Considering the evidence for pressure injuries

Andrew JullAssociate Professor, UoA

Nurse Advisor, Quality, ADHB

What goes in a change package

Bundle acronyms often insufficient for identifying interventions

SSKIN (Scottish change package) Surface selection Skin inspection Keep moving Incontinence Nutrition

What surfaces and when?

Starting point

Haynes RB. ACP Journal Club 2009;151(3):2-3.

Guidelines

High level summaries Information quality

assessed Recommendations graded

by quality of evidence A, B, C, D, CBR Practice points (consensus)

Surface selection when at risk

At Risk of PI

Use a high specification reactive (constant low pressure) support foam mattress on beds and trolleys for patients at risk of pressure injuries.

Graded A

At high risk of PI

Active (alternating pressure) support mattresses could be used as an alternative in patients at high risk of pressure injuries.

Graded A

Evidence sourced from Cochrane review

Using imperfect information

Trials of both devices compared to standard hospital mattresses

Trials recruited patients at high risk of PI to both devices

Interpretation and consensus needed Use less expensive device with lower risk More expensive device with higher risk

Evidence gap High spec foam vs AP mattress

RCT of alternating pressure overlay vs high spec foam mattress (and Q4 turning) Not included in GL Unfair comparison? Repositioning in one

group but not in the other. Or does it model clinical practice?

Surface selection if has PI

Manage patients with existing pressure injuries on a high specification reactive (constant low pressure) or active alternating pressure) support surface on beds and trolleys and when seated.

Grade A

Evidence drawn from same source as when patient at risk or higher (not patients with PI)If patient has PI are they not at high risk and thus above recommendation soemwhat inconsistent with previous recommendation?

Limitations of guideline

Data source systematic reviews or previous guidelines Currency of evidence

Missed RCTs of recent evidence Heel off-loading devices

Curious re-interpretations Honey

Heel off-loading devices (HOLD)

Any device used to prevent heel pressure injuries should be selected and fitted appropriately to ensure pressure is adequately offloaded.

Graded CBR (consensus-based recommendation)

Missed reasonable quality RCT that showed 19% reduction in all PIs when HOLD used in addition to pressure-redistributing surfaces

Donnelly J et al. J Wound Care 2011;20:309-18.

Honey as wound dressing

Systematic review found one trial comparing honey to saline dressings

Review finding The effect of honey on pressure ulcers

cannot be determined from the single trial

Guideline recommendation Consider using topical medical grade honey

to promote healing in pressure injuriesGrade D

Jull A, et al. Cochrane Database Sys Rev 2008.

Other idiosyncrasies

Systematic reviews

Cochrane database the best source of SRs Access free via

www.nzgg.org.nz

Other SRs published

Require own quality check

Quick quality assessment

Does it have an objective Does it use exhaustive searches Does it quality assess studies Does it use processes to reduce bias

More than one person checking processes Does it assess publication bias

Positive studies more likely to be published

Sheepskins

“Medical grade” sheepskin Four RCTs

Incidence halved in sheepskin group No cost-effectiveness information

If evidence accepted, questionable whether feasible in acute care setting May be more feasible in residential care

setting?

AP Mattress vs AP overlay

Large high quality RCT & cost-effectiveness study No difference in incidence of Grade≥2 PI Small difference in number requesting

change in device (19% vs 23%)

Mattresses more cost-effective due to longer time to development of PI 10.6 days longer to develop PI

Individual studies Type of study important

Privilege RCT over other designs

Require own quality check Tools available

CEBM-type CAT (http://www.cebm.net/?o=1216)

GATE (http://www.fmhs.auckland.ac.nz/soph/depts/epi/epiq/ebp.aspx)

Risk assessment using Waterlow scale and skin inspection. Document.

Start turning regimen & document frequency

At riskAt very

high riskAt high

risk

Pressure ulcer present?

Grade pressure ulcer, document in clinical record &

report on Risk Pro

Turn 2 hourly at a minimum. Document.

Is patient independently

mobile?

Reassess Waterlow score daily and following changes in clinical

condition or after significant clinical procedures. Document. Educate patient/family/whanau about necessity of prevention

strategies e.g. turning

If on a standard hospital mattress, consider high

specification foam mattress in consultation with Charge

Nurse (or delegate) or Clinical Nurse Advisor (after hours).

Document rationale.

Has malnutrition screening tool (CR 6647)

been completed?

Complete malnutrition screening tool (CR 6647) and initiate appropriate action from

nutrition management guidelines with screening tool.

Document.

If pressure damage continues to deteriorate

despite high specification foam mattress and minimum of 2 hourly turning, consider alternating pressure mattress in consultation with Charge

Nurse (or delegate) or Clinical Nurse Advisor (after hours).

Document rationale.

Yes

No

Yes

No

No

Yes

Is the patient incontinent?

Initiate continence management as per Urinary

Function Changes RBP

Yes

No

Follow nutrition management guidelines as per screening tool (CR 6647). Document.

Conclusion

Information rarely perfect Clear answer to clinical need in all or even specific

circumstances not common

What to include in change package will almost always require interpretation and consensus

Agreement on sources of information, but be aware of source’s idiosyncrasies