The issue that I identified as a healthcare safety topic currently impacting nursing is pressure ulcers. A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. I chose this topic for my paper because as a future nurse I would like to be able to prevent any new injuries, such as pressure ulcers, to the patient. Pressure ulcers cause great pain and lead to serious infections which can increase the length of stay at the hospital.They are costly and require many more supplies that would otherwise not be needed if nurses better prevented the occurrence of pressure ulcers by implementing “best practice” guidelines identified by IHI (Institute for Healthcare Improvement).
There are six essential elements of pressure ulcer prevention identified by IHI. The first element is to conduct a pressure ulcer assessment for all patients. The assessment should evaluate the risk for developing a pressure ulcer and detect existing pressure ulcers. In the US, the Braden Scale is the most widely utilized assessment tool.Many patients are at risk for developing pressure ulcers.
Key factors contributing to the development include: immobility, incontinence, inadequate nutrition, sensory deficiency, device-related pressure, circulatory abnormalities and dehydration. Nurses need to complete a pressure ulcer assessment as soon as possible prior to admission and document any risks for or any detected pressure ulcers so that all healthcare professionals can be aware and take precautions. The second element for implementing best practice is to reassess risk for all patients daily.Assessing patients daily will help the caregiver adjust any prevention strategies based on the changing needs of the patient.
For example, changes in mobility, incontinence, or nutrition may change the patient’s risk of developing pressure ulcers. Healthcare providers are rapidly trying to discover new ways to make daily assessments more efficient and to help nurses not over look the possible risk of developing pressure ulcers. A recent nursing journal noted that an NHS trust supplied nurses with pocket-sized mirrors to insure that at risk patients’ heels were inspected properly.Along with the mirrors nurses were required to document heel inspection during each shift and they were to remove anti-embolic stockings daily. These simple acts of using a mirror to better inspect pressure ulcers on heels and removing the anti-embolic stockings cut the incidence of pressure ulcers by more than 50% (Nursing Standard, 2012).
This is clearly an example of basic nursing care that should always be implemented because it is a quick act that does not require much of the nurse.The first two essential elements of pressure ulcer prevention discussed above are used more for when assessing at risk patients, the next four elements that will be discussed are implemented for the patients that are identified as being at risk for pressure ulcers. Inspecting the skin daily is the third element for implementing best practice. Skin is prone to breakdown in a matter of hours in the hospital due to rapidly changing risk factors in acutely ill patients. Caregivers need to assess patients who already have pressure ulcers or who are at risk for them daily.Patients at risk for pressure ulcers should have the areas of the body that are at high risk vigorously inspected.
These areas include the sacrum, back, buttocks, heels, elbows, and areas subjected to device-related pressure. Patients that already have pressure ulcers should have the wounds inspected daily to make sure that it is healing and that no infection has occurred. Assessing the skin can occur at anytime while assisting the patient, for example, when helping the patient move from the bed to the chair, while bathing, and when repositioning devices such as oxygen tubing, IV lines, etc.Any finding must immediately be documented, treated as needed and other healthcare providers must be notified. The fourth element for implementing best practice is to manage moisture by keeping the patient dry and moisturizing their skin. Action should be taken when patients’ skin is over moisturized due to incontinence, perspiration, or wound drainage.
These can all lead to the development of rashes and softer skin that breaks down more easily; therefore, the skin should be cleansed daily at times of soiling and bathing. To prevent dryness of the skin, the skin should be cleaned with a mild cleansing agent that minimizes irritation.In cases of treating skin that is already dry, caregivers should use moisturizers to prevent pressure ulcers. Healthcare providers should look for opportunities to integrate periodic activities such as offering toileting, if allowed for the patient, to be able to assess the skin throughout their shifts.
The fifth element for implementing best practice is optimizing nutrition and hydration. This is very important because adequate nutrition and hydration prevent muscle mass loss and weight loss. If this occurs, then the bones become more prominent making it harder for patients to be mobile which will increase the risk for pressure ulcers.If nutrition and hydration is inadequate, a registered dietician should be consulted to assess and suggest nutritional interventions.
