, E. C. (2015, January 1). Reducing hospital acquired pressure ulcers in intensive care. Retrieved from https://bmjopenquality.bmj.com/content/4/1/u205599.w3015
Education is definitely important in pressure ulcer prevention. Even with the basic skin assessment tools I feel like there can always be room for more education and awareness. In ICU there are so many lines and devices that can cause skin breakdown and nurses aren’t properly educated on different methods to help prevent breakdown from these. Many times they are just focused on coccyx pressure ulcers and forget that lines laying on the patients skin can also cause breakdown.
In practicing for 12 years, I have found that we as nurses often forget the most basic interventions required for pressure ulcer prevention. In a systematic review and meta-analysis, researchers found that nurses, including nursing assistants, and nursing students possess insufficient levels of knowledge on basic pressure ulcer prevention in the specific areas of nutrition and preventative measures which can be utilized to decrease shear and pressure. The study concluded that nurses and nursing students failed to possess adequate knowledge on turning and repositioning, methods to do so to prevent shear as well as the common areas for the development of pressure ulcers (Dalvand et al., 2018).
I noted that you stated that turning and repositioning alone is not enough, and I could not agree with you more. There are many therapeutic support surfaces available; however, I have often found that they are misused due to an information deficit. Skin assessments are critical and so is monitoring lab values for nutritional status.
Dalvand, S., Ebadi, A., & Gheshlagh, R.G. (2018). Nurses’ knowledge on pressure injury prevention: A systematic review and meta-analysis based on the Pressure Ulcer Knowledge Assessment Tool. Clinical, Cosmetic and Investigational Dermatology, 11, 613-620.
You bring up a great point on the importance of assessing nutrition status as being a risk for skin breakdown. I don’t think people realize that malnutrition is also associated with an increased risk for pressure ulcers. Inadequate nutrient intake and low body weight are associated with slow and nonhealing wounds. Many times we put down nasogastric tubes to help provide nutrition by using tube feeding to help with nutrition in our sick patients, however it is still not as good as taking in oral wholesome foods.
Hi there. I read an article about medical devices and the related pressure ulcers that can be caused from them in the ICU patient, as well as the recovery patient. The article gave practice interventions to prevent MDRPU. It talks about the assessment and evaluations of the purpose and function as well as following manufacturing guidelines to prevent unintentional injuries from medical devices. It also talks about making sure the device is fit correctly to the patient, and protecting the patient with silicone, hydrocolloid, or foam dressings from pressure. It also talks about skin shift assessments, edema, and the importance of re-positioning the medical device to reduce pressure for long periods of time (Flynn Makic, 2015).
Flynn Makic, Mary Beth. (2015). Medical device-related pressure ulcers and intensive care patients. Journal of PeriAnesthesia Nursing, 30(4), 336-337.
There are many factors that put patients at risk for MDR pressure injuries. Often, medical devices must be secured tightly to ensure a proper seal, which creates pressure in areas other than bony prominences. We use Bordered Foam a lot in my unit to help prevent skin breakdown from medical devices. I’m not as familiar with silicone, hydrocolloid dressings. We have a wound and skin team that uses all kinds of special dressings when we consult them. Edema may increase, causing a tube that was fitted appropriately at first to become too tight over time. This leads to undue pressure.the materials used to secure the device, such as tape or straps, may make it difficult to inspect the skin underneath. This is why we need to be assessing skin more frequently than once a shift.
Great article! Scary to think 60% is avoidable! I genuinely think that RNs have a good heart and attempt to protect the patient. I have worked with some lazy nurses – but I like to think the majority of us are good hearted. I know there are several care bundles and EBP practice enforced to attempt to protect patients from VAP, pressure ulcers, and falls. Are bundles enough? Nurses are human. Our staffing ratios are crazy – you may have a hard assignment with demanding sick patients. You monitor several drips, events, and get unstable new admission. Beds have been created to help and automatically turn the patient. Cords are everywhere and no matter how much you prevent it – patient sink in bed and get tangled. We can use foam dressings, frequent skin assessments, lotions, pillows, and manual/automatic turning. It is important also talks about making sure the device is fit correctly to the patient. Frequent education the matters is good – I think it secretly puts in your mind and makes you aware of it. It’s easy to get caught up in things.
Elliot R, McKinley S, Fox V. Quality improvement program to reduce the prevalence of pressure ulcers in an intensive care unit. Am J Crit Care 2008.
