Prevention Bundle to Reduce Hospital-Acquired Pressure Injuries in Critical Care

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Table of Contents

Introduction
Pressure Injury Classification and Assessment
Pressure Injury Prevention Bundle
Standard Interventions
High-Risk Interventions
Conclusion
References

Introduction

A hospital-acquired pressure injury is a preventable event that often happens in the intensive care unit. A pressure injury can be defined as localized skin and tissue damage caused by pressure and shear (Al-Otaibi et al., 2019). The risk factors for developing healthcare-acquired pressure injuries are immobility, altered mental status, advanced age, fecal or urinary incontinence, and nasogastric tube placement (Al-Otaibi et al., 2019). Indeed, critical care unit patients are at increased risk of having pressure injuries. Still, although skin and tissue damages are common in these circumstances, it is preventable. Various interventions of different effectiveness were developed to minimize such injuries. For example, the Cochrane review demonstrated the high efficacy of using specialized mattresses in preventing pressure injuries, but insufficient evidence for the benefit of pressure relief, nutritional support, dressing for bony prominence, and skin moisturizers (Al-Otaibi et al., 2019). This type of healthcare-acquired damage can negatively impact patients’ physical and emotional well-being, prolonging hospital stay and increasing morbidity (Lin et al., 2020). This review aims to uncover the importance of implementing such evidence-based interventions as pressure injury prevention bundles in reducing pressure rates in critical care units.

Pressure Injury Classification and Assessment

Pressure injuries and ulcers vary in location and severity that determine the negative impact on patients’ quality of life. Pressure ulcers appear when the skin integrity is compromised due to a sustained mechanical force (Bergstrom et al., 1987). The European Pressure Ulcer Advisory panel describes six stages of pressure injuries (Gupta et al., 2020). The first stage is mild erythema of the skin, while the second and third stages involve partial and full-thickness loss of epidermis and dermis (Gupta et al., 2020). During the fourth stage, the skin and underlying tissues are damaged (Gupta et al., 2020). The last two levels are unstageable and deep tissue injury resulting in tissue loss and persistent red discoloration, respectively (Gupta et al., 2020). An accurate assessment of the extent of tissue damage is critical for choosing an appropriate intervention.

The evaluation of the severity of pressure injuries is done with the Braden scale. This assessment tool was developed in 1987 by Braden and Bergstrom (Romanelli et al., 2018). It incorporates six separate subscales that assess sensory perception, mobility, activity, nutrition moisture, and friction on a scale from one to four, except for the latter, scaled from one to three (Bergstrom et al., 1987). According to this scale, the maximum score assigned is 23 (Romanelli et al., 2018). The activity and mobility subscales evaluate how long and frequently a patient can move, while nutrition is assessed on a person’s capacity for food intake (Bergstrom et al., 1987). Sensory perception is determined based on the ability to recognize discomfort (Bergstrom et al., 1987). The moisture scale assesses the degree of skin exposure to such body fluids as urine, perspiration, and other secretions (Bergstrom et al., 1987). The friction subscale judges how well a patient can move without having contact between one’s skin and bedding (Bergstrom et al., 1987). This scale was found to be reliable and is still used in healthcare facilities to estimate the level of pressure injuries.

Pressure Injury Prevention Bundle

Standardized intervention methods are essential assets in preventing pressure injuries. For example, several evidence-based interventions, known as a bundle, are more efficient when introduced in combination (Frank et al., 2017). Furthermore, the success of implementing this methodology depends on teamwork and clinicians’ adherence to standard operating protocols (Courtwright et al., 2017). The bundle approach was proven to be an effective method to reduce the prevalence of pressure injuries in critical care unit patients (Courtwright et al., 2017). One of the first developed methods consisted of five items: skin assessment, surface support, mobility and repositioning, incontinence, and nutrition (Romanelli et al., 2018). Moreover, the four other approaches to reduce the severity of pressure injuries, recommended by the International Pressure Ulcer Guidelines, include prophylactic dressing, silk-like textiles, electrical muscle stimulation, and microclimate, controlling temperature and humidity of the skin (Romanelli et al., 2018). The elements of the prevention bundle may vary between authors, but the goal of these tools remains the same – to prevent pressure injuries and their complications in high-risk patients.

The type of intervention in patients varies depending on the Braden score. According to the bundle designed by Rivera et al. (2020), patients with a Braden score above 19 should receive the standard intervention. In contrast, patients with points equal to or below 18 will also get high-risk intervention (Rivera et al., 2020). Implementation of this bundle in critical care, surgical, and step-down units resulted in a significant reduction in the occurrence of pressure ulcers (Rivera et al., 2020). Specifically, the index of healthcare-associated pressure injuries, which is the proportion of patients with pressure ulcers to the days spent in the hospital, dropped from 3.4 to 0.48 (Rivera et al., 2020). Moreover, a four-year quality improvement study demonstrated a 63% reduction in the prevalence of pressure ulcers in hospitals after introducing the bundle approach (Richardson et al., 2017). Another study, conducted in Saudi Arabia, showed an 83% drop in hospital-acquired pressure injuries over the 12 weeks of implementation of this method (Al-Otaibi et al., 2019). These studies show the effectiveness of the bundle approach for pressure injuries prevention in healthcare facilities.

