Hello!
The topic I found that I decided to do is on pressure injuries. This study focuses on preventative and non preventable hospital acquired pressure injuries. This was an interesting topic as I had worked in a nursing home for many years and currently work in home health for pediatric patients. I find no matter what area you work in skin integrity and prevention of pressure ulcers is important and we are constantly checking on the skin of patients. Journal Club Critique Form
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. https://doi-org.ezproxy.fhsu.edu/10.4037/ajcc2019264
I had never given thought to “unavoidable” pressure injuries and think that the concept is really really important. I very much appreciate the authors suggestion of perhaps focusing on “acute skin failure” rather than attributing development of PIs to lack of quality nursing care (Pittman, Beeson, Dillon, Yang, & Cuddigan, 2019). This could change and benefit interventions for the prevention of pressure injuries.
Pressure injury is an issue that touches nearly all nursing specialties. Although there are a multitude of known risk factors, a couple of risk factors that are often missed include low hemoglobin levels along with length of stay for critically ill patients (Ahtiala, Soppi, & Tallgren, 2018). It is good that length of stay was addressed in the article by Pittman, Beeson, Dillon, Yang, & Cuddigan (2019). It is essential that facilities are using evidence based techniques for prevention.
Ahtiala, M., Soppi, E., & Tallgren, M. (2018). Specific risk factors for pressure ulcer development in adult critical care patients – a retrospective cohort study. EWMA Journal, 19(1), 35–42.
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. https://doi-org.ezproxy.fhsu.edu/10.4037/ajcc2019264
Looking into different reasons about hospital acquired pressure injury gives light that there are certain risk factors that will increase the chance of a pt having a pressure injury. This article showed me that pressure injuries can be more complex than I thought. I agree that hospitals need to be using evidence based techniques for prevention.
As nurses we don’t always think about “unavoidable” pressure ulcers but when you think of someone with poor nutritional intake and bony prominences its bound to be a problem. They only information that confused me was the outcome of “almost 60% of the HAPIs were determined to be avoidable and 41% were determined to be unavoidable” equaling 101%. I understand the 60% did state ‘almost’. The researchers could have went a little more in depth with the percentages.
Another risk factor that is interesting to add to future research is the risk of pressure ulcers due to medical treatment either from nasal cannulas, ventilator straps and even compression hose. Compression hose can cause more harm than good even if they’re fitted properly.
Rathore, F. A., Ahmad, F., & Khan, O. J. (2017, October 10). Compression Stockings and Pressure Ulcers: Case Series of a Neglected Issue. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5722637/
I do understand the confusion with the percentages as I also wished they would of went into specifics and if there was a case that maybe didnt fit technically in either criteria and what that entailed. I had seen many times especially in elderly patients that if compression hoses are not put on properly they will cause a lot of harm.
Like you and our peers, I rarely stop to think about non-preventable pressure injuries. I believe that we are quick to assume that the patient has not followed an adequate turn schedule or that there has been neglect in other patient-care areas, like toileting.
After reading your research critique, I came across a different study that states that special consideration of age, severity of illness, comorbidity indexes and the Braden scale are important predictors for HAPIs and non-preventable HAPIs risk. The study lists Laboratory-Based Acute Physiology Score, Version 2 (LAPS2) as a good predictor for illness severity. The study also lists Comorbidity Point Score, Version 2 as a good predictor for comorbidity indexes (Rondinelli, Zuniga, Kipnis, Kawar, Kiu, & Escobar, 2018). The Braden scale predicts risk of pressure injury.
I for one had not heard of the predictors related to comorbidities or illness severity. We rely solely on the Braden scale in our charting system.
I think one of the most important factors that should be considered when discussing HAPIs and non-preventable HAPIs is patient participation. I know that many times we consult wound and skin who provide orders for a skin care, turn schedule, specialty support mattress, and toileting regimen, but many times patients will refuse to partake in one, several, or all of the interventions. This study focused more on patients that were ventilated, chemically sedated, or had other issues limiting movement, but I still believe that desire/motivation can always be a limiting factor. What do you think?
Rondinelli, J., Zuniga, S., Kipnis, P., Kawar, L. N., Liu, V., & Escobar, G. J. (2018). Hospital-Acquired Pressure Injury: Risk-Adjusted Comparisons in an Integrated Healthcare Delivery System. Nursing research, 67(1), 16–25. https://doi.org/10.1097/NNR.0000000000000258
I agree completely, motivation and desire play a huge role for a patient in not only for prevention of pressure sores but also in their overall health. If I have a patient that has no desire to follow the interventions in place or even follow their medication regimen then that is a huge limiting factor. As no matter how hard you try to keep those interventions or have a plan of care really well planned out that having no desire/motivation will ultimately be the down fall of the patients health. I have also never heard of the predictors and it is interesting that there are more ways to asses the pt as the Braden score is the only tool I have used.