Nurses can help prevent this with basic care such as assisting patients with meals and offering water periodically throughout their shift. The sixth and final element for implementing best practice is minimizing pressure. Redistribution of pressure is of primary concern especially over bony prominences. Efforts should be made to redistribute pressure on the skin either by repositioning or by utilizing pressure-redistribution surfaces.
Turning/repositioning patients every two hours temporarily shifts or relieves the pressure on the susceptible areas, diminishing the risk of pressure ulcer development. Another easy way to redistribute pressure is to utilized readily available supplies such as pillows and blankets. You can place these under the calves or in between the legs to keep the body in alignment and to alleviate pressure on bony prominences. Nurses can also use pressure-redistribution surfaces which are specialized support surfaces such as mattresses, beds, and cushions that redistribute the pressure that the patient’s body weight puts on the skin.Pressure-redistribution surfaces can be classified as powered or non-powered, reactive or active.
A powered support surface is one that requires external sources of energy for operation. A non-powered support surface on the other hand, does not require external energy sources for operation. Reactive support surfaces are powered or non-powered, possessing the capability to change their load distribution properties only in response to an applied load. An active support surface is a powered support surface with the capability to change its load distribution properties, with or without applied load.In a recent study, Guys and St Thomas’s NHS Foundation Trust implemented eTRACE, which is an online clinical ordering system that uses the patients’ clinical risk assessment in conjunction with the Trust’s clinical protocols to recommend appropriate equipment selection.
In 2011/12 the Trust achieved a 60% reduction in stage 2 and 3 ulcers against a target of 10%. In 2012/13, Trust aims to maintain zero stage 4 hospital-acquired pressure ulcers, achieve a 50% reduction in stage 3 and a 10% reduction in stage 2.Monitoring the reduction of pressure ulcer incidence monthly with the eTRACE system could help to provide evidence of a reduction in expenditure long term. The estimated cost to the NHS for treating pressure ulcers is up to 2 billion per annum.
Based on the previous 2010 data of acquired pressure ulcers versus the 2011 data, the trust were on average making a saving of 45,000 per month. Thanks to these saving, some of the money has been reinvested in reactive seating cushions.This study overall proved that the eTRACE system provided a centralized and standardized reporting system that can be adapted to suit any specific care environment (Acton, 2012). Due to these six essential elements of pressure ulcer prevention identified by the IHI, more research is being done to find ways in utilizing this information to create strategies that all healthcare providers, especially nurses, can efficiently use. The key to best practice is simply by education. Educating all caregivers to give proper care to all at risk patients will improve the prevention of pressure ulcers significantly.
A recent nursing journal recognized the Stop the Pressure campaign that was launched in the spring by NHS Midlands and East Chief nurse Ruth May. The campaign not only addresses nursing skills and training, but also educates the public and puts the issue in front of Trust boards. Dr. May pointed out that consistency was a big issue in preventing pressure ulcers. There are so many different definitions being used of avoidable and unavoidable and some trusts are categorizing ulcers on a seven-point scale rather than a four-point scale.The campaign offered staff guidance on a pressure care pathway and they were encouraged to use existing tools such as the SSKIN care bundle which puts the emphasis on prevention.
Dr. May notes that patients do not get pressure ulcers if care bundles are followed completely. It is evident that patients are benefiting form the Stop the Pressure campaign. Across NHS Midlands and East, the number of new pressure ulcers, avoidable and unavoidable has dropped from 954 to 809 in a matter of 3 months (Moore, 2012). In conclusion, the key to prevent pressure ulcers is improved basic nursing care.Pressure ulcers are avoidable and when avoided they become less of a healthcare issue that impacts nursing care.
With better documentation and education about how to prevent pressure ulcers, both patients and nurses will have one less burden to carry. Money and time used to treat pressure ulcers will be reduced and the length of stay at the hospital will be cut shorter. I hope that one day when i become a nurse i can use these best practices to better serve the patients and hopefully encourage my future colleagues to do the same.
