madges story supporting presentation · for quality of life, including susceptibility to infection,...
TRANSCRIPT
Pressure Injury Prevention Madge’s story
CLINICAL EXCELLENCE COMMISSION
February 2016
This presentation highlights learnings about Madge’s story. Madge and her family hope this will raise awareness about the importance of pressure
injury prevention
We hope to show the importance of prevention and the impact that a pressure injury has on the patient
and family
Serious hospital acquired pressure injuries continue to occur throughout New South Wales healthcare
facilities
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Outline • Introduction
• CEC resources
• Madge’s story
• Timeline of admission
• Timeline for Pressure Injury (PI) to heal
• Communication/documentation
• Impact of pressure injury on Madge
• Cost of PI
• Key learnings
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Introduction
• A pressure injury (PI), also referred to as a pressure ulcer or bed sore, is a localised injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, shear or a combination of these factors1
• Many PIs are highly preventable. It is recognised that their lengthy healing time has consequences for quality of life, including susceptibility to infection, pain, sleep and mood disturbance. They also impact on rehabilitation, mobility and long-term quality of life
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Risk assessment requirements for inpatients
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Risk assessment requirements for inpatients
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• To guide clinical decision making the two part PI assessment/screening process is to be completed within 8 hours of presentation to the health facility by appropriately skilled health staff
• Patients identified as at risk of PI development will have the two part assessment
- Daily as a minimum and: - If there is a change to mobility
- Pre-operatively, and as soon as feasible after surgery
- On transfer of care
- If a pressure injury develops 1,2
(Based on current policy and guidelines)
CEC resources • Risk assessment requirements for inpatients
• Prevention strategies
• Care planning and management
• Patient information
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Madge’s story
• 85 year old lady
• Lives alone, independent at home, uses a walking frame
• House proud and loves cooking and working in her garden
• Has two daughters, both registered nurses who live over 4 hours away
LINK to video
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Errors in Health Care
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James Reason proposed the image of "Swiss cheese" to explain the occurrence of system failures, such as medical mishaps.
Review of Missed Opportunities
Relevant details of Madge’s admission
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Emergency Department
• Chest pain pathway
• Discovered strangulated hernia and bowel obstruction
• Plan: admission, nasogastric tube and surgery
• Transferred to ward prior to surgery
• Ward transfer checklist completed - No comprehensive risk assessment attended
Documented risk assessment as: N/A
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14/05/2015
2100
Presents to Emergency Department
2110 First hole: Madge PI
risk not identified in
ED
15/05/2015 1100 18/05/2015 25/05/2015
Timeline for Madge’s admission
First ward
• Initial risk assessment attended identified Madge “at risk”
• Review of documented information at the initial assessment placed Madge at a higher risk level than documented
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14/05/2015 2100
Presents to Emergency Department
2110
First hole: Madge PI
risk not identified in
ED
15/05/2015 1100 18/05/2015
Second hole: PI risk
assessment not
correctly completed
23/05/2015
Timeline for Madge’s admission
First ward
Theatre
• Theatre for a two hour operation
• Documented intact skin prior to surgery
• Skin intact following surgery
• No risk assessment completed or prevention strategies documented
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14/05/2015 2100
Presents to Emergency Department
2110
First hole: Madge PI
risk not identified in
ED
15/05/2015 1100
Third hole: PI risk
assessment not
documented pre or post
op (from documented
information would score
very high risk)
18/05/2015
Second hole: Risk
assessment not correctly
completed
23/05/2015
Timeline for Madge’s admission First ward
Theatre
First Ward Post Surgery
• Risk assessment not documented
• Documented information would put Madge at
“very high risk”
• Pain Management
- Madge was using Patient Controlled Analgesia, documented pain was still an issue with mobility
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First ward post surgery
• No evidence that pressure injury prevention education had been provided to the patient or family/carers
• Madge offered a pressure redistributing support surfaces, but declined - Did Madge understand the importance of the special mattress?
- Was Madge able to physically reposition independently?