This research study was interesting as it evaluated the actual intervention of repositioning patients by utilizing a sensor that was placed on the patients back and recorded position data. Compliance with turning protocols in the intensive care unit is low: however, little is known about the quality of turning, such as turn angle magnitude or depressurization time. A qualified turn was one that reach >20 degree angle and was held for one minute after turning (Pickham, Pihulic, Valdez, Mayer, Duhon, et Larson, 2018). How often do we turn out patient and leave the room? When we return the patient is no longer in that position. When this occurs we have no idea how long that patient actually remained in that position. In this particular study, 555 patients and 27,566 turns were recorded in the data. Compliant time was recorded as 54%, with 39% of observed turns reaching the minimum angle threshold and 38% of patients remaining in place for > 15 minutes (depressurization), (Pickhamd et al, 2018). Looking at the actual data of how effective an actual repositioning was is eye opening. I am sure when the staff repositioned and turned the patient that the staff felt that they were effective with the repositioning of the patient. This study reinforces the need for frequent education on the technique of repositioning a patient and the important role that it plays in preventing pressure injuries.
Reference:
Pickham, D., Pihulic, M., Valdez, A., Mayer, B., Duhon, P., & Larson, B. (2018). Pressure Injury Prevention Practices in the Intensive Care Unit: Real-world Data Captured by a Wearable Patient Sensor. Wounds : a compendium of clinical research and practice, 30(8), 229–234.
This is something I never thought of. I agree that usually if you try to turn the patient on a schedule that you automatically assume they will stay that way until it is time to turn them again. Seeing that the compliant percentage was only 54% is crazy! I never would of thought of it being that low.
Skin integrity is extremely important. Preventing pressure ulcers is sometimes unavoidable. Depending on what chronic illnesses a patient has, pressure ulcers may happen more frequently. An article that I found discusses using telemedicine to manage chronic pressure ulcers. The issue that they found was that they only had a 2D video of the wound versus being able to see the whole wound in 3D. They also found that they would need a caregiver to be the one using the telemedicine video to examine the wound. What do you think about using telemedicine for management of chronic wounds?
Pak, C., Jeon, J. I., Kim, H., Kim, J., Park, S., Ahn, K.-H., … Heo, C. Y. (2018). A smartphone-based teleconsultation system for the management of chronic pressure injuries. Wound Repair and Regeneration, 26. doi: 10.1111/wrr.2
I think telemedicine can be a great tool if your not able to go in person for every once in a while but in my opinion I think going in person to manage the wound is important. Maybe mixing telemedicine visits with in person would work if the nurse is not able to go all the time. Although, I agree that if you only do telemedicine visits you are not able to fully asses the wound and this could lead to the wound getting worse or not catching an infection early.
It is sad that as a patient is already in the hospital for possibly something other than a sore that we have to really manage something else that could happen. Often I do feel as nurses we do forget the “unavoidable” pressure ulcers. I found this article that I do feel goes with your pressure ulcers. It goes into details about the intrinsic and the extrinsic factors of a patient. Some examples of intrinsic are: diabetes, malnutrition, or smoking. While some extrinsic factors are: lying on hard surfaces, nursing homes, or poor skin hygiene (Boyko et al., 2018.) These both are going to be able to help us diagnose a patient if we feel they are at a higher risk for getting a pressure ulcer.
Boyko, T. V., Longaker, M. T., & Yang, G. P. (2018, February 1). Review of the Current Management of Pressure Ulcers. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5792240/
This article definitely brought into light that their may be unavoidable pressure ulcers. I never though of a pressure injury as unavoidable as usually you think that some intervention was not done properly. This article helped in showing the importance of knowing risk factors that may inevitably cause a pressure injury so you can try to prevent, monitor more closely for one to form and to also treat as early as possible.
This is a very interesting article and important to patient care in all areas. It is hard to believe that almost 60% of the HAPI’s were determined to be unavoidable! That is a very large amount of patients. However, the amount of people with comorbidities keeps increasing and it seems like nurse patient ratios also keep increasing. There are many times when nurses have too many patients and it just isn’t possible to rotate a patient’s position as often as one would like. Also due to injuries, sometimes you are very limited to what positions you can do with a patient. Thank you for the great information!