Addressing the Challenge of Pressure Injuries

December - January 2023

Ms Hayley Ryan

Director, WoundRescue Pty Ltd. Wound Clinical Nurse Consultant

Newcastle NSW, Australia

Addressing the Challenge of Pressure Injuries

Editorial Summary

This article provides a concise overview of the significant problem of pressure ulcers and how the prevalence of this avoidable public health issue can be reduced. The various factors that increase risk of pressure ulcers are explored, as well as some of the standards and guidelines that can help healthcare practitioners identify symptoms early and prevent pressure ulcers from developing.

Introduction

Pressure injury (PI) is a significantly under recognised public health issue. The approximate total cost of pressure injury in the United States is $26.8 billion per year.1 In Australia, this number is approximately $1.8 billion.2 Clearly, we have a significant issue; we also know that in the United States around 60,000 patients will die every year specifically related to a pressure injury.3 At Wounds Australia we think it is a lot higher than that, but since we don’t actually collect data in Australia, it’s very difficult to make an estimation.

When answering these questions it is vital to review the latest evidence based practice.

Understanding the Skin

In order to treat a pressure injury, or prevent them, it really starts in understanding the skin. When it comes to understanding the skin in relation to wound healing, there are two principle layers: The epidermis, which functions to resurface wounds and restore the barrier against bacteria; and the dermis, which functions to restore structural integrity, collagen and physical properties of the skin.

When it comes to pressure injury, it is crucial to know where it affects to skin, since this is the part which helps us diagnose the correct stage.

• Stage 1: Quite superficial; top layer of skin

• Stage 2: Visible breaks in the skin

• Stage 3: Visible fatty tissue

• Stage 4: Visible bone, tendon or muscle

Importance of Skin Ph

We know that skin pH tends to be between 4 and 6.5. Optimal skin pH, however, is 5.5; this is because the acid mantle, which protects the skin against microorganisms, is protected.

One focus for maintaining skin integrity is to consider things like soap-free cleansers, and pH neutral emollients; no matter what area of healthcare you are working in, you should always encourage patients to use emollients and soaps which are soap-free, fragrance-free, and pH neutral; this is key to preventing the skin from breaking down.

Nutrition

In wound management, nutrition is pivotal. Changes in nutritional status can alter skin structure and function if there is a wound present. It is important to screen people for nutritional status.

There is debate over whether to focus on prealbumin or serum albumin levels. I request serum albumin levels when I’m considering someone who may be malnourished; if results are <30g/L, this will delay healing. This tells us that the focus we need to have is on high

Stages of Pressure Injury

“If we pre-emptively protect the skin, we are less likely to see a breakdown into pressure injuries.”

protein diet, and extra fluids.

The micronutrients that you should also focus on include iron, zinc, vitamins A and C; these will support wound healing. Deficiencies in vitamins and proteins are common in the elderly, by definition, over the age of 65.

• Use a soap free substitute

• Apply a sunscreen, even in winter

• Avoid hot and frequent showers

• Pat skin dry

• Inspect skin every shift

• Consider the need for support surfaces

• Maintain optimal nutrition and hydration

• Moisturize skin twice daily

Skin Moisturising

Carville et al., in a randomized controlled trial which was conducted in aged care homes, showed that twice-daily moisturizers on the limbs showed a reduction of skin tears to up to 50%.

The theme here is, if we pre-emptively protect the skin, we are less likely to see a breakdown into pressure injuries.

PI in the Aged Person

The skin changes as we age. We start to get decreased sensation, we get increasing dryness; skin starts to thin, there is decreased vitamin D synthesis; we get reduced immune response, and a decrease in the ability to control body temperature. The skin wrinkles, there is breakdown of collagen; the skin is more prone to susceptible to breaking down.

1. Inability to perceive pressure

2. Incontinence/ moisture

3. Decreased activity level

4. Inability to reposition

5. Poor nutritional intake

6. Friction and shear

Medical Risk Factors

Disease

Those living with dementia, have had a stroke, or are living with Parkinson’s disease, unrepaired hip fractures, frailty and sepsis; heart failure, or calcium channel antagonists and alpha blockers, are at higher risk of developing PI.

Aetiology

Factors putting patients at greater risk of PI include hypomania/ hypermania, mobility/ contractures; mobility/ tone, nutrition/ Catabolic state, or poor healing reserve; localised oedema and pedal oedema.

