Hospital-Acquired Complication: Pressure Injuries

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Table of Contents

Introduction
Pressure injuries overview
Presented case
Current Workplace Systems
Best Practice Guidelines
Areas for Improvement
Recommended Changes and Their Implementation
References

Introduction

The hospital-acquired complications (HACs) are a considerable concern for the Australian health care system. According to health and welfare institution (2019), HACs have affected 2% of a hospitalised patient in 2017-2018.Therefore, it has an impact on patient length of stay, quality and safety indicator and expenditure of health care and may lead to death (Bohlouli, B et al. 2016). This essay aims at to explore a case study of those complications. Namely pressure injury, an overview on this complication and its current prevention care that provided to relevant case study, then will compare prevention and management in current workplace and Australian policies.

Pressure injuries overview

The prevalence of hospital-acquired pressure injuries in Australian hospitals was 9.7 injuries per 10,000 hospitalizations in 2015–16. these have increased expenditure on health care services for mostly preventable cause incidents (Nguyen, K et al.,2015). Pressure injuries (PIs) are characterised as localised skin and/or underlying tissue damage that typically occurs over bone prominence or due to medical devices (National Pressure Ulcer Advisory Panel 2016). PIs are caused directly by immobility, constant pressure, strain, friction, and shear (Bhattacharya & Mishra, 2015), additionally, there are indirect cause such poor nutrition, health condition, aging skin, mental health conditions (Bhattacharya & Mishra, 2015). Those factors are leading to deformation inside tissues and cells and ischaemia, lymphatic flow blockage, and tissue damage (Bhattacharya & Mishra, 2015).

Presented case

For the respect of patient anonymity and confidentiality, will be referred to the patient as Mr M. MR M a 49-year-old male, the patient was admitted to Intensive care unit after a road traffic accident. The patient has been diagnosed of brain contusion and right femur fracture. Computed tomography has shown epidural hematoma that no need for surgical intervention. Traumatic brain injury protocol was an initiate. Thus, MR M sedated with fentanyl 50/100 mcg/hr and midazolam 1.5–4.5 mg /hour on Mechanical ventilator on CMV mode and Richmond Agitation-Sedation Scale is -5.

MR M contacted to monitor vital signs is stable, afebrile. MR Mattached on right skin traction with Wight 9 kg. During his physical assessment, both eyes pupils were sluggish reacted to light, the ETT indicted, lung assessment demonstrated there is no sign of lung infection, its noted during suction slight gag reflex present. bowel movement present, the urine output 70ml/hr. The body mass index (BMI) is 32 kg/m2, his medical history of long-standing hypertension and diabetes.

MR M assessed within the first 8 hours of admission with Braden scale score that indicated patient on high risk. The care was provided by nurse staff to prevent pressure injuries of using impaired skin integrity care plan which is consist reposition every hour, adequate nutrition and fluid to maintain hydration, keep nails short, provide gentle massage, provide egg crate mattress and keep skin clean. However, the incident report that the patient had pressure injury on sacrum area after 48 hours of Admission. In short, based on the care provided

Current Workplace Systems

Pressure injury prevention procedures and strategies in the workplace are based primarily on the guidelines of the National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA). There are two sets of interventions that are usually applied in the workplace (Prevention and treatment, 2014). The first set is aimed at preventing pressure injuries while the second set is for treatment of pressure ulcers.

Prevention of pressure injuries starts with a thorough risk assessment. The workplace follows the mentioned guidelines when evaluating what patients are at risk and what factors influence their situation. Generally, bedfast and chairfast individuals, patients with mobility limitations and individuals that already have pressure ulcers are in the group of risk (Prevention and treatment, 2014). Other factors that are considered when assessing patients’ risk are nutritional status, skin moisture and oxygenation. Also, age and general health condition may play a partial role in pressure injury development.

After identifying individuals at risk, the procedures call for a skin and tissue assessment. The goal of this stage is to decide whether a patient is in need of any preventative interventions. It is not possible to evaluate skin condition without specialised knowledge. Therefore, the workplace conducts training and seminars on identifying oedema, detecting blanching response, induration and localised heat. Skin assessments are done as soon as a patient is admitted to the hospital. In cases when it is not possible to inspect immediately, personnel conducts skin evaluations within eight hours of admission. As part of skin and tissue assessment procedures, staff in the workplace uses the impaired skin integrity care plan. The goal of this strategy is to evaluate the skin’s overall condition and check if the patient is aware of the pressure sensation (Wayne, 2019). Impaired skin integrity plan incorporates either the Braden Scale or the Norton Scale (Wayne, 2019). The workplace uses the Braden Scale, which considers perception, activity, mobility, friction and moisture.

Nutrition and hydration play a significant role in treating pressure injuries. Therefore, as recommended by NPUAP/EPUAP/PPPIA, the workplace pays serious attention to diet. The personnel ensure that energy intake, fluid consumption, and ingestion of vitamins, minerals and proteins are on an appropriate level. Registered dietitians and nutritionists, along with attending nurses and doctors, develop a diet plan for each patient that has a pressure ulcer.