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14/05/2015 2100
Presents to Emergency
Department
2110
First hole: Madge PI risk
not identified
Fourth hole: PI risk
identified, pressure
relieving mattress offered
but declined by Madge as
she did not understand
why it was needed
15/05/2015 1100
Third hole: PI risk assessment
not attended pre or post op
(from documented
information would score very
high risk)
18/05/2015
Second hole: Risk
assessment not correctly
completed
25/05/2015
Timeline for Madge’s admission First ward
Theatre
1st Ward Post
Surgery
Second ward post surgery communication and documentation
• Care plan was completed for only two days of Madge’s stay
• No risk assessment/skin inspection documented on transfer of care
• Madge’s injury was documented in notes but no interventions were documented or communicated
• No IIMS or wound chart completed
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14/05/2015 2100
Presents to Emergency
Department
2110
First hole: Madge PI
risk not identified
Fourth hole: PI risk identified,
pressure relief mattress
offered but declined by
patient as she did not
understand why it was
needed
15/05/2015
Fifth hole: pressure injury
documented with no
interventions documented
or communicated
1100
Third hole: PI risk assessment
not attended pre or post op
(from documented
information would score very
high risk)
18/05/2015
Second hole: Risk
assessment not correctly
completed
23/05/2015
Timeline for Madge’s admission First ward
Theatre
1st Ward Post
Surgery 2nd Ward Post
Surgery
Discharge
• Patient discharged after 10 day admission
- No communication with daughters about the presence of a pressure injury
• No skin assessment completed prior to discharge
- Black mark noticed on buttock by daughter after discharge
• Taken to local Emergency Department where Madge lives the day after discharge
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14/05/2015 2100
Presents to Emergency
Department
2110
First hole: Madge PI
risk not identified
Fourth hole: PI risk identified,
pressure relief mattress
offered but declined by
patient as she did not
understand why it was
needed
15/05/2015
Fifth hole: pressure injury documented
with no interventions documented or
communicated
1100
Third hole: PI risk assessment
not attended pre or post op
(from documented
information would score very
high risk)
18/05/2015
Second hole: Risk
assessment not correctly
completed
23/05/2015
Timeline for Madge’s admission
Sixth hole: Discharge -
presence of PI not
documented or
communicated to family
and no follow up care
arranged
First ward
Theatre
1st Ward Post
Surgery 2nd Ward Post
Surgery
May 2015
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Unstageable Pressure Injury right buttock
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Unstageable pressure injury: Depth unknown
Full thickness tissue loss in which the base of the PI is covered by slough
(yellow, tan, grey, green or brown) and/or eschar (tan, brown or black)
in the PI bed.
Until enough slough/eschar is removed to expose the base of the PI, the
true depth, and therefore the stage, cannot be determined. Stable (dry,
adherent, intact without erythema or fluctuance) eschar on the heels
serves as the body’s natural biological cover and should not removed.
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June 2015
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23 May 2015
Discharged from Hospital
PI identified by
daughter
Negative pressure
wound dressing
removed
July 2015
Rehabilitation
in hospital
Aug 2015
Negative pressure
wound therapy
continues, theatre
for insertion of
PICC line
Sept 2015
Theatre for
debridement,
negative pressure
wound therapy
24 Sept 2015
Timeline for Madge’s PI to heal
May 2015
Discharged home
after 4 months in
hospital
June 2015
Removed from social
network
Impact on Madge
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Pain and suffering
Unable to attend planned appointments
Home and garden not
being tended as normal
Worry about daughters
travel, absence from their
family and work
Loss of independence
Ongoing wound
management Inconvenience
for personal hygiene and
toileting
Delay in recovery,
deconditioning and lengthy
rehabilitation
Cost of PI
• A conservative estimate of the cost of Madge’s hospital acquired pressure injury is over $200,000
- Hospital accommodation
- Wound management including negative pressure wound therapy
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Learnings
The importance of:
- identifying risk
- communication and documentation
- involvement of patients and/or their carers with clinicians to develop individualised care plans
- working as a team to implement appropriate prevention strategies
- patient based care
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Acknowledgement
We acknowledge the collaboration with Western New South Wales Local Health District in the
development of this resource
And special thanks to Madge and her daughters for sharing this story
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References
1. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014.
2. Pressure Injury Prevention and Management -http://www0.health.nsw.gov.au/policies/pd/2014/PD2014_007.html
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Questions
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Resource Link