Intervention

Intervention can also lead to a higher risk of PI; over-sedation, thrombolyses and dopamine issues, and diuretics are examples here.

These factors will all impact and increase the person’s risk of PI. There are also major gaps and issues in the home and community space when people are independently looking after themselves.

Tips for Maintaining Skin Integrity

Risk Factors for Pressure Ulcer Development

“The 2019 guidelines include excellent visual guides to the stages and types of PI, and very importantly, in darkly pigmented skin, which can look very different than in lighter skin tones.”

What is a PI?

From the 2019 guidelines, a pressure injury is defined as:

“Localised damage to the skin and/ or underlying tissue, as a result of pressure or pressure in combination with shear. Pressure injuries usually occur over a bony prominence but may also be related to a medical device or other object.”

• The 2019 guidelines include excellent visual guides to the stages and types of PI, and very importantly, in darkly pigmented skin, which can look very different than in lighter skin tones:

https://npiap.com/page/PressureInjuryStages

Recognising Incontinence Associated Dermatitis

Incontinence Associated Dermatitis (IAD) is defined as “...a type of irritant contact dermatitis found in patients with faecal and/ or urinary incontinence.”

• Initially erythema that can be pink to red, darker skin tones can be paler, darker, purple

• Poor defined edges/ patchy

• May feel warmer

• Lesions: vesicles or bullae, papules or pustules

• Varying depths

• Discomfort, pain, burning, itching or tingling

• Susceptible to skin infections

IAD needs to be categorized. Naturally, if there is no redness and the skin is intact, it is not IAD. However, if there is visible redness and the skin is intact, it is category 1. If the skin is red, and broken down, it is a category 2. Most importantly, if the patient is not incontinent, then the condition is not IAD.

The Impact of the COVID-19 Pandemic

Medical Device Related Pressure Injuries

Multiple pressure injuries can be caused by common medical devices, such as oxygen delivery/ Nebuliser masks; intubation devices to ventilate, and catheters. Common locations of these are the cheeks, nose/ nostrils, neck, ears, lips, and tongue.

In terms of the COVID-19 pandemic, we have had to alter our work environments; some of us closed wound clinics, we had to merge and change wards to ‘COVID wards’ Home and Community (HCC) has seen an increase of services being cancelled, Aged Care has seen shifts in work flows and visitor limitations which added to environmental concerns, GPs seeing an increase of patients presenting with advanced symptoms, and the setting up of drive through PCR testing centers. We had redirection of resources to the COVID-19 response, and changes to wound care delivery, e.g., remote care/ Telehealth.

Wound Care in the COVID-19 Era and Beyond

The Wound Care Learning Network have done a fantastic job in putting together a proposed new focus during the COVID-19 era, which is not over; maybe we need to shift our thinking when it’s so difficult to get to patients during COVID-19 outbreaks. Rather than saying wound healing, we should maybe be focusing on wound maintenance. What can we do to stop that wound from breaking down while we can’t get to that patient?

“Prevention works, but ongoing preventative programs work better. Systematic reviews show that pressure injury prevention programs result in statistically and clinically significant reductions in pressure injury rates, from 50% to 100%..”

During the COVID-19 pandemic we have also seen damage to skin from intense, extended use of PPE by clinicians and those working in healthcare. This is pressure injury; from friction, pressure and shear. The main areas affected are the nasal bridge, forehead, cheeks and ears.

How do we prevent this safely? Dressings under PPE can disrupt their purpose and use, so thin dressings are suggested to avoid seal issues. The integrity of dressings should be monitored during work shifts and at each PPE change. The correct size of mask should be chosen (fit testing is important), adjusting to the anatomy of the face to optimize the seal, and of course, the manufacturer requirements must be followed. The skin can be protected by washing the face with pH balanced cleanser and drying it well. Apply moisturiser, 1 - 2 hours before donning PPE, ensuring it is fragrance free and is pH neutral. We can aim to reduce the friction/ shear caused by PPE; again, consider the fit. Protect the skin from moisture trapped underneath the PPE. Avoid wearing makeup. Finally, limit the length of time that PPE is worn.

PI Prevention Programs

Why should we invest time in PI Prevention Programs (PIPP)? It’s a community expectation not to develop PI; prevention avoids poor practice; depending on geographic location, PIs can be a reportable complication. It’s more cost effective to prevent PI considering the cost involved in treatment. Realistically, it’s the right thing to do.

