Pressure Injuries in 2018: our preventable global crisis

Friday, September 28, 2018

Immobility is endangering our patients!

Right now in 2018, we are at a place where we know more about the prevention and management of pressure injuries (PIs) than ever before in medical history. In recent years there has been an exponential growth in treatment with a disproportionate lack of prevention of pressure injuries, making PIs our preventable global crisis. PIs are far more expensive to treat than to prevent. PI management costs in Australia are estimated at A$1.6 billion annually1.

We are not lacking in our ability to treat, our current failing is in our inability to prevent.

By default, we are more interested in paying for treatment than investing in prevention.

Be under no illusions, patients die from PIs.

In my home state of Queensland, Australia there have been two Coroners investigations into aged care residence related deaths in the past five years.

“Education is foundational for pressure injury (P.I.) prevention”2.

Except in critical situations such as long surgeries (some neurosurgery and orthopaedic procedures can last more than 8 hours), pressure injuries ARE PREVENTABLE!

If we are serious about developing and maintaining a culture of effective pressure injury prevention we need to be considering the following:

1. Aged care wards people (also known as operational support staff). In Australia, aged care staff are statistically middle aged, female and of smaller stature with a propensity towards working quickly and suffering from the cumulative effects of lower back pain. The development of a job pathway for wards who undertake manual handling in hospitals would be one way to increase the frequency of the clearly inadequate repositioning whist decreasing the present culture of developing cumulative lower back pain.

2. Recognition that a lot more Stage 1 PIs are developing and being left unnoticed (and therefore untreated) than we realise. With personal carers/care workers (PC/PCW) and Assistants in Nursing (AINs) being the people tasked with repositioning patients as opposed to clinical staff, they need to be the ones most conversant with recognition of Stage 1 PIs. The reality though is that if asked to describe Stage 1 PIs some care staff will simply say ‘I’m not a nurse’ etc. It is the clinical staff not the care staff who attend the continuing professional development courses in advances in pressure injury prevention and management. Care staff need to be empowered to be ‘Masters of Pressure Relief’ who can describe and identify Stage 1 PIs without having to think about it or refer to posters etc. It needs to be learned and relearned and relearned with the same muscle memory development given to cardiopulmonary resuscitation training. With facility fines for pressure injury development of pressure injuries in the region of a A$30k per incident, where is the incentive to do the very best to prevent them? This leads to underreporting and finger-pointing for example ‘Mrs jones didn’t have a pressure injury when she left our aged care facility, but she came back from hospital with one’.

3. Prevent the deterioration of Stage 1 and 2 to Stage 3 and 4 pressure injuries.

The foundation of pressure injury prevention and management is education. Education of staff, patients and families.

The NPUAP redefined the definition of a pressure injuries during the NPUAP 2016 Staging Consensus Conference that was held in April 2016 in Chicago, IL. And there are now 7 categories of PIs:
-Stage 1
-Stage 2
-Stage 3
-Stage 4
-Unstageable Pressure Injury: Depth unknown
-Suspected Deep Tissue Injury: Depth unknown
-Mucosal Membrane Pressure Injury

As a nurse and paramedic of 15 years, my first experience of PIs was at a large hospital in Melbourne in 2003. An elderly female patient with a very slight build had a with a Stage 2 PI with a diameter of 2cm on her sacrum. They had her lying directly it, hoping that it would heal itself. I remember the difficulty of assisting her with toileting without getting faeces in the wound.

My most ghastly experience with PIs was in the operating theatre where every second day a female ICU patient would be hoisted up and positioned with her legs on stirrups so that the general surgeons could debride more and more devitalised tissue to the point that the patient looked like a shark had bitten her buttocks completely off.

If we had the power to look back on the timeline of a PI and say when should we have intervened to stop this from happening, it’s obviously before Stage 1 or recognising Stage 1 and doing everything we can to prevent deterioration. Otherwise we have no business in calling ourselves carers.





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