Because the guidelines are only recommendations and not strict rules, the workplace fulfils them according to its capabilities – some of the emerging therapies are not yet used. NPUAP/EPUAP/PPPIA mention microclimate control as a possible way of preventing skin injuries (Prevention and treatment, 2014). This therapy is comprised of controlling surfaces and devices that patients’ skins contact. While the workplace provides select mattresses, it does not yet control temperatures of different surfaces in the patient rooms.

Best Practice Guidelines

Because pressure injuries are a significant threat to patient well-being, various governing bodies have published their recommendations and requirements on preventing and treating pressure ulcers. Clinical Excellence Commission (CEC) of the New South Wales Government has its own set of recommendations and guidelines (Pressure injury prevention, 2014). However, they reprise the recommendations given by NPUAP/EPUAP/PPPIA in many ways. Therefore, it can be considered that the workplace follows the guidelines of CEC.

Another governing body whose care standards should be considered is the Australian Commission on Safety and Quality in Health Care (ACSQHC). This commission has health service standards published as the National Safety and Quality Health Service Standards (NSQHSS) that hospitals and other health care institutions should conform (Preventing and managing pressure injuries, 2012). While NSQHSS covers the whole journey of patients through the care process, the 8th standard deals specifically with pressure injuries (Preventing and managing pressure injuries, 2012). The critical role is dedicated to communicating the significance of pressure injury management programs to carers and patients (Preventing and managing pressure injuries, 2012). NPUAP/EPUAP/PPPIA guidelines do not mention communication as an essential criterion (Pressure injury prevention, 2014).

Also, NSQHSS often suggest systematization and reporting – without adequate data on pressure injuries, it will be much more challenging to prevent and treat them (Preventing and managing pressure injuries, 2012). These items are not mentioned by NPUAP/EPUAP/PPPIA, and the workplace does not have formal reporting mechanisms.

Areas for Improvement

To date, it has been established that the most critical factors contributing to the formation of pressure ulcers are continuous pressure, displacement forces, friction and humidity. The limited motor activity of patients, inadequate nutrition and care, and urinary and faecal incontinence also play an essential role in the development of ulcers (Pressure injury prevention, 2014). In addition, concomitant diseases such as diabetes mellitus, Parkinson’s disease, paraplegia and exhaustion are significant risk factors (Wayne, 2019). In some circumstances, a shortage of medical personnel leads to unfavourable patient outcomes in terms of pressure injuries. Because these issues are not observed in the discussed workplace, the list of areas that should be improved does not include the methods of treatment or the number of staff.

However, in order for guidelines to be followed ubiquitously, all personnel should be adequately trained and should be provided with necessary educational material for self-study. Nurses and doctors in intensive care units should pass knowledge checks prior to handling patients in risk groups. The workplace should conduct training regularly so that every employee follows the rules when admitting patients and detecting whether they are at risk of acquiring a pressure injury. Also, the reporting system should be established so that the management team has better control of the situation.

Recommended Changes and Their Implementation

There are two recommended changes – establishing a reporting system and developing a framework for controlling microclimate in the patient rooms. These are not simple tasks, and therefore, should be managed through a change management system. CEC’s guidelines provide a sample implementation plan for a pressure injury prevention strategy. This plan can be used as a basis for implementing other related practices. CEC’s implementation plan consists of four steps – gathering data, identifying stakeholders, recruiting a team and identifying any obstacles (Pressure injury prevention, 2014).

When developing a reporting system, the data should be gathered on the number of pressure injuries that were acquired after patients were admitted to a hospital. This number will give an overall picture of pressure ulcers that could have been prevented if there was a reporting platform in place. Stakeholders are the managers, employees that register patients, attending doctors and nurses. A reporting system is essentially a software platform; therefore, the team should include professionals with domain knowledge, software engineers and architects. The microclimate control strategy can be implemented in the same manner.

References

Australian Institute of Health and Welfare (AIHW) 2019, Hospitals at a glance 2017–18. Web.

Bohlouli, B., Tonelli, M., Jackson, T., Hemmelgam, B. & Klarenbach, S. 2016, ‘Risk of hospital-acquired complications in patients with chronic kidney disease’, Clinical Journal of the American Society of Nephrology, vol. 11, no. 6, pp. 956-63.

Bhattacharya, S. & Mishra, R. 2015, ‘Pressure ulcers: current understanding and newer modalities of treatment’, Indian Journal of Plastic Surgery, vol. 48, no. 01, pp. 004-16.

Nguyen, K.-H., Chaboyer, W. & Whitty, J.A. 2015, ‘Pressure injury in Australian public hospitals: a cost-of-illness study’, Australian Health Review, vol. 39, no. 3, pp. 329-36.

Magid, B., Murphy, C., Lankiewicz, J., Lawandi, N. & Poulton, A. 2018, ‘Pricing for safety and quality in healthcare: A discussion paper’, Infection, disease & health, vol. 23, no. 1, pp. 49-53.

Panel, N.P.U.A. 2016, ‘NPUAP pressure injury stages’, Series NPUAP pressure injury stages.

Pressure injury prevention and management: policy implementation guide (2014). Web.

Preventing and managing pressure injuries: safety and quality improvement guide(2012). Web.

Prevention and treatment of pressure ulcers: quick reference guide (2014). Web.

Wayne, G. (2019) Risk plan for impaired skin integrity. Web.

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