Prevention works, but ongoing preventative programs work better. Systematic reviews show that pressure injury prevention programs result in statistically and clinically significant reductions in pressure injury rates, from 50% to 100%. Other benefits include optimal client care and avoiding the cost of treating Stage 3 and above injuries.

So where do we begin? Firstly, risk assessments. There are differences in opinion in the literature about which one is best, but use one, as it provides a guide; remember, every assessment is only as good as the person doing the

assessment; if risk assessment is rushed, nonmethodical, it may not give the right result. Secondly, brainstorm together and talk to one another; discuss at meetings and handoverscollaborate! Consider manual handling; are you repositioning the person with the right devices, like a slide sheet, for example? Think about nutrition and hydration. Manage moisture. Protect the skin, and check it often. Crucially, start making referrals early. Collect data.

Surface: Make sure your patients have the right support

Skin inspection: Early inspection means early detection. Show patients and carers what to look for

Keep your patients moving

Incontinence/ Moisture: Your patients need to be clean and dry

Nutrition/ Hydration: Help patients have the right diet and plenty of fluids

Preventative Tips

• Daily Skin Inspections: consider temperature/ skin tone

• Avoid massaging bony areas

• Complete risk assessments

• Moisturize twice a day: consider barrier creams to manage moisture

• Monitor those that are incontinent: use pH neutral soaps

• Check equipment daily: e.g., mattresses

• Reposition based on the individual assessment

• Consider nutrition

Make prevention a priority and share knowledge!

SSKIN

Conclusion

To conclude, let’s consider a few take home messages. Firstly, the skin; use logical and systematic approaches to manage and prevent skin breakdown. Remember, it is the largest organ on the body. Secondly, the team; think about a constant, accurate and multidirectional flow of information sharing with everybody who works in that area, including the patient, which brings us to the third point; put the patient at the core of all decision making. If we put these three points into play, we are certainly on the right path to preventing pressure injuries.

References

1. Padula, WV, Delarmente, BA. The national cost of hospital-acquired pressure injuries in the United States. Int Wound J. 2019; 16: 634– 640. https://doi.org/10.1111/iwj.13071

2. Nguyen KH, Chaboyer W, Whitty JA. Pressure injury in Australian public hospitals: a cost-of-illness study. Aust Health Rev. 2015 Jun;39(3):329-336. doi: 10.1071/AH14088. PMID: 25725696.

3. Bauer K, Rock K, Nazzal M, Jones O, Qu W. Pressure Ulcers in the United States' Inpatient Population From 2008 to 2012: Results of a Retrospective Nationwide Study. Ostomy Wound Manage. 2016 Nov;62(11):30-38. PMID: 27861135.

4. Carville K, Smith J. A report on the effectiveness of comprehensive wound assessment and documentation in the community. Prim Intent. 2014;12(1):41‐49.

5. Issue paper: Chronic wounds in Australia, http://www.aushsi.org.au/wp-content/ uploads/2017/08/Chronic-Wounds-Solutions-Forum-Issues-Paper-final.pdf

6. Matthew Malone, Saskia Schwarzer, Michael Radzieta, Thomas Jeffries, Annie Walsh, Hugh G. Dickson, Grace Micali and Slade O. Jensen, Effect on total microbial load and community composition with two vs six‐week topical Cadexomer Iodine for treating chronic biofilm infections in diabetic foot ulcers, International Wound Journal, , (2019).

7. Young C, Stoker F. A four‐year review of pressure ulcer prevalence. Prim Intent. 2017; 8( 1): 6‐ 12.

8. Vowden P. Hard-to-heal wounds Made Easy. Wounds International 2011; 2(4): Available from http://www. woundsinternational.com

9. International Wound Infection Institute (IWII) Wound infection in clinical practice. Wounds International 2016

10. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/ NPIAP/PPPIA; 2019.

11. Peko, L., Barakat-Johnson, M., Gefen, A. (2020). Protecting prone positioned patients from facial pressure ulcers using prophylactic dressings: A timely biomechanical analysis in the context of the COVID-19 pandemic. International Wound Journal, 17(6), 1595-1606.

12. Beeckman D et al. Proceedings of the Global IAD Expert Panel. Incontinence-associated dermatitis: Moving prevention forward. Wounds International 2015.