Standard Interventions

Patients in intensive care units whose pressure ulcers can be categorized into the first two stages need the standard intervention. According to Rivera et al. (2020), this intervention includes skin assessment, changing endotracheal tube holder every four days, foam dressing to patients with face masks, and silicone dressing in tracheostomy cases every three days. Frequent replacement of dressing can relieve shear stress and prevent skin infections. In addition, the fabric for dressing should be selected based on the healing stage (Romanelli et al., 2018). For example, an infected wound needs to be covered with an antimicrobial dressing, while hydrogel dressing is used for painful ulcers (Romanelli et al., 2018). Furthermore, Romanelli et al. (2018) recommend dry skin rehydration with moisturizers and patient repositioning using cushions and mattresses. Moreover, optimizing patients’ health and boosting their immune status is essential for pressure injury prevention (Romanelli et al., 2018). The additional interventions include early mobility, head at 30 degrees, and consulting wound, ostomy, continence nurses (Rivera et al., 2020). Indeed, the standardized bundle approach is a valuable tool for precluding skin and tissue injury and managing mild pressure ulcers in critical care facilities.

High-Risk Interventions

The higher stages of pressure injuries require standard intervention combined with high-risk methods. Rivera et al. (2020) suggest changing prevention dressing on the sacrum once in three days, alter the patient’s position every two hours, use seat cushions and heel protectors, and consult about nutrition status. Furthermore, the presence of exudate in a pressure ulcer is an indication for changing dressing more frequently (Romanelli et al., 2018). The primary function of a cushion is body immersion that diminishes stress and pressure (Romanelli et al., 2018). Importantly, poor nutritional status is the risk factor for pressure injury formation and an impediment to faster healing. Therefore, a nutritional consult is vital for maintaining an adequate supply of proteins, fats, carbohydrates, vitamins, and minerals to facilitate wound repair, which is impossible without nitrogen, vitamin C, and essential fatty acids (Romanelli et al., 2018). Dietary requirements and fluid intake should be individualized to the patient’s current weight, pancreatic, renal, liver function, disease severity, and hydration status (Romanelli et al., 2018). Finally, the intervention and progress in pressure ulcer prevention should be documented appropriately.

Conclusion

To summarize, the prevention bundle for pressure injuries is a critical approach in reducing pressure ulcers incidence in critical care units. Pressure injury assessment is done with the Braden scale to determine the severity of the ulcer. Furthermore, the classification of these injuries is divided into six stages. The Braden score and stage identification allow clinicians to select proper intervention based on the seriousness of the damage. The classic bundle intervention incorporates five significant elements that serve as the foundation for formulating novel methods: skin assessment, surface support, repositioning, incontinence, and nutrition. The standard intervention described in this literature review aims to prevent the worsening of pressure ulcers in patients with a Braden score above 19. The high-risk intervention was developed to facilitate recovery in patients with higher stages of pressure injuries. Still, although clinical quality improvement studies were done to demonstrate the effectiveness of this methodology, randomized trials have not been performed to evaluate the prevention bundle approach. Therefore, future research should strive to implement unbiased experimental methods to examine the efficacy of the bundle intervention.

References

Al-Otaibi, Y. K., Al-Nowaiser, N., & Rahman, A. (2019). Reducing hospital-acquired pressure injuries.BMJ Open Quality, 8(1), 1-5. Web.

Bergstrom, N., Braden, B. J., Laguzza, A., & Holman, V. (1987). The Braden scale for predicting pressure sore risk. Nursing Research, 36(4), 205–210.

Courtwright, S. E., Mastro, K. A., Preuster, C., Dardashti, N., McGill, S., Madelon, M., & Johnson, D. (2017). Reducing hospital-acquired pressure ulcers using bundle methodology in pediatric and neonatal patients receiving extracorporeal membrane oxygenation therapy: An integrative review and call to action.Journal for Specialists in Pediatric Nursing, 22(4), 1-14. Web.

Frank, G., Walsh, K. E., Wooton, S., Bost, J., Dong, W., Keller, L., Miller, M., Zieker, K., & Brilli, R. J. (2017). Impact of a pressure injury prevention bundle in the solutions for patient safety network.Pediatric Quality & Safety, 2(2), 1-8. Web.

Gupta, P., Shiju, S., Chacko, G., Thomas, M., Abas, A., Savarimuthu, I., Omari, E., Al-Balushi, S., Jessymol, P., Mathew, S., Quinto, M., McDonald, I., & Andrews, W. (2020). A quality improvement programme to reduce hospital-acquired pressure injuries. BMJ Open Quality, 9(3), 1-9. Web.

Lin, F., Wu, Z., Song, B., Coyer, F., & Chaboyer, W. (2020). The effectiveness of multicomponent pressure injury prevention programs in adult intensive care patients: A systematic review.International Journal of Nursing Studies, 102, 1-37. Web.

Richardson, A., Peart, J., Wright, S. E., & McCullagh, I. J. (2017). Reducing the incidence of pressure ulcers in critical care units: A 4-year quality improvement.International Journal for Quality in Health Care, 1-7. Web.

Rivera, J., Donohoe, E., Deady-Rooney, M., Douglas, M., & Samaniego, N. (2020). Implementing a pressure injury prevention bundle to decrease hospital-acquired pressure injuries in an adult critical care unit: An evidence-based, pilot initiative.Wound Management & Prevention, 66(10), 20—28. Web.

Romanelli, M., Clark, M., Gefen, A., & Ciprandi, G. (Eds.). (2018). Science and practice of pressure ulcer management (2^nd ed.). Springer Nature.

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