You must work in an ICU?! You are right, we are human and can only do so much! I agree I think most nurses are good hearted people and try to their best with what the have available and then you do have the lazy ones who just don’t care. Bundles are not enough. Staffing ratios make it hard to be able to turn your patient due to no being able to find someone to help cause the are busy as well. In ICU our patients are so sick and you can be so busy just trying to keep hem alive that you don’t have time to be worrying about lines and devices causing pressure ulcers. There are so many factors that account for pressure ulcers and staffing I think plays a big role. If you are staffed well you will have more help to prevent pressure ulcers cause by medical devices.
I think an important thing to really investigate regarding ICU patients and skin breakdown is nurse staffing. Should patients be turned every two hours? Of course! Does it happen? Very rarely is this possible 100% of the time, at least in the hospitals I have worked in. Even if staffing ratios are decent with one nurse to two ICU patients, the size of the patients, availability of ancillary help, and acuity of the unit should be taken into account.
As America becomes unhealthier in general, it is common to have many patients who are 350 pounds or larger. If these patients are sedated on ventilators and reliant on the nursing staff for their every need, it could take two or more nurses to safely turn that patient, especially if there are a lot of lines or machines. If the patient is having frequent loose stools or any other kind of mess, it may take more than 4 people just to clean the patient up, wash, and change linen. I personally find it very hard to find one nurse that is available to help me do something every two hours, let alone a whole team of nurses every two hours. They are busy with their own patients, especially if there are patient who are very unstable. Most ICUs do not have aides or techs to help either. I know there are many days when I just feel helpless because I know what needs to be done, but there is no help and I don’t want to get hurt either. I just try to do the best I can and put the bed in rotation mode until I can get some assistance.
In a study, 55-98% of nurses reported missing one or more items of required nursing care, with ambulation, mouth care, or turns being the most commonly missed pieces of care (US Department of Health and Human Services, 2019). Factors associated with an individual nurse (perhaps laziness or lack of education, as previous posters have mentioned) have not been proven to be associated with missed care. However, organizational factors such as teamwork, resource adequacy, and patient safety climate are more likely culprits in care getting missed. Units with better staffing appear to have lower rates of missed nursing care (US Department of Health and Human Services, 2019).
US Department of Health and Human Services . (2019, September). Missed nursing care. Retrieved February 29, 2020, from https://psnet.ahrq.gov/primer/missed-nursing-care
Yes staffing ratios play such a big part in patient care. Our society seems to just be getting more obese and a lot of times we need multiple people to help turn the patient. It is hard enough to find one person to turn a patient as it is cause we are so short staffed and everyone else is busy as well. The people who sit behind the desk and like to dictate that we need to do this or that we didn’t do that have no concept of what really goes on at the bedside. I think they need to spend a day with a nurse and see just how hard it is sometimes to implement these things when you don’t have the staff to do it.
Pressure injuries were something we were just talking about the other day at work. There had been an increase in pressure injuries with patients on bi-pap from the mask. The unit got creative and found special pillows that fit under the mask and they haven’t had one since. Device related HAPI are not something that I had to think about in the outpatient sitting, but I can see the potential for all sorts of pressure injuries, especially in the ICU where there are so many devices to worry about.
I would like to know more about these special pillows that you have used. We use bordered foam and cut them in pieces to fit the face to help prevent skin breakdown from the mask. We tend to get creative as well with what we have to help prevent skin breakdown. Even the tape we use to help hold the ET tubes in place cause breakdown. I know in the burn unit they rig the ET tube with string to help hold it in place when the patient has burns to the face.
I don’t work in the ICU but occasionally float there to care for their less critical patients. I do see pressure injuries in patients in rehab we are really pushing to have zero acquired on our unit. We are now requiring two nurses to perform complete skin assessments within 2 hours of admission because some patients were coming with injuries that hadn’t been documented until a day later. By that time it appeared that they had gotten the pressure injury our unit. We are taking the prevention of pressure injuries more seriously now and are making excellent use of our wound nurse as our skin expert. She is providing us with ongoing education as part of her own education process. As I was looking at research on this topic I found a study indicating that general staff knowledge is lacking as the studied staff only got 70% of pressure injury questions correct in a survey of their knowledge. In examining their attitudes toward the topic, over 10% of the staff didn’t view pressure injury prevention as important in their practice. I wonder how many people are seeking out continuing education units on this topic. I know I became conscious of a knowledge deficit as I read your posting.
Kaddourahl, B., Abu-Shaheen, A.K., & Al-Tannir, M. (2016). Knowledge and attitudes of health professionals toward pressure ulcers at a rehabilitation hospital: A cross-sectional study. BMC Nursing, 15(1). doi:10.1186/s12912-016-0138-6