Our Clinical Nurse Specialist, Patti Burke Martin examines the various ways that pressure injuries are treated in hospitals and care facilities across the world and discusses why, despite all the knowledge, research and skills available now, the incidence of pressure injuries is increasing?
We as clinicians have a responsibility and the ability to make an impact on the reduction of pressure injuries worldwide. We know that they are painful, debilitating wounds that can be avoided (95% of the time). However they continue to pose a serious problem to patients and healthcare systems with an estimated 1 in 5 patients suffering a pressure injury. They can prove to be fatal and cost healthcare systems billions to treat annually.
We know that 95% are avoidable!
Yet 1 in 5 patients still suffer, why?
How are pressure injuries managed in healthcare systems worldwide?
Repositioning is key to offload pressure from bony prominences. The general guide is that patients must be repositioned at a minimum of every two hours so this can be turning from one side to another side if they are in bed, or if they are in a chair and unable to shift their weight independently functions such as tilt in space and back angle recline can relieve pressure from bony prominences. Research has shown that 45° tilt 'maximises the potential for significant blood flow increases and pressure reduction' by allowing the patient to completely off load their pelvis and allow reoxygenation of the tissue.' (Casey, Gittins et al. 2011) A chair which easily allows the patient or caregiver to achieve this 45° tilt is best as nurses/caregivers are already very busy in their daily workload so making repositioning simple is key to making sure it's done effectively.
Even getting patients out of their chair momentarily can relieve this pressure.
2. Mattresses/Therapeutic Surfaces
There has been much focus on therapeutic surfaces i.e. beds, mattresses and high cost 'pressure relieving' cushions.
Often high pressure risk patients are provided with a fantastic and highly functional pressure redistributing mattress, only to be transferred through the day to unsuitable seating or wheelchairs with a pressure cushion. We also know that those at extreme risk may be kept in bed on this therapeutic mattress for most of the day, or even all day and unfortunately the negative side effects of prolonged bed rest are extensive.
3. Hydration and Nutrition
A patient needs to be adequately hydrated and their nutrition needs to carefully monitored to ensure they are receiving the essential proteins vitamins and minerals to facilitate healing and skin integrity.
There is a huge range of wound care dressings available for clinicians to choose from including vac therapy which can be successfully used to treat pressure injuries.
5. Prevalence and Incidence Studies
Prevalence and incidence studies are very important to discover where the pressure injury has happened.
Prevalence - It tells us on any given day how many pressure injuries are in a facility - like a 'snapshot' of the number of pressure injuries that exist and how they are staged. Prevalence studies will not decipher where the pressure injuries have arisen from/occurred.
Incidence - Generally an incidence study is completed after an average length of stay has happened to determine 'new' or 'acquired' pressure injuries that happened in that facility. It is critical to measure, monitor and record Incidence studies so progress can be made to reducing the risk and number of acquired pressure injuries. Pressure Injuries can be seen as a sign of neglect of a patient and medical malpractice legal cases are on the rise with settlements averaging $250,000/£175,000.
Why are pressure injury rates rising?
Despite all the above, the research, the innovations in treatments, the problem still exists and the case is often that they are 'expected' or 'inevitable' with patients in certain settings. Some studies even suggest that pressure injury rates have risen by as much as 78.9% in recent times.
For years studies have focused on treatment and equipment that a patient with a pressure injury will require. Yet this has not proven to contribute to a reduction in rates. The focus needs to shift from 'cure' to 'prevention' and this is where we believe seating needs to be considered.
Until our recent research study there was no existing clinical trial ever completed worldwide into the effects of seating solutions on a patients health and pressure risk.
We believe that a 24 hour pressure care approach must be applied to patients at risk or the incidence will continue to rise.
Of course we know that we cannot 'relieve' pressure - we can only redistribute pressure or offload pressure from bony, vulnerable prominences of the body. Our research showed that applying 'The Four Principles of Pressure Management in Seating' can serve to reduce pressure injuries and the 'cushion/surface' is only one quarter of the success of these principles.
Standard Chairs - One size does not fit all
Many patients sit out for 8-10 hours of the day in a standard chair which provides inadequate postural support and pressure management and which can actually contribute to a rise in pressure injuries. Chairs need to be adjustable to suit patients so that they are safe, secure and comfortable in their chair. When patients are matched with an appropriately sized chair this can reduce the risk of falls and sliding from chairs; remember that shear from constant sliding can contribute to pressure injuries as well as direct pressure. Chairs that are too wide, have an inappropriate seat depth or do not accommodate hamstrings can add to this falls risk and contribute to a deviated posture.
Care chairs must allow effective repositioning through functions such as tilt in space and back angle recline functions to redistribute oxygen to tissue in the body preventing skin breakdown.
Evidence Based Practice in Seating
When clinical seating is used correctly, with researched solutions to support evidence based practice, there is much improvement in a patients functioning to aid recovery and improve their health. Our research proved real, tangible benefits -
- A significant reduction in pressure ulcer incidence.
- Increase in oxygen saturation levels by 95%.
- Increased functional ability.
- Improved posture and a reduction in the development of postural deformities or sliding/falling from the chair.
- Improvement in respiration, elimination, digestion and other physiological functions.
- Improved quality of life and psychological wellbeing.
- Improved communication and interaction.
- Improved comfort and reduction in pain levels.
- A significant reduction in expenditure on staff labour and treatment of pressure injuries.
If you're interested in reducing the risk and rates of pressure injuries in your place of work, get in touch to see how we can help you through our research, education and therapeutic seating devices.